Surgical antibiotic prophylaxis at Epworth Healthcare Dr Joseph Doyle MPH PhD FRACP Infectious Diseases Physician Epworth, Alfred Health & Melbourne Health Senior Lecturer & NHMRC Clinical Research Fellow, University of Melbourne 1
Disclosures Research funding (for virology projects not related to this presentation) from Gilead Sciences, Bristol Meyers-Squibb, Abbvie Pharmaceuticals 2
Surgical antibiotic prophylaxis at Epworth Healthcare 1. Overview of antimicrobial monitoring 2. National and local prophylaxis data 3. Potential strategies for improvement 3
Monitoring SAP at Epworth 1. Routine monitoring Victorian Nosocomial Infection Surveillance System (VICNISS) - Mandatory reporting by public hospital - Monitors a subset of surgical procedures: - Hip replacement, knee replacement, coronary artery bypass grafts - Collects data on - antibiotic choice, duration, timing - Administered by the Infection Control Practitioners (ICPs) 4
Monitoring SAP at Epworth 1. Routine monitoring Antimicrobial Stewardship Service - Data on all antimicrobials dispensed is recorded daily by Slade - Routine antimicrobials administered in theatre from ward supply (eg cephazolin) is not captured at the patient level routinely - Commenced post-prescription review in 2015, but generally does not capture very short surgical prophylaxis 5
Monitoring SAP at Epworth 1. Routine monitoring Antimicrobial Stewardship Service - Pharmacist led review of the charts of current patients prescribed a range of monitored antimicrobials, and/or have developed significant organisms on microbiology - Patients already referred for Infectious Diseases consultation are noted, but not included for further review - Prescriptions are triaged for review by AMS consultant on weekly rounds at the acute divisions - Recommendations to optimise therapy are made in the notes 6
Monitoring SAP at Epworth 1. Routine monitoring Antimicrobial Stewardship Service Recommendations made for patients admitted under a surgical specialty include: - Discontinue prolonged post-operative SAP - Review dosage for impaired renal clearance, or obesity - Consider switch to oral therapy - Refer for ID consultation (bacteraemia, deep infection) - Recommendations for alternatives during drug-supply interruptions 7
Monitoring SAP at Epworth 2. Periodic auditing - June 2014 Baseline surgical antibiotic prophylaxis audit - November 2014 National Antimicrobial Prescribing Survey (NAPS) - May 2015 Surgical National Antimicrobial Prescribing Survey (snaps) 8
Baseline SAP audit: June 2014 Chart review of current inpatients across Richmond, Eastern, Freemasons, Cliveden - Any procedures that result in an overnight stay - At a single point in time 9
Baseline SAP audit: June 2014 - Most patients received 1 antibiotic peri-procedure - 311 patients, 403 prescriptions to assess 10
Questions? 11
NAPS audit: November 2014 - Point prevalence study - Reviewed prescribing across all antimicrobials, for both treatment and prophylaxis - 280 patients were reviewed - Appropriateness assessed against Therapeutic Guidelines - Results benchmarked against comparator hospitals across Australia 12
Surgical NAPS (snaps) May 2015 - Survey to gather more detailed data on SAP than is currently collected by VICNISS - Retrospective review of documentation - Includes review of any post-operative SAP prescribed - Collects data on 30-day outcomes where available to reviewers - To be compared to benchmarks in the same format as the NAPS 13
Surgical NAPS (snaps): May 2015 - Pilot review of procedures across Epworth - 91 Patients at Epworth - snaps total: 11 institutions, 668 patients - 519 elective procedures - 142 emergency procedures 14
Surgical NAPS (snaps): May 2015 - Total procedures by specialty Epworth (left) v National (right) 15
Surgical NAPS (snaps): May 2015 - Drug selection Epworth (left) v National (right) 16
Data limitations - Limited by documentation in medical records in all hospitals - Doses, timing of administration, clinical information - Some difference between public and private documentation? - Fewer updates in progress notes to determine indication - Drug charts allow simple dispense on discharge - Small numbers - More robust assessment will develop over time with repeated samples 17
Quality improvements - Need to be system based - Recognise aim of SAP is to prevent surgical site infections - Acknowledge that overuse of SAP could lead to complicaitons without reducing surgical site infections - Examples underway - Simplifying medication supply in theatre to correct dosing (ie change from cephazolin 1g vial to 2g vial) 18