Does the Use of Prophylactic Antibiotics Ensure the Prevention of Surgical Site Infections - Research Paper Example

? Does the use of prophylactic antibiotics ensure the prevention of surgical site infections? An analysis of evidence-based nursing research Sheila Johnson Nursing Research Nur: 430 Dayle Comar May 2nd, 2011 Introduction Surgical site infection (SSI) is one of the most common complications of surgery, characterized by a constellation of clinical findings occurring within 30 days of surgery and mainly due to Gram-positive bacteria (Bucher, Warner & Dillon, 2011). Prophylactic antibiotics treatment is delivered to patients, since overwhelming evidence demonstrates that this practice lowers the incidence of SSI. Although research-based guidelines for infection prevention in surgery have been published, a relevant heterogeneity in the use of these measures exists showing the need for further regulation and implementation (Beckmann et al., 2011). Several strategies have been suggested to improve antibiotic prophylaxis (AP), including: providing education or individualized feedback to clinicians; establishing multidisciplinary protocols to ameliorate team-level communication; implementing institutional antibiotic prophylaxis programs involving integrated systems to reduce, curtail or control the administration of antibiotics (Gagliardi, Fenech, Eskicioglu, Nathens & McLeod, 2009). With the goal of optimizing antibiotic prophylaxis of surgical-site infections a multidisciplinary approach has been recently revised by Olin (Olin, 2006). The author presents the main points in prescribing, dispensing, and administration practices to achieve 100% compliance with antibiotic prophylaxis, and he cites in particular: initiating prophylactic antimicrobials within one hour of surgical incision, by choosing them according to guidelines, and discontinuing antimicrobial prophylaxis within 24 hours after surgery (Olin, 2006). A crucial issue in antibiotic-based peri-operative prophylaxis is the timing of antibiotic delivery. Although there is a general agreement on recommending antibiotic treatment within one to two hours of incision for patients undergoing surgery, contrasting results demand further research. Several clinical studies continue to be published yearly, aiming at optimizing the timing of antibiotic treatments (Gupta, Hote, Choudhury, Kapil & Bisoi, 2010). The purpose of my assay is to evaluate a recently published evidence-based nursing research aimed to assess the effects of the SURPASS checklist on implementation on antibiotic prophylaxis (de Vries, Dijkstra, Smorenburg, Meijer & Boermeester, 2010). SURPASS is the acronym for SURgical Patient Safety System, a checklist previously developed by the same authors of the study hereby analyzed, which was aimed to increase standardization surgical procedures and patient safety (de Vries, Hollmann, Smorenburg, Gouma & Boermeester, 2009). Research study synopsis and analysis De Vries et al. (2010) performed a retrospective analysis on two cohorts of patients who underwent surgery before and after implementation of the SURPASS checklist, with the specific aim to determine whether the introduction of the implemented SURPASS checklist affected the timing of antibiotic prophylaxis. Importantly, the retrospectively collected data (including those extracted from the electronic patient data management system) were validated by observations, in which actual times of antibiotic administration and incision were recorded. This approach validated the use of electronic records of hospitalized patient management. A total of 772 surgical procedures were included in the study, divided in two cohorts treated with pre- and post-implementation (PI) checklist, respectively. Patient characteristics were listed in Table 1 of the paper. The latter and the use of a PI checklist were independent variables. Dependent variables were the intervals between antibiotics administration and incision (Figure 2 of the paper), expressed as a function of checklist implementation, i.e. in surgery performed before or after checklist implementation. Since in the PI cohort the checklist was actually used in 81,4% of all the surgical procedures, also data from this specific subpopulation were presented (Figure 3 of the paper), thus representing an other set of dependent variables. Additional variables, were the antibiotic of choice but no correlation with other variables was provided for this set of data. The most relevant elements of strength in the paper were in the experimental design and in the exposure of the content at any level. This relatively simple study was very focused and straightforward. It addressed a very specific hypothesis, i.e. does the implementation of the SURPASS checklist optimizes timing of antibiotic prophylaxis? The main point of the paper is clearly indicated in the title and well presented in the schematic abstract. The introduction, albeit not fully updated, introduces the relevance and purpose of the work and provides all the elements to fully understand the results. The latter are presented in a linear and smoothly readable way, with the help of tables and flowcharts that allow to follow the most complex parts and strategies underlying the study. The data supporting the conclusion (i.e. that the implemented checklist optimizes the timing of antibiotic administration) are clearly isolated and presented in the figures. Finally, a major strength of this study is the size of the sampled population (hundreds of patients for each cohort), which in fact allowed to attain statistically significant differences in spite of big standard deviations. Some important data subsets, such as Figure 2 right graph (“Proportion of patients receiving AP after incision”), were intrinsically subjected to the risk of very wide sampling errors, since the difference between the two mean values was just 5 minutes. Thus, it was very important to deal with several hundreds records in order to clearly show that the incidence of a risky practice, such as delaying the AP intervention, was significantly diminished (p = 0.04). The paper had weaknesses in data analysis. The main criticism is to the way data are presented in Figures 2 and 3. Albeit simple, both figures had no legends. In particular, non reference was done to the statistical analysis utilized and to the meaning of the p value, and the variables were not clearly indicated. The mean values of the different data groups were shown, as mentioned in the text, but no standard error or standard deviation were shown in the graph. The latter is reported in parentheses in the text (“Results” section) and appear to be very large in comparison to the corresponding means, e.g. 23,9 ± 37.1 min for interval before implementation, in spite of the calculated statistically significant difference between means. Showing the standard deviation, which is representative of the variability of the sampled population, would have been very important to give an idea of the heterogeneity of the cohort. Awareness of this element is important for everyday practice. An other pitfall is possibly the absence of analysis of some data that could have been exploited proficiently. As reported in table 1, the study involved a great number of patients, a percentage of which were not actually treated with antibiotics, thus becoming ineligible for the analysis on checklist effects on antibiotic treatment. The authors remark that this percentage was the same between the pre-intervetion and the post-intervention cohorts (10,4% and 11,2%, respectively); however, they do not further discuss the data. More importantly they do not extend the analysis of SSI frequency to these patients, who would have represented a very interesting inner control on the effects of prophylactic antibiotic treatment. While a beneficial effect of prophylaxis being expected, it is an essential prerequisite that antibiotics have an effect on SSI at all, since one wants to study an additional effect (the checklist implementation) on this phenomenon. This inner control is expected to show that, regardless the cohort considered, the absence of antibiotic treatment increases to an equal extent SSI risk, thus demonstrating the absence of other additional interferences in the PI checklist cohort on the main measured output. Finally, the References were poorly updated, with only two cited works from 2009 among the most recent, one of which being a self citation. Discussion Prophylactic antibiotic premedication, the practice of prescribing limited antibiotic therapy to patients who are at risk of contracting microbial disease as a result of invasive procedures, is a pivotal issue in nursing practice. This practice contributes to lower the incidence of post-surgery morbidity and mortality. Patient management is a multidisciplinary, multitask effort, which involves nurses and often requires the interaction of multiple teams. Guidelines and standardizations are of pivotal importance in favoring 100% compliance with patients' needs in this multitask context. Guidelines are constantly implemented in the effort to improve performance on the AP related core measures (Olin, 2006). To this regard, the paper that I analyzed in my study presents evidence-based research on the beneficial effects of one of these implementations aimed to optimize AP timing (de Vries et al., 2010). In particular, the effects of implementation a recently validated checklist (de Vries et al., 2009) on AP timing are discussed. Continual staff education is necessary to help gain understanding of the new, updated procedures. Since timing is the central issue when dealing with AP, even more than the specific type of antibiotic used, any study aimed to optimizing timing is very important. Thus, I find the paper by de Vries and co-workers very important to nursing practice. In spite of a few elements of weakness, the paper by de Vries and co-workers is conclusive, since its strengths definitely outweigh these elements. In fact the weaknesses are more omissions than real mistakes, as expected for a peer-reviewed article. As discussed above, more in-depth data analysis and a more formal data presentation (e.g. including SD in figures) would have been of great interest, but the data are sufficient to demonstrate the main point of the paper. The major support to the conclusion comes from the significant size of the patient cohorts analyzed in the paper and from the statistical analysis performed on these populations. This makes the conclusion straightforward and solid. The conclusion is clearly evidenced in the title and sufficiently introduced and discussed. As a general remark, this paper addresses very clearly the point with a scholar style, nonetheless accessible to practicing nurses. In conclusion, the paper by de Vries et al. (2010) contributes to evidence guiding nursing practice in the very delicate issue of AP timing. References Bucher, B.T., Warner, B.W., & Dillon PA. (2011). Antibiotic prophylaxis and the prevention of surgical site infection. Current Opinion Pediatrics, 2011 Apr 13. [Epub ahead of print] Beckmann, A., Doebler, K., Schaefer, E., Koetting, J., Gastmeier, P. & Graf, K. (2011). Sternal surgical site infection prevention - is there any room for improvement? European Journal Cardiothoracic Surgery. 2011 Jan 28. [Epub ahead of print] de Vries , E.N., Hollmann, M.W., Smorenburg, S.M., Gouma, D.J. & Boermeester, M.A. (2009). Development and validation of the SURgical PAtient Safety System (SURPASS) checklist. Quality & Safety in Health Care, 18, 121-6. de Vries, E.N., Dijkstra, L., Smorenburg, S.M., Meijer, R.P. & Boermeester, M.A. (2010). The SURgical PAtient Safety System (SURPASS) checklist optimizes timing of antibiotic prophylaxis. Patient Safety in Surgery, 4, 6. Gagliardi, A.R., Fenech, D., Eskicioglu, C., Nathens, A.B. & McLeod, R. (2009). Factors influencing antibiotic prophylaxis for surgical site infection prevention in general surgery: a review of the literature. Canadian Journal of Surgery, 52, 481-9. Gupta, A., Hote, M.P., Choudhury, M., Kapil, A. & Bisoi A.K. (2010). Comparison of 48 h and 72 h of prophylactic antibiotic therapy in adult cardiac surgery: a randomized double blind controlled trial. Journal of Antimicrobial Chemotherapy, 65, 1036-41. Olin, J.L. (2006). Multidisciplinary approach to optimizing antibiotic prophylaxis of surgical-site infections. American Journal of Health System Pharmacy, 63, 2312-4. Read More