Antibacterial Prophylaxis - Essay Example

Antibacterial Prophylaxis Introduction: Antibacterial prophylaxis has become a well-established practice in present day surgical procedures, as a means to prevent postoperative infections in the patients. The use of antibacterial prophylaxis in preventing post-operative infections owes its origin to the important clinical trials conducted by Condon, Nichols, and Gorbach, sponsored by the Department of Veteran Affairs Cooperative studies, in the early 1970s. These trials clearly demonstrated the benefit of antibacterial prophylaxis in place of a placebo in reducing the rate of postoperative superficial and deep surgical site infections. Supportive evidence came from a meta-analysis of twenty-six trials over a period of more than fifteen years done by Baum et al, which concluded that antibiotic prophylaxis was an efficient means of reducing postoperative surgical site infections, and was so significant as to no longer justify the use of placebos in such trials. This led to reduced clinical research in this are till about a decade ago. In recent studies that have gone into antibiotic prophylaxis in certain specific surgical procedures like colorectal surgery the findings have led to the practice of antibiotic prophylaxis to prevent postoperative superficial and deep surgical site infections being challenged. These challenges arise from two factors. New data has led to the identification of specific predictors of postoperative in certain specific surgical procedures like colorectal surgery that calls for modifications in the antibiotic prophylaxis in selected patients. The second factor is that there are indications from data compiled that the postoperative infection rate may be higher by nearly a hundred percent, when independent surgeon-trained observers are used for detecting postoperative infection rate, calling for better observation of the benefits of antibacterial prophylaxis in surgical procedures. (Jimenez, C.J., & Wilson, E.S., 2003). Literature Review: According to the United States Centers for Disease Control and Prevention (CDC), approximately five hundred thousand surgical site infections (SSIs) occur every year in the United States of America. SSIs are considered among the highest common causes for nosocomial infections. While two to five percent of patients that undergo clean extra abdominal operations develop SSI, nearly twenty percent of the patients undergoing intraabdominal surgical procedures develop SSI. Patients with SSI have a sixty percent chance of spending more time in intensive care units, and five times more probability of the requirement for readmission. The mortality rate of patients with SSI is twice as high as patients without SSI. Health care costs are significantly higher for patients with SSI. Many guidelines for the use of antibacterial prophylaxis in preventing SSI have been issued, and still there are inconsistencies and significant issues still remain to be addressed. Areas that need to be concentrated on include timing of the first dose of antibacterial therapy, duration of antibacterial prophylaxis, screening for beta-lactamase allergy, antibacterial choice for beta-lactamase allergy, methicillin-resistant Staphylococcus aureus (MRSA), limitation of additional agents, anti-bacterial dosing, and non-antibacterial means of preventing infection. Many antibacterial prophylactic regimes are available, yet it is important that the right choice is made not just in preventing SSI, but also in preventing the development of resistance, especially to front-line antibacterial agents. The use of older anti-bacterial agents with a relatively narrow spectrum of activity is supported by many factors that include cost, half-life, safety, and antibacterial resistance. Newly developed broad-spectrum antibacterial agents that form the front line therapeutic agents against bacteria should not be used as far as possible, to reduce the chances of the emergence of bacterial strains resistant to these antibacterial agents. Depending on the kind of surgical procedure and the time that the surgical procedure requires the choice of the antibacterial agent is to be varied. In the case of beta-lactamase allergy alternative antibacterial agents are available and need to be used. (Bratzler, W.D., & Houck, M.P., 2004). Phan et al (1992) compared the combined antibacterial agents sulbactam-ampicillin with clindamycin-amikacin in 99 cancer patients over a period of two and a half years that underwent major head and neck surgery. Four doses of three grams of ampicillin and one and a half grams of sulbactam were given intravenously (iv) every six hours in comparison to four doses of clindamycin 600 mg iv every six hours and two doses of amikacin 500 mg iv every 12 hours starting from the time of induction of anesthesia as the prophylactic means. The study found a slightly higher rate of SSI with the sulbactam-ampicillin group in comparison to the clindamycin-amikacin group, but without any significant difference. However, the more striking feature of the study was the findings on comparing its findings with previous studies, wherein it was found that there was a decreased efficiency in antibacterial prophylaxis in patients with cancer undergoing head and neck surgery. Evaluating these results the authors have suggested that there are two factors that have caused the reduced efficiency of antibacterial prophylaxis. In their opinion the extensive excision and plastic reconstruction in patients with stage III and IV cancers, and the extended duration of the surgical procedures were the likely causes for the reduced efficiency of antibacterial prophylaxis. The authors have also suggested future strategies in such surgeries to increase the efficiency of antibacterial prophylaxis. These include more prolonged prophylaxis to take into consideration the extended duration of the surgical procedures, potential use of selective digestive decontamination to prevent bronchopneumonia, use of topical antibacterial agents to lower the bacterial contamination, and a fresh look and the preventive measures in the operating rooms. These future strategies need to be evaluated to provide for more effective antibacterial prophylaxis in these surgical procedures and may throw light on the possible means of increase the efficiency of antibacterial prophylaxis in other surgical procedures, especially of long duration and extensive excision. (Phan, et al., 1992). Kriaras et al in study examined the evolution of antibacterial prophylaxis in major cardiovascular surgeries over a period of fifteen years to arrive at the optimal duration of antibacterial prophylaxis in major cardiovascular surgeries. This examination took into account four randomized controlled research studies that evaluated seven prophylactic antibacterial regimens in 2970 patients that underwent major cardiovascular surgeries. In the first study in 1980/1981 a four-day cefazolin antibacterial prophylaxis was contrasted with a two-day cefuroxime antibacterial prophylaxis. In the second study in 1982/1983 a two-day cefuroxime prophylactic administration was compared with the use of a two shot ceftriaxone as the prophylactic agent. In the 1984/1987 study the use of a single day administration of cefuroxime as the prophylactic agent was compared with a single injection of ceftriaxone. In the 1994/1995 study a combination of amoxicillin and netilmicin over a period of four days as the prophylactic agent was compared with a single shot of cefuroxime as the prophylactic agent. It was found that despite the disparate antibacterial prophylactic agents, regimes and different durations used, the total infection rate carried between 4.5% and 5.7%. The wound infection range was 0.4% to 2.5%, sepsis range was 0.4% to 1.6%, pneumonia range was 0.7 % to 2.9%, urinary tract infection range was 0 to 1.4%, and the central venous catheter-related infection range was 0 to 1%. Mortality range for the thirty-day period was 0.4 to 2%. None of these ranges demonstrate any statistical significance. On the basis of these findings the authors concluded that a low infection rate in the range of 4.5% to 5.7% persisted in spite of the changes in the duration of the different antibacterial prophylaxis regimens employed with cephalosporins of the first, second and third generations. In short the duration of the antibacterial prophylaxis had no significant impact in lowering the rate of infection in major cardiovascular surgery. The authors also recommended that with a single shot prophylaxis being successfully employed in major cardiovascular surgery the use of postoperative antibiotics was to be discouraged, unless an intra-operative or postoperative infection is established, or when there are major perioperative complications. (Kriaras, et al., 2000). Vancomycin is the preferred antibacterial therapeutic agent against MRSA. Staphylococcus has the possibility of developing resistance to vancomycin. Resistance to vancomycin has been seen in the case of vancomycin-resistant enterococci (VRE). The use of vancomycin as an antibacterial prophylactic agent has been discouraged, because of the possible increased development of vancomycin resistant bacterial organisms, through restrictive guidelines. However, its potential use as a prophylactic agent to combat MRSA caused Zanetti et al (2001) to study vancomycin as a prophylactic agent in coronary artery bypass graft surgeries. The authors employed decision analytic models to compare the clinical results and cost effectiveness no antibacterial prophylaxis, antibacterial prophylaxis using cefazolin, and antibacterial prophylaxis using vancomycin in coronary artery bypass graft (CABG) surgeries The strategy of employing no prophylaxis in CABG surgeries proved to be more expensive and less effective. The use of cefazolin for antibacterial prophylaxis reserving vancomycin for antibacterial prophylaxis only for patients that had a history of beta lactamase allergy proved to be less effective and more costly than the use of vancomycin as a antibacterial prophylactic agent in CABG surgeries. In the base case the use of vancomycin for antibacterial prophylaxis led to seven percent less SSIs and one percent reduction in the all-cause mortality rate, when compared to cefazolin. In addition there was a cost saving of $117 per procedure through the use of vancomycin when compared to cefazolin in CABG surgeries. In the United States of America every year nearly 366,000 CABG surgical procedures are performed. Using these figures and the data currently available the use of vancomycin as the routine prophylactic agent for CANG surgical procedures would provide better clinical outcomes by preventing one hundred and ten deaths, and 3,184 SSIs in comparison to the routine use of cefazolin as the antibacterial prophylactic agent. In addition vancomycin would lead to a saving of $43 million in costs all over the country. Vancomycin has the benefit that VRE infections are rare in the case of CABG surgeries and that adds to the its efficiency, however the authors acknowledge that these efficiency figures would reduce, if MRSA develops resistance to vancomycin. (Zanetti et al., 2001). For the prevention of post-surgical infections as a result of urologic surgery and endourologic procedures, the usual means is through the use of antibiotic prophylaxis. Antibiotic prophylaxis is not only employed for at risk patients for local or systemic risk factors including age, immunological status, metabolic disorders and poor general condition, or with a positive urine culture, but also in patients with sterile urine. Gram-negative bacteria form the common group of pathogens that pose a risk for infection in urological surgeries, and as quinolone is the reasonable choice as the antibiotic prophylactic agent. Preziosa et al compared the effectiveness of ciprofloxacin, levofloxacin, and prulifloxacin as antibacterial prophylactic agents in urologic surgical procedures. The dosage used was ciprofloxacin 500 mg, levofloxacin 500 mg, and prulifloxacin 600 mg. The average urinary tract infection rate fifteen days after the urological surgery procedures was 8.4%, with patients that were given ciprofloxacin prophylaxis showed an incidence of 9.1% urinary tract infections, while incidence with levofloxacin prophylaxis was 11.1%, and with prulifloxacin prophylaxis the incidence rate of urinary tract infection was jus 5.5 percent. In addition to this strength of prulifloxacin, patient compliance was good, and it has a broad spectrum of activity, with favorable pharmacokinetics properties. These findings led the authors to conclude that prulifloxacin could be considered as a suitable prophylactic agent in the prevention of infections in urology surgical procedures. (Preziosa et al, 2006). Current Knowledge on Antibacterial Prophylaxis in Surgery: Antibacterial prophylaxis has become an effective tool in combating infections that result from surgeries. Studies have indicated that the antibacterial prophylactic agent and the duration for which antibacterial prophylaxis is provided have limited significance in the efficiency levels of the antibacterial prophylaxis. In recent times there has been a reduction in the efficiency demonstrated by antibacterial prophylaxis in preventing post surgical infections. Dramatic advances in medical equipments and surgical techniques have seen surgical procedures becoming more common as a medical intervention strategy. In addition many of these advanced surgical procedures lead to longer durations in the surgical procedure and extensive incisions. These factors are considered as possible reasons for the decrease in efficiency. Surgical procedures are use as medical intervention strategies on almost every part of the body and there are a number of different surgical procedures. Choosing the antibacterial prophylactic agent now assumes greater importance as the infection risk factors need to be taken into account depending on the type of surgical procedure, the site of surgery and the duration of the surgery. In some surgical procedures like implants it may not be advisable to use antibacterial prophylaxis at all. Resistance to antibacterial therapeutic agents is a growing menace, and this calls for prudent use of antibacterial therapeutic agents in antibacterial prophylaxis in surgical procedures. On one side the possible type of bacterial risk needs to be considered and on the other side conserving frontline antibacterial therapeutic agents needs to be done. Overexposure of frontline antibacterial therapeutic agents through antibacterial prophylaxis in surgery could render powerful weapons in fighting diseases useless. Further studies are needed to establish whether the cost of withholding frontline antibacterial therapeutic agents from antibacterial prophylaxis in terms of the patients undergoing surgical, procedures is worth the relevance of these therapeutic agent to society as a whole. Antibacterial Prophylaxis Policy: An antibacterial prophylaxis policy is a necessity in the healthcare environment, and it needs to take into consideration the knowledge that is available. The policy would first take into consideration the kinds of surgical procedures being undertaken in the healthcare environment and from that draw up the list of antibacterial prophylactic agents that would be utilized in the different surgical procedures and make them available. In considering the choice of antibacterial prophylactic agents to be used the cost to the establishment is to be considered. The prophylactic agent, the dosage of the prophylactic agent, timing for initiating the prophylaxis as well as the duration of the prophylaxis would be apart of the policy and it would also call for proper documentation of the prophylaxis given, which would move with the patient, as the patient moves into post operative care. Proper documentation of the SSIs would be required in the policy so as to monitor the use of prophylaxis in surgical procedures. The policy would call for review the prophylaxis policy on a regular basis and the documentation of the SSIs would be an important document in that review to enable assessment of the antibacterial prophylactic strategies being employed and their efficiency. Changes would be incorporated in the policy to enhance the efficiency of antibacterial prophylaxis. Knowledgeable and skilled staffs constitute the backbone of any successful endeavor and the policy would include provision for knowledge inputs to the concerned staffs and regular updating of it. Multi-disciplinary and multi-department interaction would be encouraged through the policy so that experience in one discipline or department is available to the others to increase the efficiency of the antibacterial prophylaxis. Strategic Plan: Change is inevitable, but it is the most difficult objective to achieve, because of the inbuilt fear that change in working systems could lead to inability to cope with it. In ‘The Prince’ Machiavelli says, “There is nothing more difficult to plan, more doubtful of success, nor more dangerous to manage than the creation of a new system”. This is the essence of the difficulty with change. Yet, the absence of change causes institutions and individuals to develop complacence and staleness. Identifying the changed work system parameters that are required would be the first step of the strategy. This would mean identifying the current state of the antibacterial prophylaxis methods employed and the changes that would be required to reach the objective of a more efficient antibacterial prophylaxis strategy. The nest step would be to make this aware to the administration and the stakeholders and ensure their cooperation. The next step would be to make the change requirements known to those concerned with the antibacterial prophylaxis. In this process the undesirability off the present antibacterial prophylactic status and the desirability of the changed antibacterial prophylactic strategy would also be made known. Through consultations and information sessions at the department levels, as well as at inter department levels, and multi-disciplinary levels cooperation for the changed antibacterial prophylactic strategy would be got and then implemented. Finally a monitoring mechanism to ensure implementation and also to assess the efficiency of the new work system would be put into place and done on a frequent and regular basis. Annotated Bibliography Bratzler, W.D., & Houck, M.P. (2004). Antimicrobial Prophylaxis for Surgery: An Advisory Statement from the National Surgical Infection Prevention Project. CID, 38, 1706-1715. In this study by Bratzler & Huck antimicrobial prophylaxis is evaluated along with the guidelines of the National Surgical Infection Prevention Project. Adequate concentration of the antibacterial agent should be present in the serum, tissue and wound during the full time the risk of bacterial contamination exists. The choice of the antibacterial agent depends on the possible type of bacterial risks and the particular type of surgical procedure. Additional care needs to be taken in the choice of the antibacterial agent, and these include safety of the patient, least possible impact on the normal bacterial flora of the patient, and economy of the hospital. Jimenez, C.J., & Wilson, E.S. (2003). Prophylaxis of Infection for Elective Colorectal Surgery. Retrieved October 1, 2006, from Surgical Infections, Medscape Today. Web site: http://www.medscape.com/viewarticle/462675. Kriaras, et al. (2000). Evolution of antimicrobial prophylaxis in cardiovascular surgery. European Journal of Cardio-Thoracic Surgery, 18, 440-446. Kriaris et al examined the different antibacterial prophylaxis regimens and durations employed in major cardiovascular surgeries over a period to find out the optimum duration for antibacterial prophylaxis. They found that there was insignificant variation in the reduction in infection rate with the different antibacterial prophylactic regimens and durations employed in the major cardiovascular surgeries. The authors have suggested that with the increased use of single shot antibacterial prophylactic agents for major cardiovascular surgeries there is no need for continuing the practice of postoperative antibiotic use, unless the preoperative, intra-operative, and post operative situation warranties it. Phan, et al. (1992). Antimicriobial Prophylaxis for Major Head and Neck Surgery in Cancer Patients: Sulbactam-Ampicillin versus Clindamycin-Amikacin. Antimicrobial Agents And Chemotherapy, 36(9), 2104-2019. Phan et al evaluated the efficiency of sulbactam-ampicillin with clindamycin-amikacin as antibacterial prophylactic agents in major head and neck surgery in cancer patients. They found clindamycin-amikacin to be slightly more effective than sulbactam-ampicillin, but with no significant value. They compared their results with that of previous studies and found that there was a significant drop in the efficiency of antibacterial prophylaxis in such surgical procedures. They have attributed this drop in efficiency of antibacterial prophylaxis to the extended duration of surgical procedures in present days, as well as the extensive excisions and plastic reconstruction involved in such surgical procedures. Preziosa et al (2006). Antibacterial prophylaxis in endourological procedures. Minerva urologica e nefrologica, 58(1), 73-80. Preziosa et al compared the efficacy of ciprofloxacin, levofloxacin, and prulifloxacin as antibacterial prophylactic agents in urologic surgical procedures and endourological procedures, They found that prulifloxacillin was the most effective in preventing urinary tract infection after fifteen days of the surgery. Prulifloxacillin has good patient compliance and broad spectrum of activity, with favorable pharmacokinetics properties. This led them to conclude that prulifloxacillin needs to be considered as the prophylactic agent for urology surgical procedures and endourological procedures. Zanetti et al. (2001). Clinical Consequences and Cost of Limiting Use of Vancomycin for Perioperative Prophylaxis: Example of Coronary Artery Bypass Surgery. Emerging Infectious Diseases, 7(5), 456-462. Zanetti et al compared the use of no prophylactic agent, cefozolin and vancomycin individually as prophylactic agents in CABG surgeries. They found that the use of a prophylactic agent was useful in reducing SSIs, in keeping with earlier studies. In addition they found that vancomycin was the more effective antibacterial prophylactic agent in reducing SSIs and mortality in CABG surgeries. In addition they also found that vancomycin proved to be more cost effective that the other two strategies. VRE is rare in the wound sites of CABG surgery patients and is one of the reasons for its efficacy. However this efficiency of vancomycin as an antibacterial prophylactic agent would reduce considerably in the event of MRSA developing resistance to vancomycin, through its use as a routine prophylactic agent. Read More