What is new on surgical site infection prevention Barriers to implementing good antibiotic prophylaxis and how to overcome them. P.

Transcription

1 What is new on surgical site infection prevention Barriers to implementing good antibiotic prophylaxis and how to overcome them P. Gastmeier Conflict of interest: none to disclose

2 Antimicrobial prophylaxis is justified for most cleancontaminated procedures -> Probable the most powerful measure to prevent surgical site infections (SSI)

3 Bratzler et al. Am J Health Pharm 2013; 70: Ideally, an antimicrobial agent for surgical prophylaxis should (1) prevent SSI, (2) prevent SSI-related morbidity and mortality, (3) reduce the duration and cost of health care, (4) produce no adverse effects, and (5) have no adverse consequences for the microbial flora of the patient or the hospital.

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5 Perioperative prophylaxis usage rate (%) in German hospitals Procedure type Procedures Utilization rate (%) Sectio Caesarea Hysterectomy Endoprothesis (femur fracture) Osteosynthesis (femur fracture) Endoprothesis (hip arthrosis) Endoprothesis (knee arthrosis) Data from the AQUA institute for quality assurance, Report from 2012

6 Objectives of implementing good antibiotic prophylaxis 1. To reduce surgical site infections (SSI) 2. To prevent collateral damage (increase of antibiotic resistance and C. difficile infections)

7 Objectives of implementing good antibiotic prophylaxis 1. To reduce surgical site infections (SSI)

8 ECDC Tender June 2013 ECDC. Systematic review and evidence-based guidance on PAP. Stockholm: ECDC; J. Zweigner, E. Meyer (Charité) A. Magiorakos (ECDC)

9 Objective of the tender 1) to identify the effectiveness of key modalities of PAP from a systematic review 2) to develop 5 key PAP modalities and process indicators for monitoring their implementation on the basis of scientific evidence and expert opinion.

10 Questions addressed Is the appropriate use of PAP associated with a decrease in the incidence of SSI? What are the factors that contribute to increased adherence by health care professionals to adequate PAP? What are the obstacles that prevent the implementation of adequate PAP? Does timing, dosage or duration of PAP have an influence on the incidence of SSIs? Does PAP have an impact on the incidence of C.difficile infection (CDI) and the development of antimicrobial resistance?

11 Literature search ECDC. Systematic review and evidence-based guidance on PAP. Stockholm: ECDC; 2013.

12 Distribution of study designs contributing evidence Distribution of study designs n % Non-controlled before/after studies (Non-CBAs) Observational cohort studies Systematic reviews/meta-analyses Randomized controlled trials (RCTs) Interrupted time series (ITS) Controlled before/after studies (CBAs) Questionnaire Only a small number of studies have been published with high quality of evidence according to the criteria developed by the EPOC Review Group and the GRADE group - The majority of the included studies revealed moderate to low quality of evidence.

13 Conclusions: The methodology and reporting of quality improvement studies on PAP is suboptimal, and factors that would improve generalizability of successful intervention implementation are infrequently reported. Clinicians should use caution in applying the results of these studies to their general practice Levy et al. J Am Coll Surg 2013, 217:770-79

14 An expert panel was established + J. Zweigner, E. Meyer, P. Gastmeier, A. Magiorakos

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16 1st expert meeting the systematic review was presented the experts were asked to comment

17 PAP modalities as outlined at the first meeting based on the systematic review

18 ECDC. Systematic review and evidence-based guidance on PAP. Stockholm: ECDC; 2013.

19 2nd expert meeting experts agreed to re-score the 10 modalities by evaluating the quality and strength of evidence and implement ability before the second meeting

20 ECDC. Systematic review and evidence-based guidance on PAP. Stockholm: ECDC; 2013.

21 Five key measures: 1. Hospitals should establish a multidisciplinary antimicrobial management (AM) team 2. PAP should be the responsibility of the anaesthesiologist to ensure appropriate timing 3. PAP should be administered within 60 minutes before incision 4. PAP should be given as single dose 5. PAP should be stopped after the end of surgery

22 3rd expert meeting to develop indicators for monitoring the five key PAP modalities to identify barriers for implementation

23 ECDC. Systematic review and evidence-based guidance on PAP. Stockholm: ECDC; 2013.

24 Checklist for indicator 1 ECDC. Systematic review and evidence-based guidance on PAP. Stockholm: ECDC; 2013.

25 ECDC. Systematic review and evidence-based guidance on PAP. Stockholm: ECDC; 2013.

26 ECDC. Systematic review and evidence-based guidance on PAP. Stockholm: ECDC; 2013.

27 ECDC. Systematic review and evidence-based guidance on PAP. Stockholm: ECDC; 2013.

28 Example for hospital A Colorectal surgery Hip replacement Sectio cesarea Total numbers of surgical procedures /year (n) Procedures checked : n (% of total number 160 (7.2 %) 120 (12 %) 50 (10 %) of surgical procedures per type of surgery) Compliance n (%) n (%) n (%) Indicator 1 (AM team) Indicator 2 (Anesthesiologist applied PAP) 160 (100%) 90 (75%) 50 (100%) Indicator 3 (Application within 60 minutes) 150 (93.8%) 95 (79.2%) 45 (90%) Indicator 4 PAP applied/pap indicated? Selection of PAP according to local guidelines Single dosage of PAP applied when indicated Second dosage of PAP applied when indicated 160/160 (100%) 130 (81.3%) 140/160 (87.5%) 15/20 (75%) 100/120 (83.3%) 10/20 (50%) 80 (66.7%) 10/10 (100%) 50/50 (100%) 47 (94%) 42/50 (84%) 0/0 (0%) Indicator 5 (PAP stopped within 24 hours) 80 (50%) 40 (30%) 46 (92%)

29 The German society for surgery is meanwhile also recommending these 5 key modalities and the indicators

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31 Barriers for implementation

32 A web based survey was distributed to 147 surgeons at Toronto hospitals, 60 % responded. Eskicioglu et al. Can J Surg 2012; 55 :233-38

33 Eskicioglu et al. Can J Surg 2012; 55 :233-38

34 Eskicioglu et al. Can J Surg 2012; 55 :233-38

35 Method to determine barriers for EU wide applicability and implementation of PAP a literature review was done agreement to distinguish barriers according to barriers for professionals, teams/interaction, organisation and structures listing of the most important barriers discussion about understanding of barriers behind the different cultural and socio-economical background in various countries rephrasing of barriers on the list invitation to score them

36 Scoring of barriers 1,2 = no real barrier, not applicable 3,4 = potential barrier 5,6 = major barrier Agreement of experts: > 6/10 experts voted for the same grade or higher Strong agreement: > 8/10 experts voted for the same grade or higher

37 Experts consensus for each barrier ECDC. Systematic review and evidence-based guidance on PAP. Stockholm: ECDC; 2013.

38 Number of barriers per modality Modality 1 Modality 2 Modality 3 Modality 4 Modality 5 potential barriers Major barriers

39 Objectives of implementing good antibiotic prophylaxis 1. To reduce surgical site infections (SSI) 2. To prevent collateral damage (increase of antibiotic resistance and C. difficile infections)

40 Carignan et al. ClD 2008 ; 46:

41 RESULTS A total of 8,373 surgical procedures were performed, and PAP was used in 7,600 of these interventions. Of 98 CDI episodes identified, 40 occurred after patients received PAP only (1.5%). CONCLUSIONS In situations in which the only purpose of PAP is to prevent infrequent and relatively benign infections, the risks may outweigh the benefits in some elderly patients. Carignan et al. ClD 2008 ; 46:

42 publications/healthcareassociated-infectionsantimicrobial-use-pps.pdf.

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44 ECDC PPS 2011/12 Surgical prophylaxis given for more than 1 day as a percentage of the total antimicrobials prescribed for surgical prophylaxis, by country

45 ECDC PPS 2011/12 Calculation for Germany: About 15 % of overall antibiotic usage could be saved if prolonged antibiotic prophylaxis would be totally stopped

46 Hansen et al. ECCMID Berlin 2013

47 PROHIBIT Questionnaire 2011/2012

48 Data from 541 surgical wards in Europe n % How is the antimicrobial prophylaxis administered? Single dose Repeated administration after 4 hours in long operations Continuous administration after the operation on the ward WP3: Charité Berlin in collaboration with UKL-Fr, UniGE, Imperial, NCE, ECDC Hansen et al. ECCMID Berlin 2013

49 Uncertainty avoidance (UA) is described in Geert Hofstede s model of cultural dimensions as a construct estimating the extent to which a society tolerates uncertainty and ambiguity Such cultures often try to counteract the unease created by situations of uncertainty through the adoption of dogmatic and excessive measures, even where there is no evidence of cost-effectiveness or risk attenuation.

50 Borg JAC 2013

51 Belgium A new refund system for PAP was introduced by Royal Decree in 1997 leading to sustained improvement. Pearson correlation analysis: A coefficient of 0.50 (CI ) Borg JAC 2013

52 Belgium When the regression model was repeated without the Belgian data, the model achieved a correlation coefficient of 0.34, p= > a third of the variation in PAP >24 h in Europe can be predicted from the national cultural dimension of UA Conclusion: Any strategy should be informed by clear knowledge of local socio-cultural barriers Borg JAC 2013

53 SCIP performance measures are collected by >3700 hospitals submitting abstracted data on >1.2 million inpatient operations annually

54 Hawn et al. Ann Surg 2011; 254:

55 Overall SCIP Adherence and SSI rates SCIP indicator* Compliance (%) 1 PAP given within 60 min. before incision 2 Appropriate antibiotic selection 3 Discontinuation of PAP within 24 h after surgery Hawn et al. Ann Surg 2011; 254: SSI rate (%) * Five types of surgical procedures: Cardiac, hip or knee arthroplasty, colorectal, arterial vascular, hysterectomy

56 Hawn et al. Ann Surg 2011; 254:

57 Hawn et al. Ann Surg 2011; 254:

58 Hawn et al. Ann Surg 2011; 254:

59 Conclusion: Adherence to SCIP measures improved whereas risk-adjusted SSI rates remained stable. SCIP adherence was neither associated with a lower SSI rate at the patient level, nor associated with hospital SSI rates. Policies regarding continued SCIP measurement and reporting should be reassessed. Hawn et al. Ann Surg 2011; 254:

60 Starting in 2011, SCIP compliance affects Medicare and Medicaid reimbursement rates. Question: Although SCIP reinforces better practices in surgical care, does compliance with SCIP measures actually result in a decrease in surgical morbidity and mortality? Garcia et al. The American Surgeon 2012; 78:

61 Conclusion: These data suggest that SCIP compliance process measures should not be used to determine CMS reimbursement rates because there is no correlation between failure of SCIP INF1 and SSI. Garcia et al. The American Surgeon 2012; 78:

62 Conclusion The reduction of inadequately administered antibiotics has become a priority due to ecological and economic impact on public health. In order to promote adequate use of PAP, hospitals should adopt key recommendations of administration of PAP, as well as indicators with which to monitor them. To become effective, multidisciplinary collaboration and infrastructure and support by the hospital administration are necessary. Barriers to implementation should be addressed, analyzed and overcome by local, national or EU-wide strategies.

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64 The choice of antibiotic used for prophylaxis has generated confusion. The acceptable PAP for transrectal prostate biopsies were listed as a quinolone OR aminoglycoside + metronidazole (in the case of quinolone allergy) However, institutional microbiology data revealed a high rate of resistance to quinolones among E.coli. Weston et al. CID 2013; 56:424-27

65 Explanation of the development, implementation and maintenance of national performance indicators It is likely that revisions to national performance measure specifications based on new medical science or unforeseen clinical scenarios in practice will continue to occur. Bratzler CID 2013; 56: