Compliance the antibiotic prophylaxis guideline at Vinmec Central Park international hospital
Author:
- Pharmacist Nguyễn Hoàng Phương Khanh - Department of pharmacy - Vinmec Central Park International Hospital
- Pharmacist Bùi Hồng Ngọc - Department of pharmacy - Vinmec Central Park International Hospital
- Pharmacist Diệp Trọng Viễn Duy - Department of pharmacy - Vinmec Central Park International Hospital
- Dr. Trương Ngọc Hải - Vinmec Central Park International Hospital
1. Overview
Surgical site infection (SSI) is one of the most common complications of surgery all over the world. In developed countries, some studies show that there are average 5% surgical patients developing SSI. In Viet Nam, the rate of SSI was about 5.7% according to the survey on 19 hospitals in 2005 [1]. Surgical antimicrobial prophylaxis is an effective solution to prevent SSI [3]. Principles of using antibiotic prophylaxis is available in: Nguyên tắc sử dụng kháng sinh dự phòng).
However, the application of antimicrobial prophylaxis in clinical practices has still possessed several difficulties, such as broad spectrum antibiotic indication, inappropriate antibiotic timing, extended duration of antibiotic prophylaxis which is assosiated with an increase risks of antibiotic resistance and adverse drug effects [3]. In order to ensure patient safety and reduce inpatient admission time, Vinmec Central Park International Hospital established a group to observe the adherence to surgical antibiotic prophylaxis guidelines, which included Pharmacy, Quality Assurance, Operation Theatre, Clinical Department (General Surgery, Obstetrics and Gynecology). The research group conducted a survey to evaluate the adherence to our hospital’s antibiotic prophylaxis policy. Based on the results, the research group provided a database to examine the efficacy of surgical antibiotic prophylaxis policy in hospital and suggested solutions to enhance the adherence to that policy.
- Materials and methods
Study designs: The cross-section description study was conducted.
The study population included all surgical patients in Gynecology Ward and General Surgery Ward from April 2019 to December 2019.
- Inclusion criteria: elective clean or clean – contaminated surgical procedures
- Exclusion criteria: contaminated or dirty procedures
Sample Size Calculator: based on the following formula:
n: sample size
Z1-2 2: value related to confidence level, choosing confidence level at 95% => Z = 1.96
p: expected proportion in population based on previous studies. According to a summary including 28 studies of compliance with the antibiotic prophylaxis guideline (2011-2015) in Pubmed, the overall compliance rate ranged from 9.4% to 80% [1]. We chose p=80%
d: absolute error or precision. Since 0.7 < p ≤ 0.9, we set d = 0.05.
So we had: n ≈ 245. In reality, our study collected data of 386 patients which satisfied with the sample size.
Methods:
- Data colletion: The data collection form was designed by clinical pharmacist team and approved by the Quality Assurance Board of the Hospital.
Nurses collected all cases of surgery met the inclusion criteria and filled in the form with the general information. Then, the data about type of surgery, choice of the antibiotic, dosage, timing of administration, time of skin incision was recorded by anaesthetist/ surgeons. Then, the duration of prophylaxis was collected from the medication chart by the nurse. In case of prolonged antibiotic prophylaxis use, the surgeons fill in the reason of antibiotic indication in the form.
- Evaluation the adherence to prophylactic antibiotic guideline: conducted by clinical pharmacist based on the “Guideline for using antibiotic prophylaxis” of Vinmec Hospital.
- Method of intervention: The assessing results were reported monthly to the Antimicrobial Management Board, Quality Assurance Board, Hospital Leadership and feedback to surgeons, anaesthetists, nurses. Depending on the results of the assessment, the interventions were made focused on departments with low adherence.
The appropriateness of prophylactic antibiotic was evaluated in terms of:
- The type of antibiotic
- The dose of antibiotic
- The timing of its administration within 60 minutes before surgical incision
- The duration of use as a single or multiple doses of antibiotic administered within 24 hours of surgery
- The repeated dosing of antibiotic prophylaxis for prolonged surgery lasting more than 4 hours.
The antibiotic prophylaxis has been judged overall appropriate if all of above parameters are appropriate.
- Results and Discussion
3.1 Demographic characteristics
During the period from April and December 2019, there were totally 386 clean and clean-contaminated surgeries evaluated. Obstetric & Gynecological procedures were the most frequent surgeries performed, accounting for 49%, followed by Gastroenterology (18%), Orthopediology (14%), Urology (10%) and other surgeries (1-2% of each type of surgery). Of these patients, 1.5% (6 surgeries) had the time of surgery longer than 4 hours.
3.2 Results
- Overall adherence to Antibiotic prophylaxis Guideline
This study showed that the rate of overall adherence to antimicrobial prophylaxis guideline was average 82%, with Gynecological Surgery and General Surgery was 94% and 74%, respectively. Compliance rate in the first 3 months was 66 - 78%, but maintained over 83% over the remaining 6 months of the year. Non-adherenced cases were mainly in wrong times of administration or wrong duration of use. The result observed was similar to the survey conducted in Cho Ray Hospital (2017) with the compliance rate was 76.6% [7]. Whereas, a study of Ahmed Abdel-Aziz in Qatar (2013) found that the guideline for antibiotic prophylaxis was complied with 46.5% [2]. In the other study in Philippines, it can be seen that overall appropriateness in using antibiotic prophylaxis was low, 13% [4].
- Adherence to Antibiotic prophylaxis Guideline in each parameter
During the study period, 100% of clean and clean – contaminated surgical procedures were given prophylactic antibiotics. Of these, the proportion of cases with appropriate choice and dose of antibiotics were quite high, 96% and 99%, respectively. About 94% of surgical cases has antibiotics indicated with right administration timing (within 60 minutes before surgical incision). These results were much higher than the study of Maria Isabel P. Nabor (2015) which showed that 44% complied with the guideline for the choice of antibiotics, 39% for dose, 45% for administration time [4].
Regarding the criteria for right duration: there were 94% of total cases using antibiotic prophylaxis with the right duration (within 24 hours after surgery). This compliance rate markedly increased compared to our hospital’s previous survey in 2018 (68%) and was higher than existing scientific literature. A study at Thanh Nhan Hospital indicated that 100% cases were given post operation antibiotics and only 2.5% had antibiogram results before using antibiotics [6]. Similarly, in the study of Maria Isabel P. Nabor (2015), there were 67% surgeries which had the appropriate duration of prophylatic antibiotic [4]. Overall, the extended use of antimicrobial prophylaxis after surgery is a common issue in many hospitals in Vietnam, especially in high-risk surgical procedures, such as adhesive wound, Group B Streptococcus infection in pregnancy...However, it is not recommended to use antibiotic prophylaxis beyond 24 hours of surgery unless proven infection indications. Utilization of antibiotic prophylaxis in the appropriate duration helps to reduce the risks of antibiotic resistance and adverse effects [3].
With regards to the criteria for right redosing: 100% surgeries lasting longer than 4 hours were given repeated dose at the appropriate time, but the dosage was not proper as recommended guideline.
- Conclusion
The present study demonstrated that adherence to the local guidelines for antimicrobial prophylaxis in our hospital was fairly encouraging. In order to achieve these results, both the Hospital Leadership and the Hospital Antibiotic Management Board have given positive response to the relevant departments and surgeons through the hospital quality report. Some initial positive achievements we had were the compliance rate of antibiotic prophylaxis guideline increased, the length of using antibiotic post-operative decreased.
In order to ensure surgical patient’s safety and rational antibiotic use, our hospital is going to continue promoting solutions to improve the adherence to surgical antibiotic prophylaxis policy in 2020.
REFERENCES
- Ministry of Health (Vietnam), Guideline for prevention and control of infection, 2012.
- Abdel-Aziz, A., El-Menyar, A., Al-Thani, H., Zarour, A., Parchani, A., Asim, M., El-Enany, R., Al-Tamimi, H., & Latifi, R. (2013), Adherence of surgeons to antimicrobial prophylaxis guidelines in a tertiary general hospital in a rapidly developing country, Advances in pharmacological sciences, 842593.
- Dale W. Bratzler, E. P. (2013). Clinical practice guidelines for antimicrobial. Am J Health-Syst Pharm.
- Nabor, Maria Isabel P. et al. (2015), Compliance with international guidelines on antibiotic prophylaxis for elective surgeries at a tertiary-level hospital in the Philippines, Healthcare Infection, Volume 20, Issue 3, 145 – 151.
- Ministry of Health (Vietnam), Guideline for prevention surgical site infection, 3671/QĐ-BYT, 27/09/2012.
- Nguyen Thi Hoai Thu, Bui Kim Tuyen, Phung Thanh Hung, Pham Quynh Anh
Practical use of antibiotics in patients with surgery and some influential factors in general surgery of Thanh Nhan Hospital, Hanoi, 2015, Public Health Magazine, 40 (3), 70- 77. - Phạm Thị Ngọc Thảo, (2018). Efficacy of Antimicrobial Stewardship Program in coltrolling antibiotic use in ICU ward and antibiotic prophylaxis at a tertiary teaching hospital in Vietnam, Conference of Vietnam National Asspociation of Emergency, Intensive Care Medicine and Clinical Toxicology.