Department of Anesthesiology, Yale School of Medicine, New Haven, Connecticut.
Yale Center for Analytical Sciences, New Haven, Connecticut.
JAMA Netw Open. 2021 Dec 1;4(12):e2137296. doi: 10.1001/jamanetworkopen.2021.37296.
Despite widespread adherence to Surgical Care Improvement Project antibiotic measures, prevention of surgical site infections (SSIs) remains a clinical challenge. Several components of perioperative antibiotic prophylaxis guidelines are incompletely monitored and reported within the Surgical Care Improvement Project program.
To describe adherence to each component of perioperative antibiotic prophylaxis guidelines in regard to procedure-specific antibiotic choice, weight-adjusted dosing, and timing of first and subsequent administrations in a nationwide, multicenter cohort of patients undergoing noncardiac surgery.
DESIGN, SETTING, AND PARTICIPANTS: This cohort study included adult patients undergoing general, urological, orthopedic, and gynecological surgical procedures involving skin incision between January 1, 2014, and December 31, 2018, across 31 academic and community hospitals identified within the Multicenter Perioperative Outcomes Group registry. Data were analyzed between April 2 and April 21, 2021.
The primary end point was overall adherence to Infectious Diseases Society of America guidelines, including (1) appropriateness of antibiotic choice, (2) weight-based dose adjustment, (3) timing of administration with respect to surgical incision, and (4) timing of redosing when indicated. Data were analyzed using mixed-effects regression to investigate patient, clinician, and institutional factors associated with guideline adherence.
In the final cohort of 414 851 encounters across 31 institutions, 51.8% of patients were women, the mean (SD) age was 57.5 (15.7) years, 1.2% of patients were of Hispanic ethnicity, and 10.2% were Black. In this cohort, 148 804 encounters (35.9%) did not adhere to guidelines: 19.7% for antibiotic choice, 17.1% for weight-adjusted dosing, 0.6% for timing of first dose, and 26.8% for redosing. In adjusted analyses, overall nonadherence was associated with emergency surgery (odds ratio [OR], 1.35; 95% CI, 1.29-1.41; P < .001), surgery requiring blood transfusions (OR, 1.30; 95% CI, 1.25-1.36; P < .001), off-hours procedures (OR, 1.08; 95% CI, 1.04-1.13; P < .001), and procedures staffed by a certified registered nurse anesthetist (OR, 1.14; 95% CI, 1.11-1.17; P < .001). Overall adherence to guidelines for antibiotic administration improved over the study period from 53.1% (95% CI, 52.7%-53.5%) in 2014 to 70.2% (95% CI, 69.8%-70.6%) in 2018 (P < .001).
In this cohort study, although adherence to perioperative antibiotic administration guidelines improved over the study period, more than one-third of surgical encounters remained discordant with Infectious Diseases Society of America recommendations. Future quality improvement efforts targeting gaps in practice in relation to guidelines may lead to improved adherence and possibly decreased SSIs.
尽管广泛遵循外科护理改进项目的抗生素措施，但预防手术部位感染（SSI）仍然是一个临床挑战。围手术期抗生素预防指南的几个组成部分在外科护理改进项目计划中没有得到完全监测和报告。
描述在全国范围内，多中心患者队列中，在接受非心脏手术的患者中，每个围手术期抗生素预防指南的组成部分的依从性，具体为特定手术的抗生素选择、体重调整剂量以及首次和后续给药的时间。
设计、地点和参与者：这项队列研究纳入了 2014 年 1 月 1 日至 2018 年 12 月 31 日期间在 31 家学术和社区医院进行的普通、泌尿科、骨科和妇科手术患者，这些医院都在多中心围手术期结果组登记处内。数据分析于 2021 年 4 月 2 日至 4 月 21 日进行。
主要终点是整体上符合美国传染病学会指南，包括（1）抗生素选择的适当性，（2）基于体重的剂量调整，（3）与手术切口相关的给药时间，以及（4）需要时重新给药的时间。使用混合效应回归分析来调查与指南依从性相关的患者、临床医生和机构因素。
在最终的 31 家医院的 414851 次就诊的队列中，51.8%的患者为女性，平均（SD）年龄为 57.5（15.7）岁，1.2%的患者为西班牙裔，10.2%为黑人。在这个队列中，有 148804 次就诊（35.9%）不符合指南：19.7%是抗生素选择不当，17.1%是剂量调整不当，0.6%是首次剂量给药时间不当，26.8%是重新给药时间不当。在调整分析中，总体不依从与急诊手术（比值比[OR]，1.35；95%置信区间[CI]，1.29-1.41；P<0.001）、需要输血的手术（OR，1.30；95% CI，1.25-1.36；P<0.001）、非工作时间手术（OR，1.08；95% CI，1.04-1.13；P<0.001）以及由认证注册护士麻醉师（OR，1.14；95% CI，1.11-1.17；P<0.001）进行的手术有关。在研究期间，抗生素给药指南的整体依从性从 2014 年的 53.1%（95% CI，52.7%-53.5%）提高到 2018 年的 70.2%（95% CI，69.8%-70.6%）（P<0.001）。
在这项队列研究中，尽管围手术期抗生素给药指南的依从性在研究期间有所提高，但仍有超过三分之一的手术与美国传染病学会的建议不符。未来针对与指南相关的实践差距的质量改进工作可能会提高依从性，并可能降低 SSI 的发生率。
