Background: Surgical site infections (SSI) can complicate any operative procedure although this risk is mitigated through the use of preoperative antibiotic prophylaxis. While antibiotic prophylaxis can provide great benefit, inappropriate use can lead to the development of multi-drug resistant organisms causing increased morbidity, mortality, and cost. Although national clinical guidelines for preoperative antibiotics prophylaxis were developed in 2013, practice adherence remains unknown. Furthermore, with the emergence of co-managed preoperative clinics, it is unknown if hospitalists can impact the standardization of appropriate preoperative antibiotic selection for SSI prophylaxis.
Methods: We evaluated preoperative antibiotic prescribing practice and adherence to national and institutional guidelines at the VA Ann Arbor Health System (VAAAHS). Preoperative antibiotic administration from 100 randomly selected surgical cases performed in June 2016 was compared to national guidelines (from the American Society of Healthy-System Pharmacists) and institutional guidelines. Additionally, an electronic survey was sent to internal medicine, anesthesia, and surgical (including subspecialty) providers to ascertain current preoperative antibiotic prescribing knowledge using 4-5 clinical vignette-based questions.
Results: Of the 100 preoperative antibiotic selections, 57 matched guideline recommendations. A variety of reasons accounted for the 43 mismatches, as detailed in Figure 1.
There were a total of 38 survey responses from VAAAHS providers including 11 (29%) from internal medicine, 13 (43%) from surgery (including subspecialties), and 7 (23%) from anesthesiology. Thirty-three (87%) respondents felt the surgical service would be best suited to provide patient-specific recommendations for preoperative antibiotic prophylaxis. Overall, respondents answered 44% of the vignette-based questions correctly. Average correct score by specialty is detailed in Figure 2.
Conclusions: National guidelines can help standardize the approach to preoperative antibiotic prophylaxis, however, our research shows that provider knowledge and implementation of these recommendations is poor. Incorporating multidisciplinary, evidence-based guidelines into preoperative management is essential for safe and cost-effective care. Hospitalists, as contributors to preoperative medication reconciliation and antibiotic stewardship, are well-positioned to lead these efforts. Pilot programs to evaluate the impact of hospitalist-driven preoperative antibiotic selection are warranted.
