The document summarizes an audit on surgical antibiotic prophylaxis practices. It found that practices did not fully comply with WHO guidelines. Only 15% of antibiotic choices were guideline-compliant. Performance was best for IV administration but worst for prolonging antibiotics after surgery. The results indicate practice was heterogeneous and did not match evidence-based guidelines. Implementing guidelines through educational materials and reauditing is planned to standardize best practices.

1. Audit on Surgical
Antibiotic Prophylaxis
Amr Hany
MBBS, MRCS

2. Evidence
 NICE guidelines on surgical site infections prevention and treatment (NG125)
 WHO guidance on surgical antibiotic prophylaxis
 Euoropean Center for Disease Control and Prevention: systematic review and
evidence-based guidance on perioperative antibiotic prophylaxis.

3. Introduction and reason
 Antibiotic resistance is alarmingly increasing and listed as one of the biggest
threats to public health by the WHO.
 Over prescription of antibiotics (Abx) is a major cause of developping
resistance.
 Surgical site infection(SSI), on the other hand, is a cuase of increased
mortality and morbidity and overstay in hospital, making it a heavy burden on
health care systems.
 Protecting surgical patients from SSI can enhance their recovery and reduce
the logistic burden on the system.
 Guidelines put the balance between over-prescription of Abx and protection
against SSI.
 This audit aims to examine how our practice is compliant with published
guidelines.

4. Criteria and standards
Criteria Standard %
1- Appropriate surgery should be given Abx 100
2- Inappropriate surgery should NOT be given Abx 100
3- Appropriate type of ABx given 100
4- Single dose before surgery 100
5- IV route of adminstration 100
6- Time of adminstration within 60 min before incision 100
7- Earlier if certain types or a tourniquet is used 100
8- Repeat dose introp if surgery is longer than t1/2 or
significant blood loss
100
9- Don’t continue after surgery 100

5. Criteria and standards – type of surgery
 Give antibiotic prophylaxis to patients before:
1- clean surgery involving the placement of a prosthesis or implant;
2- clean-contaminated surgery;
3- contaminated surgery.
 Do not use antibiotic prophylaxis routinely for clean non-prosthetic
uncomplicated surgery.

6. Criteria and standards – type of surgery
 Clean: an incision in which no inflammation is encountered in a surgical
procedure, without a break in sterile technique, and during which the
respiratory, alimentary or genitourinary tracts are notentered.
 Clean-contaminated: an incision through which the respiratory, alimentary, or
genitourinary tract is entered under controlled conditions but with no
contamination encountered.
 Contaminated: an incision undertaken during an operation in which there is a
major break in sterile technique or gross spillage from the gastrointestinal
tract, or an incision in which acute, nonpurulent inflammation is
encountered. Open traumatic wounds that are more than 12 to 24 hours old
also fall into this category.

7. Criteria and standards – type of ABx

8. Criteria and standards – type of ABx

9. Criteria and standards – type of ABx

10. Criteria and standards – dosing
 A single dose of antibiotic prophylaxis intravenously on starting anaesthesia.
Or within 60 min up to 120 min according to WHO. (except with vancomycin
and fluoroquinolones).
 Give prophylaxis earlier for operations in which a tourniquet is used.
 Take into account the timing and pharmacokinetics (for example, the serum
half-life) and necessary infusion time of the antibiotic.
 Give a repeat dose of antibiotic prophylaxis when the operation is longer than
the half-life of the antibiotic given or if significant blood loss.
 Continuing antibiotic prophylaxis after the end of surgery is not
recommended.
 Give antibiotic treatment (in addition to prophylaxis) to patients having
surgeryon a dirty or infected wound.

11. Preparation and planning
 Guidelines were reviewed for the best evidence avialable and our criteria
were set accordingly.
 A questionnaire was developped to examine the criteria in question.
 The questionnaire was published on social media for colleague surgeons in
order to pilot it and to extract examplary data to showcase the audit without
breaching hospital policy.
 Conduction was planned and agreed with team members.
 Retrospective data collection from patients files according to inclusion and
exclusion criteria was done.

12. Preparation and planning – online survey
Click me
or scan me

13. Results of data collection 1*
Criteria Result % Standard %
1 & 2 are not applicable and replaced with: surgeons who knew
what type of surgery to give and not to give Abx for
36.3 100
3- Appropriate type of ABx given n/a 100
4- Single dose before surgery 72.7 100
5- IV route of adminstration 100 100
6- Time of adminstration within 60 min before incision^ 91 100
7- Earlier if certain types or a tourniquet is used n/a 100
8- Repeat dose introp if surgery is longer than t1/2 or significant
blood loss
n/a 100
9- Don’t continue after surgery 9.1 100
* Examplary data from the online survey so that we don’t breach hospital policy on
confidntiality. N=11.
^ This however needs to be assessed against type of ABx and its pharmacodynamics.

14. Results of data collection 1
0
20
40
60
80
100
120
Knew what type of
surgery to give and
not to give Abx for
Single dose before
surgery
IV route of
adminstration
Time of
adminstration within
60 min before
incision
Don't continue Abx
after surgery

15. Results – type of ABx
 72.7% said they would change the type of Abx according to the site of surgery.
 The other 27.3% mentioned the following types as the Abx of choice for their
prophylaxis:
1- amox/clav;
2- 3rd genration cephalosporine;
3- cephalosporin with metronidazole.
4- 3rd generation cephalosporin, amox/clav and metronidazole

16. Results – type of ABx
Site 1st line Alternative 2nd line Examples of inputs Results % *
Neck Cefazolin (or
cefuroxime) +
metronidazole
Amox/clac Clindamycin +
gentamicin
- Amox/clav
- 3rd gen cephalosporin
27.2
Cardio-
thoracic
Cefazolin (or
cefuroxime)
n/a vancomycin - Cephalosporin
- Linezolid + levofloxacin
- Quinolones
- 4th g cephalo
0
Breast Cefazolin (or
cefuroxime)
n/a vancomycin - Amox/clav
- 3rd gen caphalosporin
- 3rd g cephalo + amox/clav
0
Upper GI
/ HBP /
hernia
Cefazolin (or
cefuroxime)
Amox/clav - Gentamicin +
metronidazole
- Or vancomycin for
hernia
- Amox/clav
- 3rd g cephalo
- cephalo + metronidazole
- Quinolones
18.2
* Surgeons who chose the ABx in ompliance with the WHO guidance. N=11.

17. Results – type of ABx
Site 1st line Alternative 2nd line Examples of inputs Results %
Colo-
rectal /
appendix
Cefazolin (or
cefuroxime) +
metronidazole
Amox/clav Gentamicin +
metronidazole
- Quinolones + metronidazole
- 3rd g cephalo + metronidazole
- Amox/clav + metronidazole
- 4th g cephalo + metronidazole
0
Hysterect
omy / C-
section
cefazolin
(or cefuroxime)
Amox/clav Clindamicin +
gentamicin
- Amox/clav
- 3rd g cephalo
- 4th g cephalo
9.1
Neuro /
ortho
cefazolin
(or cefuroxime)
n/a Vancomycin - Amox/clav
- Imipenem
- 4th g cephalo
0
Urology cefazolin
(or cefuroxime)
n/a Getamicin - Quinolones
- 3rd g cephalo
0

18. Results – type of ABx
0 20 40 60 80 100 120
Standard
Neck
Cardiothoracic
Breast
Upper GI / HBP / hernia
Colorectal / appendix
Hysterectomy / C-sectiomn
Neuro / ortho
Urology
Only 15% of ABx
choices were
compliant with WHO
guidelines. N=40

19. Results – dosing
27.3% unnecessarily
repeated doses during
the surgery for
irrelevant reasons
72.7% Abx given at induction of anaesthesia.
However, 27.2% chose that with quinolones.
18.2% Abx gavin
within 60min of
incision
9% Abx given 24h
before surgery
72.7% gave Abx for more
than 3 days postop
9% gave Abx for 3 day,
9% for 1 day
9% stopped it after
surgery

20. Plan for implementing changes
 Presentation of the results from data collection 1.
 Explaining how this practice differes from the best evidence available.
 Making a small pamphlet in each surgical patient’s file that contains the rules
for prescribing ABx prophylaxis.
 A follow up meeting a week later to see how the new rules are being
followed.
 Reaudit a month later.

21. Results for data collection 2
 To be collected

22. Conclusion
 The best performance was in IV adminstration, and the worst was
prolongation of ABx after surgery. This needs to be emphasised in any change
plan.
 No single response was completely compliant with guidelines. And eventhough
some of the responses might provide an effective prophylasxis, they were
accompanied by either over-prescription or choice of another ABx type.
 The types suggested by respondants might provide mutual covrage with the
types suggested by the WHO, however they tend to be more expensive and
have a broader coverage which might increase resistance.
 The results indicate that practice of ABx prophylaxis didn’t match the
guidelines, and also was very heterogenous among surgeons.
 All the measures of prevention of SSI should be put into national audit and
published in peer reviewed journal to start making a standarised evidence
based practice.