An estimated 40–60 percent of Surgical Site Infections (SSIs) are preventable with appropriate use of prophylactic antibiotics. Overuse, under use, improper timing, and misuse of antibiotics occurs in 25–50 percent of operations. A large number of hospitalized patients develop infections caused by Clostridium difficile, and 16 percent of this type of infection in surgical patients can be attributed to inappropriate prophylaxis use alone. Inappropriate use of broad spectrum antibiotics or prolonged courses of prophylactic antibiotics puts all patients at even greater health risks due to the development of antibiotic-resistant pathogens.

Changes for Improvement

• Designate responsibility and accountability for preoperative prophylactic antibiotic administration (e.g., preoperative nurse, circulating nurse, anesthesiologist) connected to key point in process
• Standardize administration process to occur with commonly performed activity within one hour prior to incision
• Through the use of antibiotic standing orders specific to surgical site, administer prophylactic antibiotics according to guidelines based on local consensus
• Make agreed upon antibiotics available in the operating room (OR)
• Standardize delivery process to ensure timely delivery of preoperative antibiotics to the holding area
• Provide visible reminder or checklist to give antibiotics on each case (e.g., brightly colored sticker)
• Ensure systematic documentation of antibiotic administration on every patient chart (paper or electronic)
• Develop system where antibiotic is hanging at head of patient’s bed ready for administration
• Design protocols to deliver antibiotic to OR with patient
• Educate OR staff regarding the importance and reasoning of antibiotic timing, selection, and duration
• Provide feedback on prophylaxis compliance and infection data monthly
• Involve pharmacy staff to ensure timing, selection, and duration are maintained
• Institute a computerized physician order entry system with procedure-specific fields for antibiotic selection, timing, and duration
• Improve screening for allergies to beta lactam antibiotics to eliminate false positives
• Consider weight-based antibiotic dosing (higher dose for larger patients). As this may be cumbersome, may want to increase cephalosporins from 1 to 2 grams for all patients since minor issues around toxicity.
• Re-dose for longer surgeries (e.g., after 3 hours for short half-life cephalosporin)

Tools

Clinical Guideline Reminder Poster