2020, Number 4
Analysis of the compliance of antibiotic prophylaxis in elective laparoscopic cholecystectomy in a Mexican hospital
Full text
10.35366/101396
Language: English/Spanish [Versi?n en espa?ol]
References: 16
Page: 274-280
PDF size: 221.65 Kb.
ABSTRACT
Introduction: The administration of preoperative antibiotic prophylaxis reduces the risk of surgical site infection development, however, although there are preset recommendations for their prescription, these are often not met. Objective: To describe the compliance and results of preoperative antibiotic prophylaxis in elective laparoscopic cholecystectomy in our center. Material and methods: An observational, longitudinal, prospective and descriptive study was conducted, including the patients who underwent elective laparoscopic cholecystectomy in our hospital from July 1 to December 31 of 2018 in search of surgical site infection and other complications. Results: Preoperative antibiotic prophylaxis was administered in 97% (n = 162) of the cases, but only in 54% of the patients (n = 87) was prescribed correctly. Only 1% (n = 2) presented surgical site infection. Conclusions: In our study, despite there being a low correct prescription of preoperative antibiotic prophylaxis, only 1% of the cases developed surgical site infection, which is why we support the arguments of some clinical practice guidelines of not prescribing it systematically, but selecting the patients according to their characteristics and risks instead.INTRODUCTION
Surgery site infections (SSIs) are defined as "surgical procedure-related infections that occur near the incision site within the first 30 days of the surgical procedure or within the first 90 days of an implant placement",1 while healthcare-associated infections (HAIs) are defined as "infections that patients acquire while receiving medical care". SSIs are the most frequently occurring HAI in low- and middle-income countries (LMICs), affecting up to one in three patients undergoing surgical procedures, and although they are seen less frequently in middle- and high-income countries (MHICs), they are still the second most frequent type of HAI in Europe and North America.2
Preoperative antibiotic prophylaxis (PAP) is defined as "the prevention of infectious complications through the effective administration of antibiotics prior to contamination during a surgical procedure".3 It combats bacterial contamination of tissues that under normal conditions are free of microorganisms and prevents endogenous or exogenous flora entering the surgical area from multiplying and favoring the development of infection.4,5 In the vast majority of surgical procedures, the effective administration of PAP is usually recommended and, although institutions such as the World Health Organization (WHO), the Centers for Disease Control and Prevention (CDC),1 the National Institute for Health and Care Excellence (NICE),6 and the Infectious Diseases Society of America (IDSA),3 among others, have published clinical practice guidelines (CPG) with precise recommendations on its management, it has been shown that these are not complied with on a daily basis and that PAP is often administered inefficiently and arbitrarily.7 In our country, the Mexican Social Security Institute (IMSS), through the CPG "Prevention and diagnosis of surgical site infection", oversees the recommendations that are specifically applied in our territory,8 and each hospital must adapt to those recommendations according to its antimicrobial resistance profile (Figure 1). Adhering to them by making good use of antibiotics reduces antimicrobial resistance and improves the patient's prognosis.9
Elective laparoscopic cholecystectomy (LEC) is the most frequently performed abdominal procedure worldwide and is the treatment of choice for patients with cholelithiasis and acute cholecystitis.10 Because of this, there have been multiple studies that have presented controversial results on the development of infections in this procedure. In 2010, Sanabria et al. conducted a Cochrane review that included 11 randomized clinical trials with 1,664 patients concluding that the clinical evidence was not sufficient to support or refute the use of PAP.11 On the other hand, in 2018, Sajid and his team conducted a systematic review and meta-analysis that included 25 randomized clinical trials with 6,138 patients with the same objective, obtaining statistically significant results in the control group and evidencing the importance of a correct PAP,12 so it is evident the need to conduct new studies that have the ability to provide an enlightening answer to this problem.
The aim of this article was to analyze the PAP compliance of patients undergoing CLE in a tertiary hospital in Mexico City.
MATERIAL AND METHODS
An observational, prospective and descriptive longitudinal study was conducted, which was submitted for review by the Hospital Bioethics and Research Committee of our institution and was approved with the number 2018EXT295. The clinical records of all patients who underwent CLE within a third level hospital in Mexico City during the period between July 1 and December 31, 2018, were reviewed in search of the development of post-surgical complications.
All patients older than one year who underwent CLE within the study time were included (n = 227), while those whose trans-surgical findings conditioned the administration of antibiotics therapeutically were excluded (n = 60). It was not necessary to eliminate clinical records due to ambiguity or lack of information. A total of 167 clinical records were considered for the analysis. The study variables were gender, age, allergies, comorbidities (smoking, overweight, obesity, type 2 diabetes and immunosuppression), diagnosis, PAP (antibiotic, dose, and time), development of ISQ, Clavien-Dindo scale, days of in-hospital stay (DEIH) and readmission. The information from the medical records was captured in electronic format for statistical analysis, which was carried out with the Statistical Package for the Social Sciences (SPSS) v.24 software to obtain measures of central tendency and dispersion.
RESULTS
Of the patients who underwent CLE, 44% were male and 56% were female. The mean age was 48 years (SD ± 15.36). The most common admission diagnosis was cholelithiasis in 88% (n = 147) of the cases, followed by polyposis in 9% (n = 15), dyskinesia in 2% (n = 3), and others 1% (n = 2).
Of the patients, 43% (n = 72) reported active smoking, while the most common comorbidities were overweight in 67% (n = 112) of cases, obesity in 26% (n = 43), type 2 diabetes in 15% (n = 25) and immunosuppression in 4% (n = 7).
Of the patients, 14% (n = 23) reported being allergic to at least one antibiotic, with penicillin allergy being the most common in 57% (n = 13) of the cases.
Ninety-seven percent (n = 162) of patients were administered PAP, with cephalosporins being the most frequently administered antibiotic group in 80% (n = 130) of cases (Figure 2).
The dose was correct in 65% of the cases for which antibiotics were indicated (n = 105), while the time for adequate administration was met in 78% of the patients (n = 126) (Figure 3); however, when analyzing the three PAP variables (correct time, antibiotic used and adequate posology), the latter was correctly indicated in only 54% (n = 87) of the cases.
Of the patients, 2% (n = 4) had postsurgical complications: 1% (n = 2) had surgical site infection and 1% (n = 2) had other complications, while only one patient was classified as grade IV on the Clavien-Dindo scale (anaphylaxis).
The mean in-hospital length of stay was 2.05 days (SD ± 1.22) and readmission was necessary in only 2% (n = 3) of cases.
Additionally, information on 3% (n = 5) of patients who underwent CLE but did not have PAP administered on the surgeon's indication, is shown in Table 1.
DISCUSSION
SSIs and the complications arising from them are a frequent and potentially lethal problem that represents a significant increase in morbidity and mortality, hospital length of stay and healthcare costs,13 and can be associated with any type of surgical procedure. In 2013, the European Centre for Disease Control and Prevention (ECDC) conducted a study in 16 countries where it reported that the highest cumulative incidence according to the type of surgical procedure was presented by colon surgery with 9.5 cases per 100 operations, followed by coronary revascularization surgery with 3.5 cases, cesarean section with 2.9 cases and cholecystectomy with 1.4 cases.14 The cumulative frequency of SSI in LSC in our hospital for the study period was 1.19 cases per 100 LSC operations. In the results it is mentioned that 1% corresponds to two patients out of 167 studied, so the numbers do not coincide, and they are slightly lower than those reported in the literature.
In our study, 93% of patients who underwent CLE were overweight or obese, 43% smoked, 15% had type 2 diabetes, and 4% were immunosuppressed, significantly increasing the risk of developing SSI.
Recent research has contrasted the information shown in different guides with respect to the principles established in the literature and experimentally, showing the lack of knowledge and arbitrary use of various antibiotics in multiple surgical centers.15 As a general rule, the time of administration of PAP should be one hour prior to the surgical incision, being usually a first or second generation cephalosporin the antibiotic of choice (Table 2), while as an alternative for patients with a history of known allergy to penicillin, vancomycin or clindamycin can be administered.8,16 In addition, periodic evaluation of the epidemiological and microbiological situation of each institution, the availability of supplies and the particularities of the medical specialties should be considered in order to determine the rotation and modifications in the antibiotics to be used.5,15
In our study, 97% of the patients were administered PAP, showing a high percentage of compliance in this aspect; however, the wrong dose was administered in 35% of the cases without complying with the recommendations in terms of application time in 22% of the patients, evidencing the lack of homogeneity in the criteria applied by different surgeons.
When analyzing the results of the three variables that were considered to determine whether the prescription was correct (antibiotic, dose, and time), an optimal indication was only achieved in 56% of the cases and despite this, only two patients in the sample developed SSI.
Regarding the five patients who underwent CLE, but who did not receive PAP due to preference or omission of the treating physician, none presented clinical manifestations compatible with an infectious process, their length of stay in hospital was like that of the rest of the population (2.20 vs. 2.05) and in no case was hospital readmission necessary.
Overall, both the low incidence of SSIs, despite the incorrect administration of PAP, and the absence of SSIs, and the lack of administration of PAP generate controversy as to whether its use is necessary on a routine basis. It should be considered that the arbitrary use and abuse of antibiotics in both ambulatory and hospitalized patients is accompanied by an increase in the appearance of new infections, adverse reactions and antimicrobial resistance, so that the prevention, approach and management of SSIs should be an active, continuous and primordial attitude for all personnel involved in health care and especially for the surgeon, who should also monitor their possible appearance during the postoperative period to enable him to make an early diagnosis with the aim of providing timely treatment.13
CONCLUSIONS
In our study, the optimal prescription of PAP was complied with in approximately half of the cases and despite this, only a minimal percentage of patients developed SSI, which is why we support the arguments of some CPGs not to prescribe it systematically, selecting patients according to their characteristics and risks. However, we consider that studies with a rigorous scientific methodology are required to issue final recommendations. In the meantime, we conclude that it is imperative to formalize continuous updating programs to standardize the criteria under which PAP is administered as well as to implement checklists to guide surgeons in their decision making.
REFERENCES
AFFILIATIONS
1 General Surgery Program, Mexican School of Medicine, Universidad La Salle, Mexico.
2 Infectious Diseases Program, London School of Hygiene & Tropical Medicine, London, United Kingdom.
CORRESPONDENCE
Daniel González Hermosillo-Cornejo, MD.E-mail: dr.gonzalezhermosillo@gmail.comReceived: 04/29/2019. Accepted: 11/08/2019