Assessing antibiotic stewardship using the surgical site infection prevention bundle

Abstract

Background: Antibiotic prophylaxis is crucial in head and neck surgery to prevent infection from clean contaminated wounds. Scottish Intercollegiate Guidelines Network (SIGN) guidance, the gold standard of practice, recommends that administration of broad spectrum antibiotics is discontinued after 24 hours post-operation. A three-audit cycle quality improvement project was conducted to assess clinical practice against SIGN guidance at a large London teaching hospital. Methods: Three change initiatives were implemented to improve antibiotic stewardship. First, an update of Trust guidelines with an associated poster campaign to educate staff and improve awareness. Second, introduction of a specific ‘prophylactic antibiotics in head and neck surgery’ bundle on the electronic hospital-wide prescribing system. Third, an update to an antibiotic prescribing guide (Microguide). Results: Over a 3-year study period the number of patients receiving antibiotics beyond 24 hours declined significantly (88% in 2015, 76% in 2016, 25% in 2018), demonstrating improved compliance with SIGN guidelines overall. Despite this, staff documentation of indications for extended antibiotic use remains suboptimal (58% in 2016 and 44% in 2018) as does the number of specimens sent for microbiological analysis (52% in 2016 and 0% in 2018). Conclusions: Appropriate prophylactic antibiotic prescribing can improve morbidity and mortality rates in head and neck cancer patients. Three change initiatives have been demonstrated which can help to improve prescribing compliance in line with SIGN guidance. Ongoing auditing is required to maintain the longevity of improvements made and encourage staff documentation of indications for extended antibiotic use and microbiology specimen analysis.

Documenting the indication for antimicrobial prescribing: a scoping review

“…An additional 15 citations were identified from the grey literature search for a total of 123 publications (figure 1). 13–135 Of the 123 studies, 64 were peer reviewed, 53 were conference proceedings and 6 were online documents (eg, reports).…”

“…Most studies evaluated the use of indication or reason for use; however, there were six studies that described the use of accountable justification (ie, where a rationale is required for potentially inappropriate prescribing such as antibiotics for upper respiratory tract infection),45 48 50 85 87 99 and two that used both indication and justification 98 119…”

“…Overall, 52 studies reported the prevalence of indication documentation 13–15 17 19 21 23 26–29 40 45–47 49 53 60 61 65 67 71 72 74 75 78 82 83 87 89 91 92 97 100–102 106 108 109 109 110 112 114 115 117 124–129 135. The median reported prevalence of indication documentation was 75%; however, there was a wide range across studies from 4% to 100% of antimicrobial orders with an indication documented, with an IQR of 51%–85%.…”

Use of the Microguide mobile phone application for ENT conditions: a national review

“…6 Other studies have also used Microguide to identify specific antibiotic protocols for other conditions, clearly showing it to be a popular resource. [3][4][5] Antimicrobial stewardship is one of the key pillars of the UK's five-year strategy to prevent antimicrobial resistance. 1 It has been shown that many initial antimicrobial prescriptions on admission are unchanged, and thus it is essential that the appropriate antimicrobial(s) are prescribed at hospital attendance.…”

“…After screening, six of these papers related specifically to the Microguide antimicrobial application. [1][2][3][4][5][6] To our knowledge, there has been no previous review of the recommendations for ENT conditions included on Microguide across different NHS trusts. Our aim was to review the ENT-related conditions listed for each NHS hospital on the Microguide application.…”