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A National Survey of Surgical Antibiotic Prophylaxis in Turkey

A National Survey of Surgical Antibiotic Prophylaxis in Turkey
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  A National Survey of Surgical Antibiotic Prophylaxis in Turkey • Author(s): Salih Hosoglu , MD; Mustafa Sunbul , MD; Serpil Erol , MD; Mustafa Altindis , MD;Rahmet Caylan , MD; Kutbettin Demirdag , MD; Hasan Ucmak , MD; Havva Mendes , MD;Mehmet Faruk Geyik , MD; Huseyin Turgut , MD; Sibel Gundes , MD; Elif Kartal Doyuk , MD;Mustafa Aldemir , MD; Ali ihsan Dokucu , MD, EBPSReviewed work(s):Source: Infection Control and Hospital Epidemiology, Vol. 24, No. 10 (October 2003), pp. 758-761Published by: The University of Chicago Press  on behalf of The Society for Healthcare Epidemiology of America Stable URL: http://www.jstor.org/stable/10.1086/502127 . Accessed: 01/02/2013 09:09 Your use of the JSTOR archive indicates your acceptance of the Terms & Conditions of Use, available at  . http://www.jstor.org/page/info/about/policies/terms.jsp  . JSTOR is a not-for-profit service that helps scholars, researchers, and students discover, use, and build upon a wide range of content in a trusted digital archive. We use information technology and tools to increase productivity and facilitate new formsof scholarship. For more information about JSTOR, please contact support@jstor.org.  . The University of Chicago Press  and The Society for Healthcare Epidemiology of America  are collaboratingwith JSTOR to digitize, preserve and extend access to  Infection Control and Hospital Epidemiology. http://www.jstor.org This content downloaded on Fri, 1 Feb 2013 09:09:38 AMAll use subject to JSTOR Terms and Conditions  758  I NFECTION  C ONTROL AND  H OSPITAL   E PIDEMIOLOGY   October 2003 A N ATIONAL   S URVEY OF  S URGICAL   A  NTIBIOTIC P ROPHYLAXIS IN  T URKEY  Salih Hosoglu, MD; Mustafa Sunbul, MD; Serpil Erol, MD; Mustafa Altindis, MD; Rahmet Caylan, MD; Kutbettin Demirdag, MD;Hasan Ucmak, MD; Havva Mendes, MD; Mehmet Faruk Geyik, MD; Huseyin Turgut, MD; Sibel Gundes, MD;Elif Kartal Doyuk, MD; Mustafa Aldemir, MD; Ali ihsan Dokucu, MD, EBPS  The incidence of postoperative wound infection hasbeen reduced remarkably during the past three decades. Antibiotic prophylaxis is effective in preventing post-surgicalinfections. 1-6 For many procedures, first-generationcephalosporins are considered the drug of choice. For most procedures, a single dose is considered adequate. 4-10  Whereas antibiotic prophylaxis has not been considered nec-essary for many types of clean operations, it has been con-sidered important for clean-contaminated procedures. 11-14 Surgical antibiotic prophylaxis accounts for a largeproportion of antibiotic consumption and likely could becontrolled more easily than other types of antibiotic use.In Turkey, antibiotics have not been strictly controlled. 15  The aim of this study was to evaluate current use of sur-gical antibiotic prophylaxis in Turkish hospitals and toidentify factors associated with appropriate prophylaxis. METHODS  Background  There are 67 million people in Turkey, where most hospitals are run by the government. In the Turkishhealthcare system, surgical antibiotic prophylaxisdepends on orders by surgeons at all hospitals. Eighty percent of the population is covered by health insurance,2% of which is private and 78% of which is governmental. The government funds healthcare for poor individuals without insurance. In both healthcare-financing systems,government insurance pays subsidies for certain treat-ments including antibiotics during a hospital stay. Setting  A cross-sectional survey was performed in 2000 and2001, with a standardized questionnaire delivered to sur-geons working at university and general public and pri- vate hospitals. One or two cities were included from eachgeographic part of Turkey. In these cities, all hospitals were included in the study.  The questionnaire was delivered to surgeons work-ing in these hospitals. The srcinal questionnaire(Turkish version) is available from the authors onrequest. The questionnaire included the following itemsrelated to the standard antibiotic prophylaxis practices  Drs. Hosoglu, Ucmak, Mendes, Geyik, Aldemir, and Dokucu are from Dicle University Hospital, Diyarbakir, Turkey. Dr. Sunbul is fromOndokuz Mayis University Hospital, Samsun, Turkey. Dr. Erol is from Ataturk University Hospital, Erzurum, Turkey. Dr. Altindis is from KocatepeUniversity Hospital, Afyon, Turkey. Dr. Caylan is from Farabi Hospital, Trabzon, Turkey. Dr. Demirdag is from Firat University Hospital, Elazig,Turkey. Dr. Turgut is from Pamukkale University Hospital, Denizli, Turkey. Dr. Gundes is from Kocaeli University Hospital, Kocaeli, Turkey. Dr. Doyuk is from Osman Gazi University Hospital, Eskisehir, Turkey. Address reprint requests to Dr. Salih Hosoglu, Dicle Universitesi Hastanesi, Enfeksiyon Hastaliklari ve Klinik Mikrobiyoloji Anabilim Dali, 21280, Diyarbakir, Turkey. OBJECTIVE:  To assess the quality of antibiotic prophylax-is for clean and clean-contaminated elective surgical procedures. DESIGN:  A cross-sectional, country-wide survey. SETTING:  Thirty-six hospitals in 12 cities in Turkey. PARTICIPANTS: Four hundred thirty-nine surgeonsfrom 6 different specialties who performed selected proceduresof interest. METHODS:  A random sample of surgeons from different hospitals was selected. A standardized data collection form wasused to record the type of procedure, the names, doses, timing of the first doses, and duration of antibiotics, important decisive fac-tors, and problems in the management of prophylactic antibioticuse for surgical procedures. RESULTS: Fifty-five percent of surgeons addressed com-pleted the survey. For clean-contaminated procedures, 6% of sur-geons did not use antibiotic prophylaxis, whereas 88% used morethan a single dose. Inappropriate antibiotics were chosen for 32%of procedures. In 39% of procedures, the first dose of antibiotics was not administered during induction of anesthesia. Duration of prophylaxis was longer than 24 hours in 80% and longer than 48hours in 46% of all procedures. Only 112 surgeons (26%) wereusing definitely appropriate prophylaxis in all ways. Multivariateanalysis revealed that surgeons in university hospitals (OR,2.353; CI 95 , 1.426–3.884;  P = .001) and general surgeons (OR,4.986; CI 95 , 2.890–8.604;  P  < .001) used antibiotic prophylaxismore appropriately. Patients not covered by health insurance(OR, 0.417; CI 95 , 0.225–0.772;  P  < .001) were associated with inap-propriate prophylaxis. CONCLUSION: Given the high frequency of antibioticsprescribed for surgical prophylaxis in Turkey, adherence to sur-gical prophylaxis guidelines is urgently needed (   Infect Control  Hosp Epidemiol  2003;24:758-761). ABSTRACT This content downloaded on Fri, 1 Feb 2013 09:09:38 AMAll use subject to JSTOR Terms and Conditions   Vol. 24 No. 10  S URGICAL  A   NTIBIOTIC  P ROPHYLAXIS IN  T URKEY  759used for different surgical procedures by each surgeon:(1) hospital affiliation (university, general, social security,military, or private); (2) hospital type (teaching or district general); (3) the number of operations personally performed by the surgeon per month; (4) sources for information and decision about prophylactic antibiotics(guidelines, textbooks, knowledge from initial training,consultation with an infectious disease physician, use of  whatever antibiotic was available, or department proto-col); (5) problems with administration of prophylaxis (thepatient is not covered by health insurance, the drug is not available in the hospital pharmacy, or there are insuffi-cient data about hospital infections); and (6) data for themost commonly performed surgical procedures with pro-phylactic antibiotics (indication of prophylaxis, chosenantibiotic or antibiotics, timing of the first dose, and thetotal time of prophylactic antibiotic use). The question-naire included exploratory questions about antibiotic pro-phylaxis for 16 different elective surgical procedures.  Evaluation of Antibiotic Prophylaxis Prophylactic antibiotic use was evaluated for onerepresentative surgical procedure chosen from each spe-cialty. These procedures (cholecystectomy for generalsurgeons, abdominal hysterectomy for gynecologists,prostatectomy for urologists, elective surgery for closedlong bone fracture for orthopedists, coronary artery bypass surgery for cardiac surgeons, and brain tumor surgery for neurosurgeons) were evaluated in five ways:(1) indication of prophylaxis; (2) antibiotic choice; (3) tim-ing for the first dose; (4) length of prophylaxis; and (5)route of drug administration. If an antibiotic prophylacticprocedure was performed appropriately according to cur-rent international guidelines in all ways, it was recordedas “definitely appropriate.” Statistical Analyses SPSS software (version 10.0; SPSS, Inc., Chicago,IL) was used for all data entry and analysis. In all univari-ate analyses, the chi-square test was used for binary vari-ables and the Student’s t test was used for continuous vari-ables. To explore the factors associated with appropriatesurgical antibiotic prophylaxis, multivariate analysis usinglogistic regression was performed. Candidate variables with a  P   value of less than .1 were entered using a back- wards, stepwise approach. Predictor variables were retained in the final modelif the  P   value was less than .05. Dummy variables wereused to code hospital type (university, general, socialsecurity, or other), surgeon specialty (general surgery,gynecology, cardiac surgery, urology, orthopedics, or neurosurgery), reason for choosing the prophylacticantibiotics (guidelines, knowledge from initial training,consultation with an infectious disease physician, text-books, the particular antibiotic was available, or depart-ment protocol), and the most important problem withadministration of prophylaxis (the patient was not coveredby health insurance, the drug was not available in the hos-pital pharmacy, or there were insufficient data about hos-pital infections). RESULTS Of 842 surgeons to whom the questionnaire wasdelivered, 463 (55%) at 36 hospitals completed it. The hos-pitals were evenly distributed in different cities through-out the country (Adana, Erzurum, Elazig, Diyarbakir,Samsun, Afyon, Konya, Mersin, Izmir, Eskisehir, Kocaeli,and Denizli). Twenty-four surgeons’ questionnaires wereexcluded because of insufficient data, leaving 439 for analysis (Table 1). These 36 hospitals had 15,921 beds. This samplerepresented 9.1% of all 175,190 hospital beds in Turkey. The mean number of beds per hospital was 442.3 (stan-dard deviation, 585.0 beds; range, 30 to 1,200 beds).Fifteen (42%) of the hospitals had more than 500 beds, 12(33%) had between 200 and 500 beds, and 9 (25%) hadfewer than 200 beds. The mean number of operations per month for each surgeon was 15 (standard deviation, 27operations). The most important reasons for selecting an antibi- TABLE 1 D ISTRIBUTION OF THE  S URGEONS BY   T YPE OF  H OSPITAL No. of Definitely Type ofNo. ofNo. ofAppropriateHospitalHospitalsSurgeons (%)Procedures (%) University13252 (57)75 (30)General1097 (22)22 (23)Social security873 (17)12 (16)Other*517 (4)3 (18) Total36439 (100)112 (26) *Two military and three private hospitals.   TABLE 2 D ISTRIBUTION OF THE  S URGEONS BY   S PECIALTY AND  T HEIR  P ROPHYLACTIC  A   NTIBIOTIC  U SE FOR THE  R  EPRESENTATIVE S URGICAL  P ROCEDURE  F ROM  E  ACH  S PECIALTY  No. of Definitely  AppropriateSpecialtyNo. of Surgeons (%)Procedures (%) General surgery110 (25.1)49 (45)Gynecology79 (18.0)18 (23)Cardiac surgery46 (10.5)9 (20)Urology92 (21.0)16 (17)Orthopedics62 (14.1)15 (24)Neurosurgery50 (11.4)5 (10) Total439 (100.0)112 (26)   This content downloaded on Fri, 1 Feb 2013 09:09:38 AMAll use subject to JSTOR Terms and Conditions  760  I  NFECTION  C ONTROL AND  H OSPITAL  E PIDEMIOLOGY  October 2003otic for prophylaxis were found to be department protocol(31%), knowledge from initial training (29%), textbook rec-ommendations (20%), and antibiotic availability (17%). For only 9.6% of the surgical procedures was a national or international guideline the reason. One hundred eight (24.6%) of the surgeons stated that they had no difficulty  with surgical prophylaxis. The most important problems were said to be insufficient data about agents for postop-erative infections (39.9%), patients not covered by insur-ance (22.1%), and antibiotics unavailable in the hospitalpharmacy (21.2%).  Evaluation of Surgical Prophylaxis Procedures Overall, surgical prophylaxis was usually used for 94.1% of the 6 selected procedures (Table 2). For the rep-resentative procedures, 88% of the surgeons usually usedmore than a single dose. The duration of antibiotic pro-phylaxis was said to be less than 24 hours for only 20% of the procedures. Only 112 (26%) of the surgeons were con-sidered to be using definitely appropriate prophylaxis ineach way questioned. Six percent of the surgeons statedthey did not use antibiotic prophylaxis for clean-contami-nated procedures, 32% chose an inappropriate antibiotic,46% said they used prophylaxis longer than 2 days and 80%longer than 24 hours, and 39% administered the first doseat an inappropriate time and 3% administered the antibiot-ic in an inappropriate manner. Third-generation cephalosporins were the most commonly used antibiotics (42% of all prophylaxis, with anadditional 3% of combined use). Cefazolin was used in 30%of the procedures, quinolones in 9%, and second-genera-tion cephalosporins in 7% (Table 3). Statistical Analyses Univariate analysis revealed that surgical prophylaxis was more often appropriate at university hospitals (oddsratio [OR], 1.72; 95% confidence interval [CI 95 ], 1.10 to 2.69;  P = .02) and that general surgeons used antibiotics moreappropriately (OR, 3.35; CI 95 , 2.13 to 5.4;  P = .001). Surgicalantibiotic prophylaxis was less likely to be appropriate at social security hospitals (OR, 0.52; CI 95 , 0.27 to 1.01;  P  =.056) and among urologists (OR, 0.55; CI 95 , 0.31 to 0.99;  P  =.045) and neurosurgeons (OR, 0.29; CI 95 , 0.11 to 0.76;  P =.006). Patients not covered by health insurance (OR, 0.54;CI 95 , 0.30 to 0.96;  P  = .035) were less likely to have appropri-ate prophylaxis. These variables were entered into a logisticregression model. On multivariate analysis, only working at a university hospital (OR, 2.353; CI 95 , 1.426 to 3.884;  P  =.001), general surgeons (OR, 4.986; CI 95 , 2.890 to 8.604;  P  <.001), and lack of health insurance (OR, 0.417; CI 95 , 0.225 to0.772;  P  < .001) remained significant predictors. DISCUSSION  Antibiotic prophylaxis is important for preventingpostoperative infections. This study provides the first country-wide Turkish data regarding surgeons’ antibiotic TABLE 3  A   NTIBIOTICS  U SED FOR   P ROPHYLAXIS  A  CCORDING TO  S URGICAL  P ROCEDURE MostNext MostCommonlyCommonlyMeanNo. ofUse ofUsedUsedDurationProcedureSurgeonsProphylaxis (%)Antibiotic (%)Antibiotic (%)(days) Hernia repair10661 (58)Cefazolin (47)3GCS (14)1.9Cholecystectomy*110106 (96)3GCS (55)Cefazolin (22)3.8Breast surgery10660 (57)Cefazolin (49)Meropenem (14)2.0 Acute appendectomy109105 (96)3GCS (48)Cefazolin (24)3.8 Abdominal hysterectomy*7974 (94)3GCS (44)Cefazolin (37)2.8Myoma uterine surgery5440 (74)Cefazolin (49)3GCS (23)4.5 Varicocelectomy9257 (62)3GCS (33)Cefazolin (25)4.2Cystoscopy9277 (84)Ciprofloxacin (39)AG (20)2.4Prostatectomy*9289 (97)3GCS (45)Ciprofloxacin (18)4.9 TUR9188 (97)3GCS (42)Ciprofloxacin (19)4.7CLBF surgery*6254 (87)Cefazolin (60)3GCS (28)4.4Orthopedic prosthetic5857 (98)Cefazolin (56)3GCS (28)4.4implantationCABG*4644 (96)Cefazolin (45)3GCS (23)5.0Mediastinal tumor surgery4139 (95)Cefazolin (42)3GCS (22)5.0Brain tumor surgery*5046 (92)3GCS (55)Cefazolin (16)4.9Spinal disk surgery5045 (90)3GCS (42)Cefazolin (11)4.9 3GCS = third-generation cephalosporins; AG = aminoglycoside; TUR = transurethral resection; CLBF = closed long bone fractures; CABG = coronary artery bypass graft.*Representative surgical procedure.   This content downloaded on Fri, 1 Feb 2013 09:09:38 AMAll use subject to JSTOR Terms and Conditions   Vol. 24 No. 10  S URGICAL  A   NTIBIOTIC  P ROPHYLAXIS IN  T URKEY  761preferences and difficulties encountered at different typesof hospitals. The most important reasons given by the surgeonsfor deciding on an antibiotic for surgical prophylaxis weredepartment protocol and knowledge from initial training.Several studies have indicated that guidelines canimprove the quality of antibiotic use and therefore thequality of patient care. 16  There are guidelines in some Turkish hospitals, but currently there is no nationalguideline. Some authors have suggested that local con-sensus is the most important factor for implementingguidelines to reduce irrational antibiotic use. 17 In this study, the problem considered most impor-tant by the surgeons was insufficient data about agents for postoperative infections (39.9%). This suggests either insufficient use of the microbiology laboratory or inade-quate support for the laboratory to help manage surgicalinfections. It also could imply inadequate infection controlprograms at these hospitals. In this study, not being cov-ered by insurance was an independent predictor of inap-propriate antibiotic use. The hospital’s supply of available antibiotics hasbeen previously reported to have an important effect onchoice of antibiotic for prophylaxis. 18 Many surgeons have had a tendency to use prophy-laxis longer than recommended. 17,19 In a Spanish study,the duration of perioperative antibiotic prophylaxis wasless than 24 hours for 75% of procedures, and a singledose of antibiotic was given for 52% of surgical proce-dures. 20 In the current study, 12% of the surgeons used a single dose of antibiotic for clean-contaminated proce-dures, and antibiotic prophylaxis was said to be less than24 hours for only 20% of the selected procedures. Third-generation cephalosporins generally have not been recommended for surgical prophylaxis. 8 In our study,third-generation cephalosporins were the most popular pro-phylactic agents for many procedures, even though first-gen-eration and second-generation cephalosporins have been rec-ommended as first-line choices in all published guidelines. The timing of the first dose of surgical antibioticprophylaxis (ie, administration not more than 1 or 2 hourspreoperatively) is important. Timing error was one of themost important problems identified in this study. In onestudy, correct timing increased from 39% to 69%. 21 In a French study, for most procedures (93%), the first dose of antibiotic was administered at the time of induction of anesthesia, as recommended by French guidelines. Inanother study, 8 the correct timing of the first dose of antibiotic increased to 99% of the procedures. In our sur- vey, 39% of the surgeons said they gave the first dose at aninappropriate time and 3% said they administered it in aninappropriate way.Given the high frequency of antibiotics being pre-scribed for surgical prophylaxis in Turkey, adherence tostandardized guidelines for surgical prophylaxis isurgently needed. A national guideline for surgical prophy-laxis would be useful for improving local consensusregarding guidelines and increasing the quality of antibi-otic use. REFERENCES 1.Woods RK, Dellinger EP. Current guidelines for antibiotic prophylaxisof surgical wounds.  Am Fam Physician 1998;57:2731-2740.2.Gyssens IC. Preventing postoperative infections: current treatment recommendations.  Drugs 1999;57:175-185.3.Scher KS. Studies on the duration of antibiotic administration for sur-gical prophylaxis.  Am Surg  1997;63:59-62.4.Silver A, Eichorn A, Kral J, et al. Timeliness and use of antibiotic pro-phylaxis in selected inpatients’ surgical procedures.  Am J Surg  1996;171:548-552.5.Pestotnik SL, Classen DC, Evans RS, Burke JP. Implementing antibiot-ic practice guidelines through computer-assisted decision support:clinical and financial outcomes.  Ann Intern Med  1996;124:884-890.6.Classen DC, Evans RS, Pestotnik SL, Horn SD, Menlove RL, Burke JP. The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection.  N Engl J Med  1992;326:281-286.7.Thomas M, Govil S, Moses BV, Joseph A. 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