Peri-operative Antibiotic Prophylaxis

2nd QI Cycle results

Compiled by: Dr Stella Sasha

2nd QI cycle

• 4 weeks (11 April – 8 May)• Elective MIS cases

– Hysterectomy +/- salpingo-oophorectomy– Myomectomy– Oophorectomy– Cystectomy– Others

• Excluding diagnostic laparoscopy, pregnant women

• Total 63 eligible cases

All eligible elective MIS surgeries•Cystectomy

•Oophorectomy•Myomectomy

•TLH +- BSO

In induction room, after IV plug is set30 to 60 min before knife to skin

No penicillin / cephalosporin allergies ALLERGIC to penicillin / cephalosporin

IV Cefazolin 1g for pts < 80kgOR IV Cefazolin 2g for pts ≥ 80kg± IV Metronidazole 500mg once (for major pelvic/bowel surgery)

IV Clindamycin 600mg once± IV Ciprofloxacin 200mg once

Record data in data capture formPlease do not give routine post-operative PO / IV Abx unless clinically indicated

Implementations from 1st Cycle

• OT staff – First case to be at the OT by

8am – Subsequent cases should be

sent for ≥ 1h before estimated start of operation

• Anaesthetists– Reminded to administer

antibiotics at the induction room within 30-60 mins to KTS

• Surgeon – Reminded to only prescribe

post-op antibiotics if indicated

• Reminder cards – Placed in OT to remind

doctors and nurses of ongoing audit

• Audit process – Made easier with the help of

OT staff inserting audit forms into MIS case notes

• Attempted for MOs at Day Surgery to administer IV Abxfor all MIS first case– Abandoned after 1 week

because of concerns regarding patient safety

Characteristic of CohortFrequency % of total cohort

Weight

< 80 kg 56 88.9

> 80kg 5 7.9

Unknown 2 3.2

BMI

< 30 52 82.5

≥ 30 7 11.1

Unknown 4 6.3

Diabetes status

Diabetic 2 3.2

Non-diabetic 61 96.8

ASA

1 34 54.0

2 25 39.7

3 4 6.3

Diagnosis

Benign 52 83.9

Pre-malignant 5 7.9

Malignant 6 9.5

Types of Elective MIS Operations

20

3

14

6

16

4

Cystectomy

Oophorectomy

Myomectomy

TLH BS

TLH BSO

Others

Other laparoscopic operations: • Endometriosis ablation • Salpingostomy• Ovarian drilling• Tubal recanulation

Total: 63 cases

Preop Abx Choice

55%

27%

8%

3%

1% 2%

2% 2%IV cefazolin

IV cefazolin + IV metronidazole

IV cefazolin + IV metronidazole + ivgentamicin

IV clindamycin

IV clindamycin + IV metronidazole

IV clindamycin + IV ciprofloxacin

IV ceftriaxone + IV metronidazole+ IV gentamicin

Unknown

• Wide range of pre-operative antibiotics used • Non-compliance with the recommended antibiotic regime

Dosage of IV cefazolin, Weight >80kg

3

2

IV cefazolin 1g

IV cefazolin 2g

• Only 2 out of 5 patients, weighing > 80kg, received the adequate dose of IV cefazolin 2g

7

23

28

1

0

5

10

15

20

25

30

More than 60 min 30 to 60 min Less than 30 min After start ofoperation

Time interval between Abx and KTS

• 36% achieved target antibiotics to KTS time interval of 30-60 mins• Most antibiotics are given <30mins before KTS

Reasons for not giving antibiotics within 30-60 min interval

Interval <30 mins, First cases

3

7

2

0

1

2

3

4

5

6

7

8

Delay in pt arriving into induction Anaesthetist too busy Patient factors - difficult IVcannulation, diarrhoea

Reasons for not giving antibiotics within 30-60 min interval

Interval <30 mins, Subsequent cases

4

7

2

1 1 1

0

1

2

3

4

5

6

7

8

Sent for <1h fromKTS

Delay in ptarriving into

induction

Anaesthetist toobusy

Anaesthetistunsure what

antibiotics to give

Unscheduledearly end in prev

op

Patient factors -came in late

Reasons for not giving antibiotics within 30-60 min interval

Interval > 60 mins Given after operation

• 1 case whereby the surgeon decided to give antibiotics after the operation had started.

• 6 cases are due to unscheduled delay in the preceding operations

• 1 case was due to the surgeon arriving late for the operation

Postop IV Abx (Days)

10

39

10

2 1 1

0

5

10

15

20

25

30

35

40

45

None given 1 Day 2 Days 3 Days 4 Days 9 Days

• Most surgeons routinely prescribe IV antibiotics post-operatively• 5/10 patients who did not receive antibiotics are DS cases

Postop IV Abx (Choice)

16%

35%32%

1% 5%

1% 8%

2%

Not given

IV cefazolin

IV cefazolin + IV metronidazole

IV cefazolin + IV metronidazole+ iv gentamicin

IV ceftriaxone + IVmetronidazole

IV ceftriaxone + IVmetronidazole + IV gentamicin

IV clindamicin

IV clindamycin + IVmetronidazole

Postop PO Abx (Days)

6

31

22

31

0

5

10

15

20

25

30

35

None given 5 days 7 days 10 days 14 days

• Most surgeons routinely prescribe PO antibiotics post-operatively

Postop PO Abx (Choice)

10%

76%

6%

2%6%

Not given

PO augmentin

PO clindamicin

PO cephalexin

PO ciprofloxacin

Post-op Fever8

55

Post-op Fever

Afebrile

• Post-op fever appears to be the main reason for prolonged usage of IV AbxHowever: • Only 8 patients had post-op fever T>38• Most of the post-op fever occurred on POD1 • Only 2 patients had septic work-ups done

Readmission

• Only 2 cases of readmission

– POD 13: non-specific fever + abdo pain

• No source identified

• Discharged with PO augmentin x 5/7

– POD 7: haematuria

• Likely catheter-associated UTI

• Urine culture: NBG

SHINe Initiative Target

1st Audit 2nd Audit

Audit Cycle 15 Feb – 11 March 11 April – 8 May

No. of patients 48 63

(1) Antibiotics to KTS interval within 30-60 mins

23% 36%

(2) No post-op antibiotics 6% 7%

Combination of (1) and (2) 2% 1%

Conclusion

• To reduce the use of unnecessary antibiotics for surgical prophylaxis, more education is needed for doctors and staff regarding the use of single-shot antibiotic.