antibioticaprofylaxe en verbetertraject inge c. gyssens md phd hasselt university, belgium &...
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Antibioticaprofylaxe en verbetertraject
Inge C. Gyssens MD PhDHasselt University, Belgium&Radboud University Medical Center, Nijmegen, The Netherlands
(2) Hospital: Cochrane Systematic Review
• First review [2005; Issue 3: CD003543]• Included studies up to November 2003
• Revised review [2013; Issue 4: CD003543]• Included studies up to December 2006• Meta-analysis for ITS• EPOC Risk of Bias criteria.
Courtesy of Ian M GouldICG 2014
Barriers to intervention
• Non acceptance of the principle• “Therapeutic freedom of the prescriber”• Non acceptance of external interference• Fear of:
political consequences
legal consequences• Financial and logistic barriers
START WITH AN INVENTORY OF BARRIERS
Grimshaw JM et al. Health Technol Assess. 2004;8:1-72. Review:ICG 2014
Quality standard for antimicrobial prophylaxis in surgical procedures
1. Indication
2. Choice of drug
3. Duration
4. Timing
• Bratzler et al. Clinical practice guidelines for surgical prophylaxis. Am J Health-Syst Pharm. 2013; 70:195-283
• SIGN guideline Surgical prophylaxis rev. July 2008 http://www.sign.ac.uk/pdf/sign104.pdf
ICG 2014
Indications for surgical prophylaxis: cost effectiveness
• Define outcome and expected baseline risk– Surgical site infection (SSI) rate
• Superficial• Deep• Organ/space
• What are the Odds ratios (OR)?• What is the number needed to treat to avoid the
adverse outcome = number to treat (NNT)
http://www.sign.ac.uk/pdf/sign104.pdf version July 2008 ICG 2014
What is the evidence? Surgical procedures for which prophylaxis is indicated
http://www.sign.ac.uk/pdf/sign104.pdf version July 2008
Clean operations; the risk of infection is low but the consequences are serious
• Cataract surgery OR 0.36, NNT 451
• Cardiac pacemaker OR 0.26, NNT 38
• Total hip arthroplasty OR 0.27, NNT 42
• …..
ICG 2014
Percentage of patients with clean procedures and antibiotic prophylaxis
Semarang Surabaya
Bambang Wibowo, Hari Parathon, Gyssens I, unpublished data
Quality improvement of surgical prophylaxis in Dutch hospitals:evaluation of a multi-site intervention by time series analysis
Marjo E. van Kasteren, Judith Mannien, Bart-Jan Kullberg, Annette S. de Boer,Nico J. Nagelkerke, Marja Ridderhof , Jan C. Wille and Inge C. Gyssens
J Antimicrob Chemother 2005;56:1094-1102
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-6 -5 -4 -3 -2 -1 1 2 3 4 5 6
months to intervention
% o
f ca
ses 1st gen cephalosporin
2nd gen cephalosporin
amoxi/clavulanic acid
miscellaneous
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intervention
Total consumption of antibiotics for surgical prophylaxis in 13 hospitals
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1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10
time-period
DD
D/1
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du
res intervention
Quality improvement of surgical prophylaxis in Dutch hospitals:evaluation of a multi-site intervention by time series analysis
Marjo E. van Kasteren, Judith Mannien, Bart-Jan Kullberg et al.
J Antimicrob Chemother 2005;56:1094-1102
ICG 2014
Antibiotic Prophylaxis and the Risk of Surgical SiteInfections following Total Hip Arthroplasty: Timely
Administration Is the Most Important FactorM.E.E. van Kasteren, J. Manniën, A. Ott, B.J. Kullberg, A.S. de Boer, I.C. Gyssens.
Clin Infect Dis 2007;44(7):921-7
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-200/-91 -90/-61 -60/-31 -30/-1 0-30 31+
time to incision in minutes
% S
SI
n=17 n=538 n=1141 n=95 n=33n=98
ICG 2014
Timing after intervention
-6.0 -5.0 -4.0 -3.0 -2.0 -1.0 1.0 2.0 3.0 4.0 5.0 6.00
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within 30 min before incision
between 2 h-30 min before incision
more than 2 h before incision
after incision
ICG 2014