antibiotics prophylaxis in appendicectomy

Use of prophylactic antibiotics in appendectomy (Audit): 

1 Use of prophylactic antibiotics in appendectomy (Audit) Zahid Bahli (Surgery) Mr J Meer (Surgery) Dr Glynn (Microbiology) May 2010- Nov 2011

Surgical prophylaxis: 

Surgical prophylaxis Goals To reduce the incidence of surgical site infection(SSI). Use antibiotics in a manner that is supported by evidence of effectiveness and minimize adverse effects Benefits of prophylaxis Reduce SSI and long or short-term postoperative mortality. Reduce short-term morbidity and hospital stay 2

Stats: 

Stats Rates of wound infection vary from <5% in simple appendicitis to 20% in cases with perforation and gangrene. Appendectomy is relatively safe with a mortality rate for non-perforated appendicitis of 0.8 per 1,000 and mortality after perforation of 5.1 per 1,000. The mortality rate is more than 20% in patients older than 70 years, mainly because of delays in diagnosis and treatment. 3

Evidence: 

Evidence Perioperative antibiotics have been shown to decrease the rates of postoperative wound infections. Cochrane Database Syst Rev . January 21, 2009 . 4

SPECIFIC RECOMMENDATIONS FOR ANTIBIOTIC PROPHYLAXIS: 

SPECIFIC RECOMMENDATIONS FOR ANTIBIOTIC PROPHYLAXIS Non penicillin allergy Co-Amoxiclav 1.2g IV +Gentamicin IV 2mg/kg Penicillin allergy Ciprofloxacin IV 400mg + Metronidazole IV 500mg 5

Objectives of the audit: 

Objectives of the audit 6

Audit protocols: 

Audit protocols Retrospective case notes study of 54+54 (two audit cycles) appendicentomies (05/2010-11/2011). Timing and type of antibiotics used Number of doses. Operative findings Wound infection (definition) Culture and sensitivities result if found. 7

Spread Sheet for two audit cycles: 

Spread Sheet for two audit cycles 1 st Audit cycle Appendicectomy antibiotics prophylaxis audit -1.xlsx 2 nd Audit cycle Appendicectomy antibiotics prophylaxis audit- 2.xlsx

Wound infection-definition: 

Wound infection-definition Surgical site infections must fulfill the following criteria Infection must occur within 30 days of surgery Infection must involve only the skin and subcutaneous tissue There must be at least one of the following Purulent discharge from a superficial infection Organisms isolated from aseptically obtained wound culture Must be at least one of the following signs of infection Pain or tenderness Localized swelling Redness or heat . Infect Control Hosp Epidemiol 1992; 13 (10): 606-8 9

Wound infection-definition: 

Wound infection-definition Deep incisional surgical site infections must meet the following three criteria : occur within 30 days of procedure (or one year in the case of implants) are related to the procedure involve deep soft tissues, such as the fascia and muscles. Plus At least one of the following criteria: purulent drainage from the incision but not from the organ/space of the surgical site a deep incision spontaneously dehisces or is deliberately opened by a surgeon when the patient has at least one of the following signs or symptoms - fever (>38°C), localized pain or tenderness - unless the culture is negative an abscess or other evidence of infection involving the incision is found on direct examination or by histopathologic or radiological examination diagnosis of a deep incisional SSI by a surgeon or attending physician. infect Control Hosp Epidemiol 1992; 13(10): 606-8 10

Results 1st audit cycle vs. 2nd audit cycle: 

11 Male: Female (35/54:19/54) Male: Female (29/54:25/54) Results 1 st audit cycle vs. 2 nd audit cycle

Preoperative antibiotics: 

12 1 st Audit cycle 2 nd Audit cycle Preoperative antibiotics

Type of antibiotics (pre-operative) (1st Audit Cycle): 

13 Co- Amoxiclave (21/46) Co Amoxiclave+ Metronidazole (16/46) CoAmoxiclave+Metronidazole+Gentamicin (4/46) Others (5/46) (Ciprofloxacine,Tazocine, others) with or without Gentamicin and Metronidazole Type of antibiotics (pre-operative) (1 st Audit Cycle)

Type of antibiotics (pre-operative) (2nd Audit Cycle): 

14 Co- Amoxiclave (4/54) Co-Amoxiclave + Gentamicin (44/54) CoAmoxiclave+Metronidazole+Gentamicin (3/54) Others (3/54) (Ciprofloxacine,Tazocine others) with or without Gentamicin and Metronidazole Type of antibiotics (pre-operative) (2 nd Audit Cycle)

Post-operative antibiotics: 

15 1 st audit Cycle 2 nd audit Cycle Post-operative antibiotics

Recommendations: 

Recommendations 1 st Audit Cycle Antibiotics prophylaxis for all appendicectomies Inappropriate combination of prophylactic antibiotics (co-Amoxiclave/Gent & ciprofloxacin/Gent). Importance of culture and sensitivity results. Reduction in surgical site infection rate in routine appendicectomies Less switching to expensive antibiotics (Tazocine) Microbiologist help 2 nd Audit Cycle 100% antibiotics prophylaxis for appendicectomies 84% patients received antibiotics according to trust guidelines(Co-Amoxiclave/Gent & Ciprofloxacin/Gent). Reduction in surgical site infection rate in routine appendicectomies (9.25% to 1.85%.) 0% switching to expensive antibiotics (Tazocine). 16

Surgical site infection rate (SSIR): 

Surgical site infection rate (SSIR)

Main outcomes of Audit: 

Main outcomes of Audit 1 st Audit Cycle Results Summary Only 14.81 % of patients undergoing appendicectomy are not receiving prophylactic antibiotics. Inappropriate combination of prophylactic antibiotics. Only 8.69% patients had nearly appropriate choice of prophylaxis. Surgical site infection rate is slightly higher (9.25% vs. 5%) in routine appendicectomies). More and more switching to expensive antibiotics (Tazocine) 2 nd Audit Cycle Results Summary 100% of the patients undergoing appendicectomy received prophylactic antibiotics. 81.4% patients received antibiotics according to trust guidelines Appropriate combination in majority of cases. Surgical site infection(SSIR) was 1.85% (well below acceptable national range )(<5%) 18

Recommendations: 

Recommendations 1 st Audit Cycle Antibiotics prophylaxis for all appendicectomies Appropriate combination of prophylactic antibiotics (co-Amoxiclave/Gent & Ciprofloxacin/Gent). Importance of culture and sensitivity results. Reduction in surgical site infection rate in routine appendicectomies Less switching to expensive antibiotics (Tazocine) Microbiologist help 2 nd Audit Cycle 100% antibiotics prophylaxis for appendicectomies 84% patients received antibiotics according to trust guidelines(Co-Amoxiclave/Gent & Ciprofloxacin/Gent). Reduction in surgical site infection rate in routine appendicectomies (9.25% to 1.85%.) 0% switching to expensive antibiotics (Tazocine). 19

PowerPoint Presentation: 

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Thank you: 

Thank you 21

Questions/Suggestions: 

Questions/Suggestions 22