Administering the Right Antibiotic at the Right Time

Infection Prevention

By: , Marimargaret Reichert, Colleen Gazzillo, Stacey VanZale

Published: 10/10/2007

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How we got to near-perfect compliance by reassigning responsibility and changing a few forms.


If your facility is searching for a way to consistently give patients the correct amount of the correct antibiotic at the correct time, our hospital's story may hold some important lessons for you. We're not 100-percent compliant yet, but we're close enough that we can say that what we're doing works.

On the Web

Click here to download copies of the Physicians Order Adult Pre-Operative Antibiotic for Surgical Prophylaxis and the Penicillin Allergy Algorithm.

When we studied ways to improve our compliance rate for the delivery of prophylactic antibiotics within 60 minutes of incision time, we identified three opportunities for improvement:

  • establishing accountability for ensuring the pre-op prophylactic antibiotic was administered within the 60-minute window;
  • integrating procedure-driven orders for the selection and use of prophylactic antibiotics; and
  • creating a fail-safe method to assess penicillin allergy.

We have since achieved 97 percent compliance for delivering antibiotics within 60 minutes of surgery, and we have transitioned from surgeon-driven pre-op standing orders to procedure-driven orders for prophylactic antibiotics. Here's a look at what we've done.

Establishing accountability
During our investigation, we found that the majority of the fall-outs were due to either timing or documentation. The delivery of the pre-op antibiotic was being initiated by the PAA nurse, the anesthesiologist or the circulating nurse - a perfect setting for finger-pointing.

We decided the circulating nurses would be the logical choice to initiate delivery. After all, they're the only ones who would know how much time was needed for positioning, prepping and draping; whether a tourniquet would be used; and the status of their rooms (on time, ahead of time or delayed) day-to-day and case-to-case.

Fortunately, auditing our compliance was not an added activity. Our involvement with the Surgical Infection Prevention Project required that we audit 100 percent of the selected surgical procedures. Colleen ensured this information was made available to our associate administrator of the OR, who pulled and reviewed the charts for fall-outs and worked with the circulating nurses one-to-one.

Our second focus was identifying the issues associated with documentation. When charts indicated the fall-outs were due to incomplete documentation, we found that the documentation was there, just not in the right place. This confusion was created by too many forms and too many different methods for handling all patients. So we standardized the forms and methods.

Understanding Antibiotics

Antibiotics aren't indicated for every surgical procedure.

While prophylactic administration of antibiotics has been demonstrated to decrease post-surgical infection rates after some types of surgical procedures, there are other issues to consider. Sometimes they won't eliminate potential infecting organisms. And antibiotics carry their own risks: potential adverse reactions with other drugs, bacterial resistance created by overuse and allergic reactions.

Using antibiotics appropriately will help you make their prophylactic use cost effective and efficacious. Here's what you need to know.

Procedure class
Guidelines found in documents such as the Medical Letter recommend the use of antibiotics for prophylaxis only for procedures with high infection rates, for implant cases and for patients who are at risk of serious infection.1 Prosthetic device implantations, as a rule, require prophylactic antibiotics.

In determining when to use prophylactic antibiotics, the National Research Council's four-tiered breakdown of surgical classifications is useful.

For clean procedures - primarily elective procedures that do not involve acute inflammation and no surgical entry into the gastrointestinal, genitourinary, biliary, oropharyngeal and tracheobronchial tracts - the efficacy of antibiotic prophylaxis is not well established.

The use of prophylactic antibiotics often is indicated for clean-contaminated procedures, however. Commonly, these are outpatient procedures in which there is controlled entry into colonized, viscous tracts with minimal spillage. Re-operation within seven days on clean sites after blunt trauma also falls under this category.

Antibiotic prophylaxis also should be used in contaminated procedures, including GU surgery in the presence of urine. For the fourth category - dirty procedures - the administration of antibiotics constitutes treatment, not prophylaxis, as post-op infection rates in this category generally are over 30 percent.

Antibiotic type
The three major categories of antibiotics are cephalosporins, aminoglycosides and fluoroquinolones. First-generation cephalosporins are the primary category of antibiotics used for prophylaxis for most surgical procedures. Other antibiotics commonly recommended for surgical prophylaxis by consensus guidelines include second-generation cephalosporins, clindamycin, vancomycin and metronidazole.

It should be noted that Medical Letter consultants don't recommend third or fourth-generation cephalosporins, nor extended-spectrum penicillins for routine surgical prophylaxis.

Cefazolin, a first-generation cephalosporin, is the most commonly recommended antibiotic for surgical prophylaxis. It is effective against most gram-positive bacteria, including penicillin-resistant staph and strep. It also is effective against a limited spectrum of gram-negative bacteria. Cefazolin should be administered in one to two-gram doses pre-op. If a procedure lasts longer than four hours, a second dose may be given during the procedure.

Second-generation cephalosporins such as cefoxitin and cefotetan cover some anaerobes that cefazolin doesn't cover. They are more effective than cefazolin against gram-negative bacteria and are more commonly recommended for bowel procedures.

Vancomycin is recommended generally only for patients with allergies to penicillins or cephalosporins or in hospitals where methicillin-resistant staph aureus is of concern. Because of the emergence of vancomycin-resistant enterococci, the CDC has published guidelines for the appropriate use of vancomycin.

Clindamycin is also an alternative for penicillin- and cephalosporin-allergic patients in many types of procedures where gram-positive organisms need to be covered, as well as having anaerobic coverage.

You may use other antibiotics such as gentamicin and metronidazole in colorectal procedures, as well as oral neomycin and erythromycin.

By procedure
Broken down into the type of procedure, following is the suggested antibiotic regimen, according to the 2004 Medical Letter.

  • Orthopedics. Cefazolin (1g to 2g IV) or vancomycin (1 g IV) if allergic to PCN
  • Ophthalmology. Many antibiotics and dosing regimens are recommended, including multiple topical drops of gentamicin, tobramycin, ciprofloxacin, gatifloxacin, levolfloxacin, moxifloxacin, ofloxacin or neomycin-gramicidin-polymyxin
  • ENT. Cefazolin (1g to 2g IV), or clindamycin (600mg to 900mg IV) and gentamicin (1mg/kg to 5 mg/kg IV)
  • GYN. Cefoxitin (1g to 2g IV) or cefotetan (1g IV)
  • Urology. Ciprofloxacin (500mg PO or 400mg IV) for high-risk patients only
  • Neurosurgery. Cefazolin (1g to 2g IV), vancomycin (1g IV) if allergic to PCN
  • GI (esophageal). Cefazolin (1g to 2g IV) for patients with obesity, esophageal obstruction, decreased gastric acidity or GI motility
  • GI (biliary tract). Cefazolin (1g to 2g IV) for patients older than 70, acute cholocystitis, non-functioning gall bladder, obstructive jaundice or common duct stones.
  • GI (colorectal). Oral - neomycin and enthromycin regimen the day before surgery; parenteral - cefoxitin (1g to 2g IV), cefotetan (1g to 2g IV), or cefazolin (1g to 2g IV) and metronidazole (0.5g to 1g IV). -Eric L. Chernin

Mr. Chernin ("[email protected]")) is a clinical pharmacologist practicing in the OR at Sarasota Memorial Hospital in Sarasota, Fla.

Reference
1. "Choice of Antibacterial Drugs." The Medical Letter Treatment Guidelines. March 2004;Vol. 19:7.

Eliminating surgeon-driven orders
Our next step was to ensure the right antibiotic was selected for the right procedure based on best practice guidelines.

We started by getting a copy of every surgeon's preprinted standing orders. When we reviewed them, we found many variances - some of which were inappropriate - and an automatic prescription of vancomycin for patients who said they were allergic to penicillin. Stacey, our PharmD, began an aggressive strategy for transitioning these surgeon-specific orders to procedure-driven orders for prophylactic antibiotics.

We now require pre-op antibiotics for abdominal, cardiac/thoracic, gynecologic, genitourinary, head/neck/neuro, orthopedic, podiatric, vascular and general surgeries. Only for very minor procedures, cardiac catheterization, varicose vein surgery, thoracentesis, paracentesis and most dermatologic and plastic surgery do we not administer antibiotics.

For each type of procedure on the physician order form, there are several choices of antibiotics - including cefazolin, cefotetan, metronidazole, cafazolin, gentamicin, clindamycin, vancomycin or ciprofloxacin - but there is now a standard method for selection. Go to www.outpatientsurgery.net/forms to download a sample of our procedure-driven standing orders.

The biggest change we made as a result of our standard selection method was the switch to cefazolin from vancomycin for patients with a stated allergic reaction to penicillin. This was partly because we felt we used too much vancomycin, a drug whose abuse has helped create a whole generation of resistant organisms.

In addition, Stacey pointed out that many patients' allergic reactions to penicillin were not allergic reactions at all. Many patients say they are allergic because they had a rash, nausea/vomiting or diarrhea. These symptoms are in fact side effects, not manifestations of severe Type I hypersensitivity. Further, less than 10 percent of patients with Type I hypersensitivity to penicillin will have true allergic reaction to cephalosporins (such as cefazolin).

And, finally, our surgeons have noted that, depending on the nurse doing the assessment, there were variances in determining a penicillin allergy. They, too, wanted a method that would ensure a standardized approach for determining a penicillin allergy.

The result: an algorithm to ensure each nurse follows the same format for gleaning the needed information from the patient that engages the patient as an active member of the healthcare team.

Here's how that works: We ask the patient in pre-op whether he has ever had a reaction to a penicillin-based medication or a commonly prescribed antibiotic. If he answers no, we prescribe the drug of choice: cefazolin (cefotetlan and metronidazole in abdominal surgery).

Putting the Pieces in Place for Change

One of Southwest General Health Center's major objectives in 2000 was improving its compliance rate for the delivery of prophylactic antibiotics within 60 minutes of incision time. Using the plan-do-check methodology, the hospital attained an average compliance of 85 percent that year, and maintained this average in 2001 and 2002. But the goal was 100 percent.

So in the fall of 2003, the Middleburg Heights, Ohio, hospital formed a broad-based ad hoc committee to the patient safety committee. This multidisciplinary team included the chairmen of the departments of surgery and anesthesia, pharmacy, infection control, the surgical care center (OR, PAT, PAA and PACU), quality management, medical care review, surgical intensive care and surgical post-op nursing.

However, if the patient answers yes, we ask about the specific symptoms. If nausea, vomiting, diarrhea and sore mouth and tongue were present, it's likely he doesn't have true penicillin allergy, and we prescribe the drug of choice. If the symptoms were rash, hives, fever and dizziness, we conclude type two hypersensitivity and based on the time frame of occurrence differentiate from there. If the symptoms occurred more than 10 years ago, we prescribe the drug of choice; less than 10, we notify the surgeon. For patients who say they experienced wheezing, anaphylactic shock, fever/chills and edema, we prescribe the alternate drug (vancomycin, ciproflaxacin, clindamycin or gentamicin, depending on the procedure).

The patient and nurse must both sign off on the algorithm, and it becomes a permanent part of the patient's record; the algorithm is printed on the back of our procedure-driven order sheet. Go to www.outpatientsurgery.net/forms to download a copy.

Building on the results
By December 2004, we had attained 98 percent compliance (see graph on page 46). To put this in perspective, the national rate of compliance is about 57 percent. In addition, our actual time of delivery for the prophylactic antibiotic is now closer to the preferred 30-minute window.

Still, we're not done. Our next step is to improve our rate of compliance to the national recommendation to discontinue antibiotics within 24 hours post-op, a performance measure aimed at reducing the number of antibiotic-resistant organisms.

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