Timing of Antimicrobial Prophylaxis and the Risk of Surgical Site Infections: Results From the Trial to Reduce Antimicrobial Prophylaxis Errors

Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Emory University Hospital Midtown, 550 Peachtree St. NE, Rm. 5.4403, Atlanta, GA 30308, USA.
Annals of Surgery (Impact Factor: 8.33). 06/2009; 250(1):10-16. DOI: 10.1097/SLA.0b013e3181ad5fca
Source: PubMed


Objective: The objective of this study is to determine the optimal timing for surgical antimicrobial prophylaxis (AMP).
Summary Background Data: National AMP guidelines should be supported by evidence from large contemporary data sets.
Methods: Twenty-nine hospitals prospectively obtained information on AMP from 4472 randomly selected cardiac, hip/knee arthroplasty, and hysterectomy cases. Surgical site infections (SSIs) were ascertained through routine surveillance, using National Nosocomial Infections Surveillance system methodology. The association between the prophylaxis timing and the occurrence of SSI was assessed using conditional logistic regression (conditioning on hospital).
Results: One-hundred thirteen SSI were detected in 109 patients. SSI risk increased incrementally as the interval of time between antibiotic infusion and the incision increased (overall association between timing and infection risk P = 0.04). When antibiotics requiring long infusion times (vancomycin and fluoroquinolones) were excluded, the infection risk following administration of antibiotic within 30 minutes prior to incision was 1.6% compared with 2.4% associated with administration of antibiotic between 31 to 60 minutes prior to surgery (OR: 1.74; 95% confidence interval, 0.98-3.04). The infection risk increased as the time interval between preoperative antibiotic and incision increased or if the antibiotic was first infused after incision. Intraoperative redosing (performed in only 21% of long operations) appeared to reduce SSI risk in operations lasting more than 4 hours (OR of 3.08 with no redosing; 95% confidence interval 0.74-12.90), but only when the preoperative dose was given correctly.
Conclusions: These data from a large multicenter collaborative study confirm and extend previous observations and show a consistent relationship between the timing of AMP and SSI risk with a trend toward lower risk occurring when AMP with cephalosporins and other antibiotics with short infusion times were given within 30 minutes prior to incision.

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Available from: Barbara I Braun, Sep 04, 2014
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    • "Ideal timing of tourniquet onset should be as early as peak inhibitory concentrations in tissue are obtained and before the decline in antibiotic concentrations occur. Steinberg et al., and van Kasteren et al., already showed decrease of surgical site infections when antibiotics are administered within 30 min before incision [24] [33]. Friedman and Friedrich showed that with administering cefazolin 5, 2, and 1 min before tourniquet inflation adequate bone concentrations can be achieved [17] [18]. "
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    ABSTRACT: Periprosthetic infection is regarded as one of the most feared complications following total knee arthroplasty, developing in 0.4-2% of patients. Staphylococcus aureus and Staphylococcus epidermidis are credited for more than half of all infections. Cefazolin is the most commonly used antibiotic drug in arthroplasty antibiotic prophylaxis worldwide. Guidelines and studies recommend that prophylactic antibiotics should be completely infused within 60min before the surgical incision. Cefazolin achieves highest peak bone concentrations 40min after parenteral application with serum half-life of 108min and bone half-life of 42min. Respecting the given pharmacokinetics of cefazolin and theoretical mathematical model we hypothesise that parenteral application of cefazolin should be in time period not longer than 30min before incision (tourniquet inflation) and not less than 10min before tourniquet inflation if given in bolus. This new regime would provide maximal blood concentration of the cefazolin and almost maximal bone concentration of the cefazolin at the beginning of the operation and at the beginning of the tourniquet inflation.
    Medical Hypotheses 03/2014; 82(6). DOI:10.1016/j.mehy.2014.03.020 · 1.07 Impact Factor
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    • "The expert inclusion criteria were adapted from those advocated by Fehring (1987): (a) master's degree in infectious disease or intensive care (four points); (b) specialization/ residence in infectious disease or intensive care (four points); dissertation on infectious disease or intensive care (one point); doctorate in infectious disease or intensive care (two points); professor for at least 1 year on topics about infectious disease or intensive care (one point); clinical experience with infectious disease or intensive care for at least 1 year (one point); and research with publications on infectious disease or intensive care (one point). Due to the difficulty in finding nurses who could meet the criteria established to be an expert, and considering that risk for infection was also a concern of the medical field (Hortal et al., 2009; Steinberg et al., 2009), content validation was performed by two physician experts, along with four nurse experts, with an average score of 12.2 ± 4.0 (minimum of 6, maximum of 17 points). Among the four nurse experts, three had over 20 years of experience and one had 10 years of experience in hospital infection control and/or adult intensive care. "
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    ABSTRACT: To construct and validate a data collection instrument (DCI), and a corresponding instructional guide, for assessment of the nursing diagnosis, risk for infection, in patients following cardiac surgery. Construction of conceptual and operational definitions for risk factors based on literature, content validation by experts, and clinical validation by clinical nurses. There were significant internal consistency and reproducibility in the content validation. In the clinical validation, agreement among nurses was higher than 70% for all risk factors. The DCI was constructed and validated. This DCI could be used for assessment of adult patients after cardiac surgeries worldwide because of its detailed cues for risk factors, which facilitate clinical reasoning and diagnostic judgment. Construir e validar um instrumento de coleta de dados (ICD) e seu roteiro instrucional (RI) para avaliação do diagnóstico de enfermagem Risco de infecção em pacientes pós-cirurgia cardíaca. MÉTODOS: Construção de definições conceituais e operacionais dos fatores de risco baseada na literatura, validação de conteúdo por experts e validação clínica por enfermeiras assistenciais. Consistência interna e reprodutibilidade significativas na validação de conteúdo. Na validação clínica, a concordância foi maior que 70% para todos os fatores de risco. CONCLUSÕES: O ICD foi construído e validado. IMPLICAÇÕES PARA PRÁTICA DE ENFERMAGEM: O ICD poderia ser utilizado para avaliação de adultos pós-cirurgia cardíaca internacionalmente devido às suas pistas detalhadas sobre os fatores de risco, que facilitam o raciocínio clínico julgamento diagnóstico.
    International journal of nursing knowledge 12/2013; 25(2). DOI:10.1111/2047-3095.12018 · 0.40 Impact Factor
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    • "Furthermore, the second time-out is a good time to redose antibiotics and draw necessary labs. Reports have shown that redosing of antibiotics significantly decreases the rate of surgical site infections, especially in surgeries which last longer than 4 hours [36,37]. Redosing, however, may be forgotten in longer operations; only approximately one out of five cases with extended surgical times receive antibiotic redosing [37]. "
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    ABSTRACT: Robotic surgeries of long duration are associated with both increased risks to patients as well as distinct challenges for care providers. We propose a surgical checklist, to be completed during a second "time-out", aimed at reducing peri-operative complications and addressing obstacles presented by lengthy robotic surgeries. A review of the literature was performed to identify the most common complications of robotic surgeries with extended operative times. A surgical checklist was developed with the goal of addressing these issues and maximizing patient safety. Extended operative times during robotic surgery increase patient risk for position-related complications and other adverse events. These cases also raise concerns for surgical, anesthesia, and nursing staff which are less common in shorter, non-robotic operations. Key elements of the checklist were designed to coordinate operative staff in verifying patient safety while addressing the unique concerns within each specialty. As robotic surgery is increasingly utilized, operations with long surgical times may become more common due to increased case complexity and surgeons overcoming the learning curve. A standardized surgical checklist, conducted three to four hours after the start of surgery, may enhance perioperative patient safety and quality of care.
    Patient Safety in Surgery 06/2013; 7(1):19. DOI:10.1186/1754-9493-7-19
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