828 infection control & hospital epidemiology july 2017, vol. 38, no. 7
table 3. SAP Administration in Procedures With Indication According to Drug Choice, Route of Administration, Timing, Dura- tion, and Dose
Surgical Procedures With SAP Indication and Administration (n=317)
Drug choice Optimal (concordant with guidelines) Adequate (comparable spectrum of activity) Inadequate (unsuitable choice for SAP)
Route of administration Appropriate Inappropriate
Timing
Appropriate (within 60 min before incision) Inappropriate
>60 min before incision After incision, within 24 h After incision, over 24 h
Duration
Appropriate (within 24 h) Inappropriate (over 24 h)
Dose
Appropriate Inappropriate Insufficient Excessive
Appropriate drug choice, route of administration, timing, duration, and dose
NOTE. SAP, surgical antibiotic prophylaxis.
emergence of resistant microorganisms or antibiotic side effects. Moreover, as reported in previous studies,15,20,21 an extreme variation in SAP practice according to the different surgical interventions has also been revealed in our investigation. We identified only 2 studies in which SAP administration
in procedures without indication was taken into account. However, we only pursued this information as a marginal objective;5,22 most studies have focused on procedures with an SAP indication. In our study, we chose to analyze the overall picture of SAP administration regardless of indication because the most frequent interventions in pediatric patients have no SAP indication; in our study population, almost two-thirds of procedures were in this group. Therefore, a substantial burden of inappropriate SAP administration pertains to these kinds of procedures that, in our study population, contributed to 243 of 560 total SAP administrations (43.4%) that were completely unnecessary. Multivariate analysis showed that SAP was more frequently inappropriately administered in surgical specialties wards, in ordinary admissions compared to day surgery, in clean contaminated procedures, and with increasing duration of surgical procedures. Taken together, these findings seem to indicate that SAP is cautiously overused whenever an inter- vention is perceived as complex, regardless of the associated SSI risk. Low adherence to SAP guidelines because of a cautious approach exposing pediatric patients to unnecessary
290 (91.5) 27 (8.5) 3 (0.9)
24 (7.6) 5 (1.6)
46 (14.5) 271 (85.5)
154 (48.6) 163 (51.4) 53 (16.7) 62 (19.6) 48 (15.1)
No. (%) 18 (5.7)
208 (65.6) 91 (28.7)
243 (76.7) 74 (23.3)
antibiotics has already been reported in a previous study.23 To improve the appropriate use of SAP, surgeons should be educated to distinguish overall complexity of interventions from the associated SSI risk. The benefits of educational intervention for SAP have been demonstrated in several previous studies. Hedef et al24 found that compliance to SAP guidelines improved with increased awareness among junior surgeons. Zvonar et al25 suggested that the administration of SAP by the anesthesiologist at the time of anesthesia resulted in a significant improvement in the timing of the preoperative dose of prophylactic antibiotic and decreased the median interval between antibiotic administration and skin incision. The finding that SAP administration when it is not indicated is more frequent in hospitals without a pediatric surgery ward is unacceptable, and we hypothesize that physicians do not take into consideration the unique characteristics of pediatric patients but rather extrapolate them from the adult population. Although the overall proportion of children who did not
receive SAP when it was indicated was not particularly high (11%), a more in-depth analysis of the ways SAP was admi- nistered overall and according to each of the single compo- nents reveals a very concerning situation. The overall rate of adherence to SAP guidelines is unacceptably low (1.6%). Previous studies on compliance with SAP guidelines in the pediatric population have similarly highlighted low rates of full adherence, ranging between 6.5%23 and 25.3%,26 but never as low as our study. The main components that con- tributed to the low overall adherence rate were drug choice and duration. Drug choice was not concordant with the guidelines in
94.3% of cases, with the highest discordance pertaining to hypospadias or epispadias repair; our data deviate significantly from results reported in previously published studies, in which the rate of adherence ranged between 16.7%26and 42.7%.27 Even if in most cases the chosen drugs provided coverage against the expected microorganisms, they frequently had too broad a spectrum of activity, contributing to the risk of emerging antimicrobial resistance. This finding is extremely concerning because Italy is among the European countries with the highest consumption of antibiotics and the highest levels of antibiotic resistance.28 Moreover, antimicrobial resistance in Italy has increased to as much as twice (cf, methicillin-resistant Staphylococcus aureus) to 4 times (cf, with carbapenem-resistant Klebsiella pneumoniae) higher than the European average.29 Recommended duration was achieved only in 14.5% of
surgical procedures. Unnecessarily prolonged SAP was observed for all types of interventions, with the highest frequency in abdominal and tegument procedures. Previous studies have likewise shown prolonged administration, with adherence ranging from 16% to 40.9%.22,23,26,27 It is well known that prolonged postoperative antibiotics do not provide additional benefits and are useless for prophylaxis, and several studies confirm equal effectiveness of single compared to multiple
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