Peri-operative Antibiotic Prophylaxis. 2 nd QI Cycle results Compiled by: Dr Stella Sasha

Transcription

1 Peri-operative Antibiotic Prophylaxis 2 nd QI Cycle results Compiled by: Dr Stella Sasha

2 2 nd 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

3 All eligible elective MIS surgeries Cystectomy Oophorectomy Myomectomy TLH +- BSO In induction room, after IV plug is set 30 to 60 min before knife to skin No penicillin / cephalosporin allergies ALLERGIC to penicillin / cephalosporin IV Cefazolin 1g for pts < 80kg OR 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 form Please do not give routine post-operative PO / IV Abx unless clinically indicated

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6 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 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 Abx for all MIS first case Abandoned after 1 week because of concerns regarding patient safety

7 Characteristic of Cohort Frequency % of total cohort Weight < 80 kg > 80kg Unknown BMI < Unknown Diabetes status Diabetic Non-diabetic ASA Diagnosis Benign Pre-malignant Malignant 6 9.5

8 Types of Elective MIS Operations Total: 63 cases Cystectomy Oophorectomy Myomectomy TLH BS 6 3 TLH BSO Others 14 Other laparoscopic operations: Endometriosis ablation Salpingostomy Ovarian drilling Tubal recanulation

9 Preop Abx Choice 8% 3% 1% 2% 2% 2% IV cefazolin IV cefazolin + IV metronidazole IV cefazolin + IV metronidazole + iv gentamicin IV clindamycin 27% 55% 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

10 Dosage of IV cefazolin, Weight >80kg 2 IV cefazolin 1g IV cefazolin 2g 3 Only 2 out of 5 patients, weighing > 80kg, received the adequate dose of IV cefazolin 2g

11 Time interval between Abx and KTS More than 60 min 30 to 60 min Less than 30 min After start of operation 1 36% achieved target antibiotics to KTS time interval of mins Most antibiotics are given <30mins before KTS

12 Reasons for not giving antibiotics within min interval Interval <30 mins, First cases Delay in pt arriving into induction Anaesthetist too busy Patient factors - difficult IV cannulation, diarrhoea

13 8 7 Reasons for not giving antibiotics within min interval Interval <30 mins, Subsequent cases Sent for <1h from KTS Delay in pt arriving into induction Anaesthetist too busy Anaesthetist unsure what antibiotics to give Unscheduled early end in prev op Patient factors - came in late

14 Reasons for not giving antibiotics within min interval Interval > 60 mins 6 cases are due to unscheduled delay in the preceding operations 1 case was due to the surgeon arriving late for the operation Given after operation 1 case whereby the surgeon decided to give antibiotics after the operation had started.

15 Postop IV Abx (Days) 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

16 Postop IV Abx (Choice) 1% 5% 1% 8% 2% 16% Not given IV cefazolin IV cefazolin + IV metronidazole 32% 35% IV cefazolin + IV metronidazole + iv gentamicin IV ceftriaxone + IV metronidazole IV ceftriaxone + IV metronidazole + IV gentamicin IV clindamicin IV clindamycin + IV metronidazole

17 Postop PO Abx (Days) None given 5 days 7 days 10 days 14 days Most surgeons routinely prescribe PO antibiotics post-operatively

18 Postop PO Abx (Choice) 6% 2% 6% 10% Not given PO augmentin PO clindamicin PO cephalexin PO ciprofloxacin 76%

19 Post-op Fever 8 Post-op Fever Afebrile 55 Post-op fever appears to be the main reason for prolonged usage of IV Abx However: 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

20 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

21 SHINe Initiative Target 1 st Audit 2 nd Audit Audit Cycle 15 Feb 11 March 11 April 8 May No. of patients (1) Antibiotics to KTS interval within mins 23% 36% (2) No post-op antibiotics 6% 7% Combination of (1) and (2) 2% 1%

22 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.