830 infection control & hospital epidemiology july 2017, vol. 38, no. 7


table 5. Multiple Logistic Regression Analysis Results Examining Appropriateness of Timing of SAP Administration in Procedures With SAP Indication According to Several Explanatory Variables


Variable


(No. of observations=358) Gender Male


Female Age, y


Ward of hospital stay General surgery


Surgical specialties


Surgical procedure group Other surgical disciplinesb Orthopedic


Type of surgery Elective Urgent


ASA score <3 ≥3


Implantation of prosthesis No Yes


OR SE 95% CI P


Model 2. Appropriate Timing of SAP Administration in Procedures With SAP Indication


1.00a


2.28 0.60 1.36–3.82 .002 1.07 0.02 1.02–1.12 .006


1.00a


0.38 0.12 0.20–0.71 .003 1.00a


2.42 0.79 1.27–4.59 .007 1.00a


0.59 0.16 0.35–1.00 .050 1.00a


0.35 0.24 0.09–1.34 .125 1.00a


1.82 0.58 0.97–3.40 .061 NOTE. SAP, surgical antibiotic prophylaxis; OR, odds ratio; SE, stan-


dard error; ASA, American Society of Anesthesiologists. aReference category. bIncluding urological, gynecologic/obstetric, tegument, and abdom- inal surgery.


doses.30 Conversely, prolonged SAP, probably related to a cau- tious attitude of surgeons, is associated with increased risk of emerging resistant bacteria strains and increased hospital costs associated with diagnosis and treatment of antibiotic-adverse events. Differently from other studies,26,27 SAP duration was more appropriate in urological and gynecologic/obstetric pro- cedures in our study. Correct timing of SAP administration was achieved in


<50% of surgical procedures, which is within the range reported elsewhere in the medical literature (31.9%– 71.3%).22,23,26,27 However, it is unacceptable that almost 35% of patients received antibiotics after surgical incision, when they are almost useless. An appropriate drug dosewas given to almost the entire cohort


(91.5%); this component shows the highest adherence to guide- lines. This figure is similar to the 92% reported by Groselj Grenc et al26 and is higher than those reported in other studies.23,27 Overall, several main concerns have been highlighted by our


results: (1) Some patients who do not need SAP are exposed to unnecessary antibiotics (23%). (2) Some patients who need SAP do not receive it (4%) or receive it when it is no longer effective (~11%) and are therefore exposed to SSI risk. (3) Some patients need SAP and do receive it, but in many cases it is ineffective or excessive (20%). The risk of overuse


and inappropriate use is higher than with underuse, thus representing a problem for the emergence of resistance but not for the effectiveness of SAP. On the contrary, among patients who underwent procedures with an SAP indication, we analyzed in detail the timing of administration, the most crucial component responsible for ineffective SAP. SAP is fundamental in reducing the risk of SSIs,31–35 and SAP was administered after incision in a substantial proportion of cases, thus undermining its effectiveness. Appropriate SAP timing was associated with certain patient characteristics (eg, being female and older) and with the type of ward of admission and type of procedure (general surgery wards and in orthopedic procedures), and, as expected, was less respected in urgent surgery. In none of the studies of SAP in pediatric patients have predictors of appropriate timing been investigated, and further research is needed in this area of study. This study had several potential limitations. First, data were


retrospectively assessed and relied on accuracy of the clinical records, whichmay not alwaysbe ascomplete asis desirable. Moreover, this data source did not allowany direct evaluation of reasons for nonadherence to guidelines. Second, patients were recruited fromhospitals located in southern Italy andmay not be representative of the entire country or generalizable to other populations. Finally, the lack of any SSI documented in the clinical recordsmay represent an underestimation related to lack of postdischarge surveillance of SSI and/or very short hospital stay related to most evaluated procedures. In conclusion, there are substantial discrepancies between


SAP guidelines and practice behavior in pediatric surgery, more frequently oriented to excessive and inappropriate use of antibiotics than to underuse.


acknowledgments


We extend our sincere thanks to the Collaborative Working Group for allowing us to carry out the study and for their support in the retrieval of clinical records: Caterina De Filippo, MD; Ilario Lazzaro, MD; Francesco Fera, MD; Luisa Pavone, MD (Teaching Hospital of Catanzaro); Nicola MS Pelle, MD; Gianluca Raffaele, MD; Antonio Gallucci, MD (Regional Hospital of Catanzaro); Annalisa Spinelli, MD; Rita Marasco, MD (Local Hospital of Lamezia Terme, ASP of Catanzaro); Michelangelo Miceli, MD; Anna Maria Renda, MD (Local Hospital of Vibo Valentia, ASP of Vibo Valentia). Financial support: No financial support was provided relevant to this article. Potential conflicts of interest: All authors report no conflicts of interest


relevant to this article. Address correspondence to Maria Pavia, Chair of Hygiene, Department of


Health Sciences Medical School, University of Catanzaro “Magna Græcia,” Via T. Campanella, 115, 88100 Catanzaro, Italy (pavia@unicz.it).


references


1. Anderson DJ. Surgical site infections. Infect Dis Clin North Am 2011;25:135–153.


2. Shah GS, Christensen RE, Wagner DS, Pearce BK, Sweeney J, Tait AR. Retrospective evaluation of antimicrobial prophylaxis in prevention of surgical site infection in the pediatric population. Paediatr Anaesth 2014;24:994–998.


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