Surgical site infections (SSIs) are a serious but often preventable risk that patients face when they go under the knife. But despite the implementation of measures and surveillance programs to reduce their occurrence, they remain among the main sources of healthcare-associated infections and a major cause of unplanned postoperative hospital readmissions.
Now, researchers are finding that variation in antibiotic administration during surgery may be a factor in stagnating SSI rates. A collaborative study between the Yale School of Medicine and the University of Michigan Medical School found that practices in more than a third of surgical procedures in the United States did not meet Infectious Diseases recommendations Society of America. The researchers published their findings on December 14 in Open JAMA Network.
“This is the first time we’ve been able to see in a large, nationally representative sample what really happens in the administration of antibiotics at the time of surgery,” says Robert Schonberger, MD, associate professor of anaesthesiology and lead author of the study. . “We looked at several hundred thousand surgeries across the country over five years and found one area where current practice falls far short of what patients deserve.
SSIs affect approximately 125,000 surgeries each year, resulting in $1.6 billion in additional healthcare costs. Experts estimate that about half of these cases are preventable. “When a patient has a surgical site infection, it can sometimes be relatively minor. But it’s not uncommon for it to be a major, life-altering process, resulting in multiple additional surgeries. , prolonged hospitalizations, sepsis, or even death,” Schonberger says.
To reduce the risk of SSI in health care settings, the Surgical Care Improvement Project (SCIP), a collaboration between the Centers for Medicare & Medicaid Services and the Centers for Disease Control and Prevention, has launched initiatives over the past two decades to standardize and publicize appropriate antibiotic administration rates. Data shows that provider compliance with SCIP guidelines is close to 100%. However, says Schonberger, the guidance offered by SCIP is limited.
“SCIP only looks at the timing of the first dose of antibiotics,” he says. “It doesn’t tell us which antibiotic to give in multiple case types, how to adjust antibiotics for differences in patient weight, or when, if at all, to re-dose antibiotics during prolonged procedures.”
As a result, he continues, a patient may receive an antibiotic at the right time, but may not receive the right type or amount, or the antibiotic may not be dosed correctly. In these cases, although the provider has adhered to the SCIP, a patient can still be affected by inappropriate administration of antibiotics. To address these factors, the Infectious Diseases Society of America offers more detailed guidelines on antibiotic selection, weight-adjusted dosing, and timing of first and subsequent doses.
To better understand overall compliance with these additional guidelines, the team studied data from 414,851 surgical encounters at 31 hospitals in 21 states. The data came from surgeries on adults 18 years of age or older from 2014 to 2018. They found that while adherence to SCIP guidelines is nearly universal for practices related to antibiotic dosing, the specific class of antibiotic and practices around the new assay were not consistent with what experts believe to be best practice. About a third of the time, according to the study, common practice in the United States did not meet the parameters of the Infectious Disease Society of America.
“There’s a real disconnect between what the Infectious Disease Society says we should be doing and what we’re actually doing in national practice,” Schonberger says. “The next proposed question is, ‘Who’s right?'”
Proper management of antibiotics is not only important to prevent infections, but also to prevent the emergence of antibiotic resistant organisms. Schonberger hopes this research will lead to future studies of which care practices have the most impact, which need to change, and how care practices can be improved in line with the best evidence. “Our long-term goal is to develop systems for improving care, not just around this problem alone, but more broadly around surgical care in general,” he says. “We want to bring evidence-based best practices to the bedside to make care safer.”
When asked about his inspiration for his research, Schonberger brandishes his own medical identification bracelet. “I don’t just want to provide the best care possible to the patient on my table, but also improve surgical practice for all patients where I can on a larger scale.”