Antibiotic Stewardship

Introduction

Welcome to the APSA Quality and Safety Committee Antibiotic Stewardship Toolkit. This page is intended to help anyone who is interested in quality improvement pertaining to antibiotic stewardship and surgical infection.

Available toolkit projects are listed below. Many of the approaches described are evidence based - some are not. These approaches have not been approved by APSA.

Promoting Stewardship for Surgical Antibiotic Prophylaxis

Boston Children’s Hospital

Overuse of antibiotics is associated with a higher risk of adverse events and increased antimicrobial resistance. Consensus guidelines for surgical antibiotic prophylaxis (SAP) endorsed by the WHO, Infection Disease Society of America and Surgical Infection Society currently recommend no SAP for clean cases without foreign body implantation and not to continue SAP past incision closure in elective clean contaminated cases (and clean cases with foreign body implantation) [1]. Despite these guidelines, many children undergoing clean cases without foreign body implantation receive SAP and a significant proportion of children undergoing elective clean contaminated procedures receive SAP well past incision closure [2].

Project overview

The goal of this project is to reduce practice variation and overuse of SAP in general pediatric surgery by improving compliance with current SAP guidelines. The project can be rolled out in stages (first promoting no SAP for clean cases without FB implantation, then focusing on reducing the use of SAP in clean contaminated procedures), or addressing improved compliance with SAP guidelines with both clean and clean contaminated cases simultaneously. We strongly recommend a staged approach starting with clean procedures then moving on to clean contaminated procedures once success has been achieved with clean procedures. This may be a more successful way to gather momentum as it is generally easier to establish departmental consensus around withholding SAP for clean procedures rather than limiting postoperative SAP for clean contaminated cases (especially colorectal cases).

Project strategy and intervention

The proposed strategy has been developed from an analysis of primary drivers of noncompliance and successful implementation at a freestanding children’s hospital. The identified primary drivers of noncompliance include

  1. attending surgeons who give unindicated (or prolonged) SAP are often unaware of contemporary consensus guidelines
  2. tendency of rotating trainees to give antibiotics in all pediatric cases by default
  3. attending surgeons who would otherwise comply with current SAP guidelines being unaware that residents have written for SAP for clean cases.

With these primary drivers in mind, the project is composed of multiple related steps/interventions.

  • education of attending surgeons in a faculty meeting around current guidelines and the harm of SAP overuse
  • obtaining consensus at the same faculty meeting around goals (no SAP for clean cases and/or limiting SAP after incision closure for clean-contaminated cases); identifying which members want to participate if complete consensus cannot be established
  • proactive education of rotating residents around departmental SAP guidelines and communication loop closure to facilitate compliance
  • auditing of compliance with SAP guidelines for targeted cases (department wide or only for surgeons indicating participation if full consensus is not established)
  • feedback to surgical attendings and residents in cases of noncompliance

Resources

To support project success, multiple resources are included in the project file. These include

  • A presentation file to facilitate discussion & endorsement of the project at a departmental/faculty meeting. The presentation contains information regarding current consensus guidelines, data surrounding adverse events (i.e. resistance patterns and antibiotic associated adverse events). The file also provides guidance for discussion around SAP compliance for both clean and clean-contaminated procedures.
  • A document including several email templates for faculty and rotating residents/trainees. The file includes multiple email templates including announcements of the guidelines/project to both surgical attendings and rotating residents and emails to assess reasons for SAP utilization (or extended duration) in noncompliant cases.
  • A spreadsheet to facilitate auditing and to monitor SAP compliance rates over time. In the attached version, there are four criteria for possible immunocompromised status. If any of these are present, then the case should be excluded from SAP auditing.

Recommended project roll out strategy

The recommended strategy for roll-out is as follows.

  1. Present PowerPoint at faculty meeting; establish consensus around goals to improve SAP compliance.
  2. Send out education/announcement emails to current residents (and obtain a schedule of future resident rotations so they can be sent the emails when they begin); mandate communication loop closure with a response that they understand the guidelines.
  3. Send out templated reminder email to faculty about the consensus agreement established in faculty meeting and plans to begin auditing (when auditing begins).
  4. Daily auditing of targeted cases using Excel template based on goals established in 1 above.
  5. Send out templated emails to faculty and residents for noncompliant cases as a reminder and to assess reasons for noncompliance.

submitted by Shawn Rangel

Antibiotic Prophylaxis for Neonatal Abdominal Surgery

Children’s Medical Center Dallas - University of Texas Southwestern

The optimal dosing regimen for surgical antibiotic prophylaxis in neonates undergoing general surgery procedures remains undefined. While multiple guidelines for surgical antibiotic prophylaxis have been published, these guidelines have been validated only through studies of adult patients [3]. The purpose of this project is to determine the optimal perioperative antibiotic prophylaxis regimen for neonates undergoing general surgery procedures.

Resources

  • eIRB protocol
  • Intervention Educational Powerpoint: DMAIC QI Methodology, with intervention to include grand rounds presentation on antibiotic prophylaxis education to both Surgery/Anesthesia and NICU teams as well as a standard EMR order set.
  • EPIC orderset outline
  • Postintervention presentation

Stakeholders: neonatal intensive care unit, pediatric surgery, anesthesia, EMR informatics team

Challenges and solutions: Attempted to create a standard “pre-op” antibiotic order set for all NICU patients undergoing surgery at CMC in order to streamline the process and limit antibiotic administration errors. The informatics team refused to validate the order set based on a shocking number of perceived “work-flow” challenges:

  • Who would enter the orders?
  • Which pharmacy (OR or NICU) would fill the prescription?
  • Who would pick up the antibiotics (anesthesia or NICU)?
  • Where would the antibiotics be administered (NICU or OR)?

The issue remained unresolved after several months worth of meetings.

Submitted by Ryan Walk

References

  1. Sandora TJ, Fung M, Melvin P, et al. National Variability and Appropriateness of Surgical Antibiotic Prophylaxis in US Children's Hospitals. JAMA Pediatr. 2016;170(6):570-6.  [PMID:27088649]
  2. Bratzler DW, Dellinger EP, Olsen KM, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70(3):195-283.  [PMID:23327981]
  3. Bratzler DW, Dellinger EP, Olsen KM, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Surg Infect (Larchmt). 2013;14(1):73-156.  [PMID:23461695]
  4. Bruny JL, Hall BL, Barnhart DC, et al. American College of Surgeons National Surgical Quality Improvement Program Pediatric: a beta phase report. J Pediatr Surg. 2013;48(1):74-80.  [PMID:23331796]
  5. Bucher BT, Warner BW, Dillon PA. Antibiotic prophylaxis and the prevention of surgical site infection. Curr Opin Pediatr. 2011;23(3):334-8.  [PMID:21494149]
  6. Hooven TA, Polin RA. Healthcare-associated infections in the hospitalized neonate: a review. Early Hum Dev. 2014;90 Suppl 1:S4-6.  [PMID:24709456]
  7. Khoshbin A, So JP, Aleem IS, et al. Antibiotic Prophylaxis to Prevent Surgical Site Infections in Children: A Prospective Cohort Study. Ann Surg. 2015;262(2):397-402.  [PMID:25243561]
  8. Murray MT, Corda R, Turcotte R, et al. Implementing a standardized perioperative antibiotic prophylaxis protocol for neonates undergoing cardiac surgery. Ann Thorac Surg. 2014;98(3):927-33.  [PMID:25038006]
  9. Rangel SJ, Fung M, Graham DA, et al. Recent trends in the use of antibiotic prophylaxis in pediatric surgery. J Pediatr Surg. 2011;46(2):366-71.  [PMID:21292089]
  10. Toltzis P, O'Riordan M, Cunningham DJ, et al. A statewide collaborative to reduce pediatric surgical site infections. Pediatrics. 2014;134(4):e1174-80.  [PMID:25201794]

Last updated: May 7, 2019