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 (QI) pertaining to antibiotic stewardship such as surgical infectionand antibiotic associated colitis.

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

The 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 World Health Organization (WHO), Infection Disease Society of America (IDSA) and Surgical Infection Society (SIS) recommend no SAP for clean cases without foreign body (FB) implantation and discontinuation of SAP past incision closure for 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].

Given these findings, Boston Children’s Hospital initiated a QI project with the goal of reducing practice variation and overuse of SAP in general pediatric surgery procedures, by improving compliance with current SAP guidelines. The project was rolled out in a staged approach, first promoting no SAP for clean cases without FB implantation, then focusing on reducing the use of SAP in clean contaminated procedures. The implementer strongly recommends a staged approach when addressing this at your institution, 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 in colorectal cases). Alternatively, one can address improved compliance with SAP guidelines with both clean and clean contaminated cases simultaneously.

Protocol:

• Project strategy and intervention:
  • This 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:
      • Attending surgeons who give unindicated (or prolonged) SAP are often unaware of contemporary consensus guidelines
      • Tendency of rotating trainees to give antibiotics in all pediatric cases, by default
      • 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
• Recommended project roll out strategy:
  • Present PowerPoint at faculty meeting; establish consensus around goals to improve SAP compliance.
  • 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.
  • Send out templated reminder email to faculty about the consensus agreement established in faculty meeting and plans to begin auditing (when auditing begins).
  • Daily auditing of targeted cases using Excel template based on improving SAP compliance goals discussed during the faculty meeting.
  • Send out templated emails to faculty and residents for noncompliant cases as a reminder and to assess reasons for noncompliance.

Resources:

• BCH - Surgical Antibiotic Prophylaxis Stewardship in Pediatric Surgery - Faculty Presentation
  • Used to facilitate discussion and endorsement of the project at a departmental/faculty meeting. Contains information regarding current consensus guidelines, data surrounding adverse events (i.e., resistance patterns and antibiotic associated adverse events). Also provides guidance for discussion around SAP compliance for both clean and clean-contaminated procedures.
• BCH Email Templates (for attending and residents)
  • Several email templates used for announcements of the guidelines/project to both surgical attendings and rotating residents, as well as to assess reasons for SAP utilization (or extended duration) in noncompliant cases.
• BCH Antibiotic Prophylaxis Auditing Form
  
  • 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.

Stakeholders: Infectious Disease, Surgery

Challenges and Solutions:

• Challenges
  • Poor awareness of existence of consensus guidelines
  • Confusion around procedure-level recommendations
• Solutions
  • Faculty meetings to address points of confusion and establish consensus
  • Resident-targeted email interventions
  • EMR-based decision support during antibiotic ordering
  • Auditing of compliance with guidelines
  • Feedback to surgical attendings and residents in cases of noncompliance

Links to published data (used to develop the protocol): [3]

Submitted by: Shawn Rangel, MD, MSCE

Children’s Hospital Colorado implemented a QI initiative aimed at assessing the excess perioperative antibiotic use within their facility, and then identifying specific patterns leading to non-compliance with national guidelines in order to improve processes. Though this data was collected for their own use, it may be applied to other facilities who wish to evaluate compliance within their centers.

Protocol:

• All procedures were collected for the calendar year of our choice. This data was then uploaded into REDCap for chart review. Once procedures were uploaded into REDCap and appropriate exclusions were applied, antibiotics associated with collected and duration was assigned. Then hours of antibiotic were assigned for calculation of excess. Data reports were then imported to a Microsoft Excel sheet for further categorization. Procedures were first classified by the whole hospital and then further delineated by surgical subspecialties. Procedures were also broken down into procedure similar categories in order to further compare to national guidelines. Once data was collected and evaluated, it was taken to division heads in order to come up with strategies to improve compliance with national guidelines. This project required minimal statistical analysis, but any statistical analysis that was done was performed in Minitab statistical software.

Resources:

• CHOC ToolKit Slides
• CHOC SAP Dataset Example

Stakeholders: pediatric general surgery, pediatric urology, pediatric antimicrobial stewardship team

Challenges and Solutions:

• Difficulty to immediately discern indications for antibiotics associated with procedures. This required extensive chart review using REDCap and EPIC with the occasional exclusion, if chart review remained inadequate.
• When meeting with the surgical subspecialties not all quoted same source for guidelines, therefore, it was difficult to have one unifying group of guidelines. However, we used the IDSA guidelines as they were the most thorough across all surgical specialties.

Links to published data (used to develop the protocol): [4][5]

Submitted by: AnnaMaria Salas, PA-C

Additional implementers: Elise VanEtten, PA-C, Sarah Parker, MD, Jennifer Bruny, MD

Surgical Antibiotic Prophylaxis for Neonatal Abdominal Surgery

The optimal dosing regimen for SAP in neonates undergoing general surgery procedures remains undefined. While multiple guidelines for SAP have been published, these have been validated only through studies of adult patients[4]. As such, the Children’s Medical Center Dallas-University of Texas Southwestern sought to determine the optimal perioperative antibiotic prophylaxis regimen for neonates undergoing general surgery procedures at their institution.

Protocol:

• UTSW-CMC Dallas IRB protocol

Resources

• DMAIC QI Methodology on Antibiotic Prophylaxis Education to both Surgery/Anesthesia and NICU teams
  • UTSW-CMC Dallas Educational Powerpoint: Neonatal Perioperative Antibiotic Prophylaxis Grand Rounds
  • UTSW-CMC Dallas Pediatric Surgery Neonatal Surgery Antibiotic Prophylaxis Orderset
• UTSW-CMC Dallas Postintervention Neonatal Perioperative Antibiotic Prophylaxis Grand Rounds

Stakeholders: neonatal intensive care unit (NICU), 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.

Links to published data (used to develop the protocol): [4][6][7][8][9][10][11][12]

Submitted by: Ryan Walk, MD

At Children’s Memorial Hermann Hospital, a quality improvement team led by pediatric surgery and the infectious disease/infection control department was formed to develop a series of standard and alternative surgical antibiotic prophylaxis medications, as well as the appropriate doses for neonatal surgery. This work represents a culmination of several years and iterations of surgical antibiotic prophylaxis guidelines for neonatal surgery. There were several stakeholders involved in this project, but all ultimately agreed on the final product.

After development of the initial guidelines, we took the specifics to each service line and had them review and approve what was appropriate for their operations. For example, orthopedics was in charge of signing off their portion of the guidelines. We asked the service line to ensure all the surgeons had seen and approved these recommendations. There was some negotiating back-and-forth but for the most part, most of the service lines quickly approved the guidelines.

Pediatric anesthesia played a very important part in the compliance of these guidelines. In our work with our surgical safety checklist, the anesthesiologists are responsible for administering the appropriate antibiotic after confirmation with the surgeons. The actual process of giving the drug is in the hands of the anesthesiologist. As such, we had to work with them to identify the proper process in our institution. Since the drugs are ordered through the NICU preoperatively, we needed to make sure that our anesthesiology group received the medication when the patient arrived to the operating room. This was especially important to log down the process because for infants less than 44 weeks corrected gestational age, antibiotics are not reduced. In a previous study, we had identified failure to redose properly as one of the major fallouts of antibiotic prophylaxis compliance. Obviously, we work with our pharmacy and neonatology to ensure the correct dosing and interval for medications given.

At this point in our institution, these drugs are ordered prior to coming to the operating room and with the correct dosing for that infant. The drugs are either delivered directly to the operating room or they come down with the patient from the NICU. The key to implementation of this project was early buy in from all the surgical subspecialties.

Protocol:

• Memorial Hermann UT Houston - Pediatric Pre-Op Prophylaxis Orders Version 17

Resources:

Stakeholders: all surgical subspecialities, neonatology, pharmacy, anesthesiology, NICU, infection control/disease

Challenges and solutions:

• As mentioned previously, the biggest hurdle was to make sure everyone approved of the drugs used for prophylaxis. We started with an evidence based analysis. We then created the initial guidelines and sent them to the individual service lines for their approval. In those emails, we included every surgeon so that everyone had a chance to see them. There were only a few minor changes after that.
• The other hurdle was identyfing and creating the proper process to ensure compliance. We empowered the anesthesiologist to give the medication. As such, they were intimately involved in creating the process that worked for them. For some medications, they existed in their Pyxis in the operating room so access was not an issue. Other medications, such as vancomycin, required to be ordered ahead of time and delivered from pharmacy directly. Because they were involved early on, they dictated how they wanted the medications to be brought to the operating room. Ultimately, we needed the medications to be provided in a timely fashion with the correct dosing.

Links to published data (used to develop the protocol):

Submitted by: KuoJen Tsao, MD

Additional implementers: Maria Matuszczcak MD, pediatric anesthesiologist

Penicillin Allergy Surgical Prophylaxis

The use of cephalosporin antibiotics as surgical prophylaxis has historically been avoided in patients with a penicillin allergy due to perceived high rates of cross-reactivity[13]. However, cross-reactivity following cephalosporin use in penicillin allergic patients has been shown to be as low as 1%[13][14]. Finally, as compared to utilization of second line agents, cephalosporin utilization for prophylaxis is associated with lower rates of surgical site infections and drug reactions[15][16][17][18][19][20][21]. Given the considerations above, cephalosporins should be used as first-line surgical antimicrobial prophylaxis in all patients without a history of severe allergic reaction to penicillin agents.

Boston Children’s Hospital implemented a process improvement project to reduce practice variation and inappropriate use of second line agents for surgical prophylaxis in patients with mild to moderate penicillin-allergies. Barriers to appropriate cephalosporin utilization include poor documentation of allergic response (i.e., the “information gap”), precluding accurate assessment of the presence and severity of a true allergy at the point of care, and lack of education regarding the safety of cephalosporin use in non-severe penicillin allergies (i.e., the “knowledge gap”)[22][23]. The interventions described as part of this initiative aim to address both of these barriers through a multidisciplinary and multi-pronged process improvement effort. The project was rolled out in stages (first improving penicillin-allergy reaction documentation, then focusing on reducing the use of second line agents in patients with non-severe penicillin allergies). The implementer strongly recommends a multi-pronged approach addressing both documentation and antibiotic use for maximal effect.

Protocol:

• BCH - Overview - Promoting Cephalosporin Utilization for Prophylaxis in Non-Severe Penicillin Allergies

Resources:

• BCH - Sample Algorithm for Surgical Prophylaxis with Penicillin Allergy
• BCH - Sample Presentation to Faculty for Prophylaxis in PCN Allergic Patients
• BCH - Sample email templates for penicillin allergy prophylaxis project
• BCH - Sample Antibiotic Prophylaxis Auditing Form (2023)
• BCH - Sample Report of PCN Allergy Scheduled Cases

Stakeholders: Allergy/Immunology, Infectious Disease, Pharmacy, and Surgery

Challenges and Solutions:

Challenges:

• Poor documentation of allergic response, precluding accurate assessment of the presence and severity of a true allergy at the point of care
• Lack of awareness regarding the safety of cephalosporin use in non-severe penicillin allergies

Targeted solutions:

• Caregiver outreach to clarify incomplete allergy documentation
• Creation of a decision-support algorithm for SAP use in penicillin-allergic patients
• Standardized educational resources for surgical faculty and rotating trainees
• Education of attending surgeons in a faculty meeting around current guidelines and the harm of second line agent utilization
• Proactive education of rotating residents around departmental SAP guidelines and communication loop closure to facilitate compliance
• Email reminders with prophylaxis recommendations sent out prior to scheduled cases
• EMR-based decision support during antibiotic ordering
• Auditing of compliance with SAP guidelines for targeted cases
• Feedback to surgical attendings and residents in cases of noncompliance

Links to published data (used to develop the protocol): [13][14][15][16][17][18][19][20][21][24][25][26][27][28][29]

Submitted by: Shawn Rangel, MD, MSCE

Additional Antibiotic Stewardship Resources

2019, APSA Antibiotic Stewardship TEC Talk - Dr. Shawn Rangel

Recent Research

For recent research pertaining to antibiotic stewardship, please refer to references: [30][31][32]

References