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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 9  |  Issue : 2  |  Page : 40-47

Surgical antimicrobial prophylaxis: Knowledge and compliance of guidelines among surgeons in a tertiary care teaching hospital


1 Department of Microbiology, J. N Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
2 MBBS 3rd Professional, J. N Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
3 Department of Community Medicine, J. N Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
4 Department of Surgery, J. N Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
5 Intern, J. N Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India

Date of Submission02-Nov-2020
Date of Decision21-Nov-2020
Date of Acceptance20-Jul-2021
Date of Web Publication1-Feb-2022

Correspondence Address:
Dr. Bhanu Chaudhary
Room No: 246, Hadi Hasan Hall, Aligarh Muslim University, Aligarh Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpsic.jpsic_36_20

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  Abstract 


Introduction: Surgical antimicrobial prophylaxis (SAP) is considered vital for reducing surgical site infection, however, if inappropriate, it prolongs the hospital stay of patients, increases morbidity, promotes antimicrobial resistance and puts an economic burden on the health system. This study was carried out to assess the knowledge and compliance of SAP among surgeons in a hospital.
Methods: A quantitative, non-interventional study was done among surgeons from a tertiary teaching hospital. First, we evaluated participant knowledge from different surgical specialities by the pre-designed questionnaire, and second, we audited surgeries during the study period of 3 months for a compliance rate of SAP. The score of responses and compliance to SAP variables during surgeries was studied.
Results: We assessed a total of 184 participants for knowledge and 271 surgeries were audited. Among the variables of surgical prophylaxis, majority of the participants answered correctly about the route and timing of administration of SAP in 179 (97.3%) and 145 (78.8%) respectively. Only 66 (35.9%) knew about the correct choice of SAP while 78 (42.4%) responded correctly about the duration within which it should be stopped. However, two-third 138 (75%) were aware of the assessment of beta-lactam allergy before administration. Among the surgeries audited, 83.7% compliance was noted for the timing of administration of antibiotics, however, in only 42 (26.7%) cases SAP was stopped within 24 h of surgery and in only 38 (24.2%) cases cefazolin/cefuroxime was given as prophylaxis.
Conclusion: This study highlighted the importance of knowledge and awareness of SAP guidelines among surgeons. There is a need to train surgeons regarding this important issue.

Keywords: Antimicrobial prophylaxis, compliance, guidelines, surgeons, surgical site infection


How to cite this article:
Khan F, Chaudhary B, Sultan A, Alvi Y, Ahmad M, Kumar P, Shah MS, Khan HM. Surgical antimicrobial prophylaxis: Knowledge and compliance of guidelines among surgeons in a tertiary care teaching hospital. J Patient Saf Infect Control 2021;9:40-7

How to cite this URL:
Khan F, Chaudhary B, Sultan A, Alvi Y, Ahmad M, Kumar P, Shah MS, Khan HM. Surgical antimicrobial prophylaxis: Knowledge and compliance of guidelines among surgeons in a tertiary care teaching hospital. J Patient Saf Infect Control [serial online] 2021 [cited 2022 Jun 30];9:40-7. Available from: https://www.jpsiconline.com/text.asp?2021/9/2/40/337093




  Introduction Top


Surgical site infections (SSIs) are infections occurring at or near a surgical incision within 30 days of the procedure or within 90 days if an implant is left in place.[1],[2] SSIs are the second-most frequent cause of health-care-associated infections and are mainly responsible for increased post-operative morbidity and mortality.[3] Literature shows that the overall rate of SSI varies from 7.4% in high-income countries to 20% in low-income countries.[4]

About one-third of the SSI could be prevented by taking appropriate infection control measures in the pre-, intra- and post-operative periods. Surgical antimicrobial prophylaxis (SAP) refers to a very brief course of an antimicrobial agent which is initiated just before surgery, to prevent infections at the surgical site.[1] However, despite the evidence of its effectiveness and the available national and international guidelines for antimicrobial prophylaxis, its use is often found to be suboptimal and inappropriate in 30%–90% of cases.[5],[6]

Recent data suggest inapt SAP practices worldwide prolong the hospital stay of patients, increase patient morbidity (by exposing them to the adverse effects of antibiotics), promote antimicrobial resistance (AMR) and put an economic burden on the health system.[7],[8],[9]

SAP is a leading indication for antibiotic use in the hospital setting.[10] High rates of inappropriate SAP prescribing are also considered a driver of the emergence of AMR.[11] In India, not much data are available on the pattern of use of prophylactic antibiotics. Judicious and appropriate use of SAP would not only curtail SSI rates but would also prevent the development of AMR by avoiding the needless and incorrect administration of antibiotics sometimes beyond 24 h.[12]

Proper SAP practice requires good knowledge of international and national guidelines among the hospital staff and regular evaluations of prophylaxis protocols. In developed countries, these SAP protocols are regularly monitored and revised.[13] There is a paucity of such researches in developing countries, especially in terms of knowledge and attitude of surgeons about appropriate SAP. Hence, this study was planned to assess the knowledge of surgeons through structured questionnaires and compliance rate through SAP audit tool, regarding SAP and actual practices in our hospital.


  Methods Top


Study location

The study was conducted at Jawaharlal Nehru Medical College Hospital (JNMCH), a tertiary care referral centre and teaching hospital of western Uttar Pradesh, India.

Study participants

All the consultants and residents of the hospital from different surgical branches, namelyorthopaedics, surgery, obstetrics and gynaecology, otorhinolaryngology, plastic surgery and pediatric surgery, those involved in SAP practices were eligible for participation in the study. We also included doctors from anaesthesiology department as it was also involved in providing SAP practices. All the surgeries from above mention department during the study duration of 3 months were eligible to be audited.

Sampling

For the selection of the sample, we performed stratified random sampling, strata being each department. We prepared the sampling frame of all the eligible participants from the list obtained from the medical superintendent, stratified into various departments. With an aim to sample half of the study population, a total sample size of 184 participants was selected, drawing participants from respective departments by probability proportional to size. Meanwhile, actual practices of SAP were recorded through randomly selected surgeries in each surgical specialty for 3 months.

Study design

A hospital-based collective, quantitative, non-interventional cross-sectional study was done to assess the knowledge and compliance rate among the surgeons of above mentioned surgical departments towards SAP guidelines.

Inclusion criteria

Consultants and residents of JNMCH from the specialities providing SAP practices, who gave consent to participate in the survey were included in the study. In regard to the selection of surgeries to be audited, all surgeries from above mention department during the study duration of 3 months were included.

Exclusion criteria

Residents and consultants of nonsurgical departments and those from surgical specialities who did not give consent for the study were excluded from being selected. Surgeries of patients with carcinoma, immunodeficiency and dirty surgeries were excluded from being audited.

Study instruments

We developed two tools for our study. For assessment of knowledge of SAP, a structured self-administered questionnaire based on World Health Organisation (WHO) formulated evidenced-based SAP guidelines were developed.[14] The questionnaire consists of six different domains of SAP in form of six closed-ended questions with multiple choice. Participant's response was considered correct when found in accordance with WHO recommendations. For assessment of compliance, an SAP audit tool was developed for recording of/the SAP practices from different surgical OTs. Apart from general surgical information, the SAP audit tool enquired data on the choice of the antimicrobial agent, the timing of its administration, and the total duration of the prophylaxis.

Statistical analysis

The statistical analysis of the questionnaire was done using SPSS v20.0 (IBM Corp, Armonk, NY, US) to characterise the population parameter and study variables. Data were tabulated and descriptive data were presented as frequency, mean, percentage and standard deviation (SD).

Ethics

Ethical clearance was obtained from the Institutional Ethics and Research Advisory Committee, Faculty of Medicine, Aligarh Muslim University, Aligarh before starting the collection of data. Verbal informed consent was obtained from participants for their voluntary participation in the study before administering the questionnaire. Participants were also conversed that the information will be kept confidential.


  Results Top


Total 184 surgeons and anesthetists from different specialities were approached and recruited over a period of 3 months who filled the pre-designed questionnaire. The participants included general surgeons (n = 39, 21%), gynaecologists (n = 33, 17.9%), orthopaedic surgeons (n = 43, 23.3%), paediatric surgeons (n = 2, 1%), plastic surgeons (n = 6, 3.2%), neuro surgeons (n = 4, 2.1%), oto-rhino-laryngologists (ENT) (n = 9, 4.9%) and anaesthetists (n = 48, 26%). Majority of the participants were junior residents 136 (73.9%) followed by Assistant professors 24 (13%). The average surgical experience of junior residents was 1.34 years (SD = 0.78), while that of Assistant professors was 11.1 years (SD = 3.7). Professors 7 (3.9%) were least recruited in the study. Total 271 surgeries were evaluated during this 3 months study period regarding actual SAP practices. Of these, 56 (20.6%) were general surgeries, 28 (10.3%) orthopedic surgeries, 27 (9.9%) paediatric surgeries, 9 (3%) neurological surgeries, 21 (7.7%) plastic surgeries, 22 (8.1%) gynaecological surgeries, 88 (32.4%) obstetrics surgeries, 16 (5.9%) ENT surgeries while 4 (1.4%) were cardio-thorasic surgeries. Details of this are given in [Table 1].
Table 1: Department wise distribution of participants and audited surgeries during study period

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Knowledge score

Among the six common components of the pre-designed questionnaire on SAP, majority of the participants answered correctly about route 179 (97.3%) while 145 (78.8%) had correct knowledge regarding the timing of administration of SAP. Surprisingly, only 37 (20.1%) knew that SAP is not compulsory in all surgeries. Nonetheless, the right choice of antibiotics and the optimum duration of SAP as per guidelines were known to only 66 (35.9%) and 78 (42.4%) of participants, respectively. However, two-third 138 (75%) answered correctly about the assessment of beta-lactam allergy before injecting the drug [Table 1].

On quantitative analysis of the knowledge on SAP it was noted that the senior residents and junior residents (1st year) had the highest scores of approximately 60%. It was noted that the surgeons with maximum experience (professors) had minimum scores (42.9%). Scores of Assistant professors (56.2%) were almost similar to that of other junior residents (57.7%). On comparing knowledge of individual variable of the questionnaire, it was found that senior residents were more aware (35.3%) that SAP is not required in all surgeries while other participant's response was between 14% and 20%. Maximum variability among different participant groups was regarding the choice of antibiotics [Table 2].
Table 2: Percentage of correct response of each question along seniority/experiences

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On comparing the scores of various specialities, gynecologists were found to have the highest scores (78.3%) followed by the anaesthetists (58.7%). The lowest score was of orthopaedic surgeons (46.5%) and paediatric surgeons (41.7%). Responses on individual variables of the questionnaire showed that neurosurgeons considered all surgeries as an indication for SAP (0%) but they had good knowledge about the timing of SAP (100%). Nearly all the specialities and groups knew the correct preferred route of SAP. However, the big discrepancy was observed regarding the duration of SAP varying from 0% to 78.8% among plastic surgeons and gynecologists, respectively. As far as the preferred choice of SAP is concerned, only gynaecologist (100%) scored well while scores were poor in nearly all specialties. Despite the fact, plastic surgeons did not scored well on the preferred choice of SAP (0%), they had good knowledge about prior testing of beta-lactam allergy (83.3.%) and that SAP is not required in all surgeries (33.3%) which was the highest among all specialties. ENT surgeons (100%) also knew about prior testing of beta-lactam allergy [Figure 1].
Figure 1: Frequency of Correct response of each question among various specialities

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Compliance

On observing the actual data of surgeries audited during the study period, maximum compliance was found for the route of administration (100%), followed by appropriate requirement and timing of SAP administration which was correctly followed in 86.4% and 83.7% surgeries, respectively. Only exception to timing of administration was pediatric surgeries, where it was followed in only 4 (14.8%) of audited surgeries. The least compliance was observed to the duration of SAP 52 (19.1%), the maximum being obstetric surgeries 36/52 (69.2%). Moreover, SAP was given beyond 24 h in nearly 80% of audited surgeries. The maximum duration of post-operative antibiotics reported was 14 days which was followed mainly in neurosurgeries. The mean duration of post-operative antibiotic therapy was 5.43 days [Table 3]. On examining the choice of antimicrobial, cefazolin was only employed in 130 (47.9%) surgeries followed by ceftriaxone/cefoperazone 72 (26.5%). Other antibiotics, i.e: Pipercillin-tazobactam, cefoperazone salbactum and amoxyclav were given in 20 (7.3%), 28 (10.3%) and 21 (7.7%) of surgeries, respectively.
Table 3: Compliance rate of surgical antimicrobial prophylaxis variables in audited surgeries

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  Discussion Top


Improper implementation of SAP is one of the contributing factors towards AMR, whereas proper attainment of SAP practices is a challenge and requires good knowledge of the guidelines and attitude towards practices as per recommendations. This study was planned with the aim to evaluate knowledge and compliance rate among all grades of surgeons in various branches and to compare this knowledge with actual SAP practices being followed in our hospital during surgeries.

A total of 184 surgeons and anaesthetists participants from different specialities filled the predesigned questionnaire. Majority of the participants were junior residents 136 (73.9%) followed by assistant professors 24 (13%). Professor 7 (3.9%) were least recruited in the study. Enrollment of residents in our study was more as compared to other studies.[15] However, the proportion of assistant professors and professors involved in the study was lower when compared to a study on cardiothoracic surgeons.[16] This lower involvement of professors in our study may be because of their busy schedule and other administrative responsibilities, as our's is a teaching hospital. Majority (77%) of participants had ≤2 years of surgical experience, which is in concordance with a similar study.[17]

The participants included in our study were surgeons (n = 136, 84%), and anaesthetists (n = 48, 26%). Other studies also reported a similar proportion of participants.[17] Among the surgeons recruited, (n = 39) 21% were general surgeons, gynaecologists (n = 33, 17.9%), orthopaedic surgeons (n = 43, 23.3%), paediatric surgeons (n = 2, 1%), plastic surgeons (n = 6, 3.2%), neuro surgeons (n = 4, 2.1%) while oto-rhino-laryngologists (ENT) (n = 9, 4.9%). This is probably first report from developing countries like India on assessment of knowledge which included nearly all surgical specialities in the survey. All the other reports involved either surgeons of one or two specialities along with anaesthetist.[13],[15],[16],[17]

In our study, the majority of the participants answered correctly about route 179 (97.3%) while 145 (78.8%) had correct knowledge regarding the timing of the administration of SAP. A study from Iran reported similar responsiveness among their cardiothoracic surgeons regarding the timing of SAP bolus.[16] In another study from Sudan, 13% of respondents gave correct responses regarding the choice of drug (cefazolin), which is quite low as compared to our survey (35.9%) while a study from Iran reported higher 70% awareness among their study group.[16],[17] Surprisingly, only 37 (20.1%) participants in our study were aware of the fact that clean surgeries can be performed without SAP. Other reports have documented a higher level of awareness among surgeons.[16],[17] Authors have described 60.6% awareness regarding the duration of SAP, while in our survey, it was found to be only 42.4%.[15]

However, two-third 138 (75%) answered correctly about the assessment of allergy before injecting the drug. In the study by among medical staff from Ethiopia, 42.4% had knowledge of beta-lactam allergy testing and its recommendations.[15]

On analysing the knowledge on SAP it was noted that the senior residents and junior residents (1st year) had the highest scores of approximately 60%. Scores of Assistant professors (56.2%) were almost similar to that of other junior residents (57.7%). Knowledge among residents and Assistant professors could be attributed to ongoing assessments at all levels. It was noted that the surgeons with maximum experience (professors) had minimum scores (42.9%). A study among cardiothoracic surgeons also reported a similar correlation with the age of participants.[16] Maximum variability among different participant groups was regarding the choice of antibiotics. This could be due to the overprotective attitude, fears, false belief and ongoing practices that high-end antibiotics and prolonged therapy will be more effective in preventing SSI.

Among the various specialties, gynaecologists were found to have the highest scores (78.3%) followed by the anaesthetists (58.7%). Reasonably high responsiveness among gynaecologist was attributed to their ongoing participation in educational activities, continuous checks at the government level, the enthusiasm of senior professionals and recent formulation of SAP guidelines by the department. Another study from similar settings to ours also reported higher compliance among gynaecological surgeries.[12] The lowest score was of orthopedic surgeons (46.5%) and peadiatric surgeons (41.7%). Even though neurosurgery literature concluded that 3rd generation cephalosporins has no superior role over routine SAP antibiotics.[18] Responses on individual variables of the questionnaire by neurosurgeons showed every surgery as indication for SAP and consideration of third-generation cephalosporins as SAP. However, the big discrepancy was observed regarding the duration of SAP varying from 0% to 78.8% among plastic surgeons and gynaecologists, respectively. A study among cardio-thoracic surgeons reported 66% awareness regarding the duration of SAP among their surgeons.[16] On the choice of SAP, only gynaecologist (100%) scored well while scores were poor in nearly all specialities. The study from Ethiopia, reported 62.7% responsiveness regarding the choice of drug.[15] Overall, poor adherence to the guidelines has been reported by various studies, specifically in the area of antimicrobial selection, timing and the duration of antimicrobial prophylaxis.[19]

Nearly 75% of general surgeons were aware of the timing of SAP administration which is high as compared to other reports.[17],[20] In our study, plastic surgeons were found to have good knowledge about prior testing of beta-lactam allergy (83.3.%) and SAP indication (33.3%) which was highest among all specialties.

Of 271 surgeries audited for compliance to SAP formulations, overall compliance in our study was found to be 67% which is in concordance with others.[12] Other authors have reported lower compliance.[13],[21] Of the procedures, 37 (13.6%) were wrongly given SAP in our study while the timing of SAP administration was correctly followed in 83.7% which corroborates with the report from our neighbouring country.[13] Noncompliance to SAP indication in clean surgeries leading to unnecessary antibiotic use is one of the factors responsible for the development of AMR.[22]

Another compounding factor observed in our study was the choice of antimicrobial. Cefazolin was only employed in 130 (47.9%) surgeries followed by ceftriaxone/cefoperazone 72 (26.5%). This finding corroborates with the report from Qatar.[23] Another study reported that 42.4% of procedures received ceftriaxone.[13] Reports from India also described the use of third-generation cephalosporins for routine prophylaxis,[24] while an Italian study showed a higher compliance rate of 84.5% regarding the choice of drug in the hospital.[25] Other antibiotics used in our study were piperacillin-tazobactam, cefoperazone salbactum, amoxy-clav were given in 20 (7.3%), 28 (10.3%), 21 (7.7%) of surgeries, respectively. SAP was given beyond 24 h in nearly 80% of audited surgeries. Maximum duration of post-operative antibiotics reported was 14 days which was followed mainly in neurosurgeries. These findings indicate a general trend among the surgeons to prefer broad-spectrum drugs and prolonging it for usually longer durations which aggravates the above-mentioned problem of AMR in developing countries like India.

As shown in table, maximum compliance was found for the route of administration (100%) in our study as well as other reports.[24],[25],[26],[27],[28],[29],[30] Regarding the timing of SAP administration, it was followed in 83.7% of procedures in our study while previous reports from India documented uneven administration of antibiotics ranging from 30 min to 6 h before surgery.[24] The reason for noncompliance to timing was the routine practice of administering the first dose of prophylaxis in the ward instead of operation theater in paediatric patients. Despite the awareness of beta-lactam allergy testing among our participants, it was followed in comparatively less procedures. This practice was routinely followed in gynae and obstetrics and a few general surgeries. Researchers from Pakistan reported similar practices while other reports did not mention this variable [Table 4].[13]
Table 4: Comparison of previous literature with the present study

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  Conclusion Top


This study highlighted the important issue of knowledge and attitude of SAP guidelines towards better practices among surgeons, which was observed to be towards the lower side. Among SAP guidelines, not only knowledge regarding a few indicators (indication, duration and choice of SAP) were lower, their compliance in routine practice was also poor. In the background of surgeons' advocacy for local guidelines based on patient profile and antibiotic susceptibility, we also concluded that hospital-based guidelines for presurgical antibiotics prophylaxis could be prepared in consultation with surgeons, microbiologists and pharmacologists. All these points towards the immediate need for routine induction and periodic follow-up training for promoting better SAP knowledge in training institutions and hospital settings, along with the need for a regular audit of prescriptions to maintain any improvement in standards.

Acknowledgements

We are extremely thankful to Mr. Soyab Khan, Infection Control Nursing Officer for helping us with the audit of SAP practices during surgeries.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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