Abstract:
Introduction: Good surgical antimicrobial practices is of utmost importance to avoid exposing the patient unnecessarily to adverse effects of antibiotics, to prevent antimicrobial resistance, and to decrease hospitalization costs. Although well-established guidelines on surgical antimicrobial prophylaxis exist and there is not much debate on the principles of the prophylaxis, such as choosing a relatively narrow-spectrum antibiotic and cessation of its administration as soon as the surgery is over, we had the impression that adherence to guidelines is very low in making the decision to start prophylaxis, selecting the antibiotic, and setting the prophylaxis duration. Therefore we designed a study to reveal whether, or to which extent our impression is true.
Materials And Methods: In this cross-sectional, single-center study, the hospital records of 1,646 pediatric patients undergoing surgery between January 1, 2019 and December 31, 2019 were investigated in respect of adherence to current surgical antimicrobial prophylaxis guidelines.
Results: Sixty-four percent of the patients were male. The median of age was 7.7±5.8 years. Surgical wounds of the patients consisted of clean (68.6%), clean-contaminated (26.5%), and contaminated (4.9%) ones. Surgical procedures were mostly elective (70.5%). The most commonly used antibiotics were cefazolin (23.4%), ceftriaxone (14.2%), and amoxicillin-clavulanate (10.4%). Although prophylaxis was indicated in 70.6% of the cases, antibiotics for this purpose were administered to 59.9% of the patients. Selected antibiotics and their dosage was not appropriate in 80.4% and 90.0% of those patients receiving prophylactic antibiotics, respectively. In 68.2% of the patients, prophylactic antibiotic administration was extended well beyond surgical operation although guidelines suggest against this practice. Cefotaxime, ceftriaxone, and ampicilline-sulbactam were erroneous selections in 98.0%, 90.3%, and 71.4% of the cases, respectively. Amoxicillin-clavulanate, ampicillin, gentamicin, metronidazole, trimethoprim-sulfamethoxazole, and ciprofloxacin were chosen incorrectly in all cases. Cefazolin was ordered in 323 cases, 28.5% of them being incompatible with the guidelines. The dosage was wrong in all cases in which gentamicin, meropenem, trimethoprim-sulfamethoxazole, clindamycin, or ciprofloxacin was used for prophylaxis. Antibiotics, when ordered out of indication, tend to be given in a wrong dosage, compared to those ordered in line with guideline suggestions (P<0.001). Unnecessary costs regarding irrational antibiotic use alone amounted to approximately $7,000 per year.
Discussion: There are relatively few studies investigating surgical antimicrobial prophylaxis practices in children with the adherence to guidelines. To the best of our knowledge, our study is the first of its kind revealing the outlook of this neglected field of irrational antibiotic use in Turkey. Although carried out in a single center, we think that the study has a value as a reflection of the big picture in Turkish and global healthcare. Programs of decreasing antibiotic consumption focus on therapeutic antibiotic prescription ignoring the immense irrational antibiotic usage field of surgical antimicrobial prophylaxis in hospitals.
Conclusion: Surgeons making the decision to start antibiotics for prophylactic purposes to children should be kept up-to-date with seminars, courses, printed and electronic sources, and all the means possible with the guidance of routine surveillance by the hospital infection control committee.
