Healthcare

1. Improvement Project to Keep
Prophylactic Antibiotic for
Surgical
Cases not more than 24 hours
(reduction by 50 %)
Pharmacy and Infection Control Departments
FROM 15-12-1433 to 15-6-1434

2. Background about antibiotic
prophylaxis for surgical site
infection
1. Antimicrobial Prophylaxis is used to reduce the
incidence of post operative wound infections

3. 2. The following are the main categories
who should receive antimicrobial
prophylaxis:
a. Patients undergoing procedures
associated with high infection rate.
b. Those involving implantation of
prosthetic material.
c. Those in which the consequences of
infection are serious

4. 3. Cephalosporins (e.g. cephradine)are
considered first line choice for most of surgical
procedures.
4. Duration of surgical procedures should not
exceed 24 hours.(For the majority of
procedures).
5. A single preoperative dose is as effective as a
full 5 days course assuming an uncomplicated
procedures.

5. 6. Prophylactic antibiotic should be administered within 1
hour prior to incision.
7. Complicated, contaminated, or dirty procedures should
receive additional postoperative coverage.
8. Prophylactic antibiotic should target the anticipated
organisms
9. Prophylaxis is unnecessary if the patient is already
receiving antibiotics that cover likely pathogens.
10.The timing of antibiotic administration should be adjusted
to maximizing the prophylactic
efficacy.

6. 11. During prolonged procedures , antibiotic
prophylaxis should be readministered every 3 hours,
except with vancomycin,aminoglycosides and
flouroquinolones.
12. Surgical site infections account for approximately 15
% of nosocomial infections.
13. The main goal for prophylactic antibiotic is to
reduce the incidence of post operative wound
infection.

7. 2. The following are the main categories
who should receive antimicrobial
prophylaxis:
a. Patients undergoing procedures
associated with high infection rate.
b. Those involving implantation of
prosthetic material.
c. Those in which the consequences of
infection are serious

8.  It was noticed from pharmacy monthly statistics that we are
not using antibiotic wisely because about 70-80% of all
prescriptions contain antibiotics. We search in most of files
and found that in all surgical cases the policy of prophylactic
antibiotic was not applied and all surgical patients receive
prophylactic antibiotic on time (maximum 60 minutes before
skin incision) then patients continue on antibiotic for 5 days to
7 days without any reason and not according to our policy
F:Focus

9.  1-Exposing patients to the side effect of the drug
without indication
 2-Research shows there is no value to use
prophylactic antibiotic for more than 24 hours
 3-High cost for hospital without indications
 4-Increase multiresistant bacteria in hospital because
of using broad-spectrum antibiotic without indication
What is the effect of using
prophylactic antibiotic for more than
24 hours?

10.  1-Mr.Farhan Ali :Pharmcy director Leader
 2-HAMED SHAFIQ :Pharmacist
 2-Dr.Aziz Allaha :Head of infection control
 3-Dr .Emad Kotb :Quality director
 4-Dr Hamed Harhash : Surgical specialist
 5-Mr. Modhi : Assistance nursing director
 6-Mr. Abdulla :Pharmacist
 7-Sister Anumol : Head nurse OR
 8-Dr foad lababidi :Medical director
O:Organize the team

11. Number of patients with prophylactic
antibiotic discontinue after 24 hours
Number of patients with prophylactic
antibiotic given in proper time (within 60…
Total number of surgeries
0
20
40
60
80
100
120
Month 9
Month 10
Month 11
0
0
0
84
103
57
84
103
57
Number of patients with prophylactic antibiotic
discontinue after 24 hours
Number of patients with prophylactic antibiotic
given in proper time (within 60 minutes from
starting surgery)
Total number of surgeries

12. percent of the patients which prophylactic antibiotic
discontinues after 24 hours
percent of the patients which prophylactic antibiotic
given in proper time
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Month 9
Month 10
Month 11
0%
0%
0%
100% 100% 100%
percent of the patients which prophylactic
antibiotic discontinues after 24 hours
percent of the patients which prophylactic
antibiotic given in proper time

13. Antibiogram before starting the
project from 1-3-1433 to 1-9-1433

14. Bacteria Nitrof Norfil Tiena Amik Cipro Aztre Nalid Genta Ciftaz Pipra Cefat Eryth Clind Mrthi Vanc Cefep Cotri Ampi Ceph Chlor
E. coli
103 cases
81% 58% 93% 63.4% 53.5% 42% 39% 47% 43.4%
Proteus
24
79% 29% 16.6%
Citrobacter
6
80% 40%^ 83.3% 66.6% 40% 40% 40%
Klebseilla
14
50% 78.6% 63% 71.4% 50% 54.1% 57% 50%
Acintobacter
23
13% 8% 8% 8% 8% 8% 8%
Strept pyogens
31
29% 29% 45% 90% 80% 58% 45%
Staph aureus
42
85% 57.1% 45% 93% 54.7% 42.9% 45.2%
Pseudomonas
19
68.4% 64.2% 63.1% 42.1% 47%
Enterococci
10
50% 80% 20% 20%
Stenomultiophilia
13
64.2% 53.8% 76.9% 61.5%

15.  Fishbone analysis done to see the causes of
continuing prophylactic antibiotic more than 24
hours
 NB. Prophylactic antibiotic is giving in time because
we have double check one in red line for OR the
second in time out procedures before skin incision
U: Understand the cause of
variations

17.  1-Distribute the antibiotic policy for all staff
 2-Lectures about proper use of antibiotic
 3-Workshop about antibiotic policy and how to
implemented
 4-Lecture for pharmacy staff about how to monitor
antibiotic and to implement antibiotic policy
 5-Distribute the list of antibiotic which allowed to be
prescribed by the consultant specialist and resident
S: Select improvement

18. ACTION PLAN Page 1 of 1
RCH-004-1431
ACTION PLAN
Date:_______28-12-2013_______________________ Department:___________Pharmacy______________________ Receiving All departments
NO SOLUTION REQUIRED RESOURCES ACCOUNTABILITY DEADLINE TARGET STATUS
1
• 1-Distribute the antibiotic policy for all
staff
Policy and procedures Head of pharmacy 1-1-2013 to
15-1-2013
100%
2
• 2-Lectures about proper use of
antibiotic
Computer projector Head of infection
control
16-1-2013 to
30-1-2013
80%
3
3-Workshop about antibiotic policy and how to
implemented
Computer projector
papers
Quality director and
pharmacy director
20-1-2013 to
25-1-2-13
80%
4
• 4-Lecture for pharmacy staff about how
to monitor antibiotic and to implement
antibiotic policy
Computer projector Quality director and
pharmacy director
26-1-2013 to
2-2-2013
100%
5
Distribute the list of antibiotic which allowed to
the consultant specialist and resident
List pharmacy director 1-1-2013 to 7-1-
2013
100%

19. 1-Antibiotic policy distributed to all physicians
2- lectures done for proper use of antibiotic and poster for
stopping prophylactic antibiotic within 24 hours
3- Workshop about antibiotic policy done
4- Lectures for pharmacy staff about monitoring antibiotics and
how to implement antibiotic policy
5-List of antibiotic which allowed to consultant and specialist
and ROD were distributed
DO:

20. 45%
25%
30%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
Prophylactic injectable antibiotic
stopped within 24 hours
Prophylactic injectable antibiotic
stopped within 24 hours and
shifted to oral antibiotic
Prophylactic injectable antibiotic
not stopped(continue)
Check Month 6/1434

21. Antibiogram after 6 months from
starting project (1-3-1434 to 1-9-1434)

22. Bacteria
Total # of cases
Nitroffura
nt
Norfl Tienam Amik Cipro
Aztre
onam
Nalid ixic Genta Ciftaz Pipra Cefta Eryth Clind Augm Vanc Cefep Cotri Ampi
Cephalaxi
ne
Chlor
E. coli
77 cases
90.8%
(urine)
43% 94.8% 84.4% 50.1%
(urine)
50.6%
Proteus
14 cases 57.1% 42.9%
Klebseilla
11 cases 100% 63.6% 54.5% 54.5% 54.5%
Acintobacter
12 cases 33.3% 33.3%
Strept pyogens
14 cases 80% 57% 78.6% 92% 78.6% 42
Staph aureus
18 cases 61% 95% 2809 44
Pseudomonas
32 cases
57.1%
(urine)
75% 65.6% 65.6% 59.4%
Enterococci
7 cases 90%
Stenomultiphilia
9 cases 66.7% 88.9% 77.8% 66.7%
Aeromonas
4 cases 100% 75%
Enterobacter
6 cases 100% 83% 83% 66.6% 50% 50%
Chryseomonas
5 cases 100% 60% 60% 60% 80%

23. CASES OF SURGICAL SITE
INFECTION IN THE YEAR 1434
0
1
2
3
4
5
0 0 0 0 0
1
2
0 0 0 0 0 0
Total Number of Surgical Site Infection
Total Number of Surgical Site Infection

24.  Month 6and 7 we have surgical site infection (one in
month 6 and 2 cases in month 7)cause may be
because we started to do endoscopy and
colonoscopy in main OR so we decided to shift all
endoscopy and colonoscopy to emergency OR and
after this infection was zero
 All patient for OR receiving prophylactic antibiotics in
time
continue

25. Benefits from following
prophylactic antibiotic
preoperative
1-Improving antibiogram
2-Improve turnover of beds(no IV antibiotic so patients can discharge
home)
3-reduce cost of antibiotic (within 6 months rocehpin 600000Riyals –
Augmentine 240000riyals-Flagyl 180000riyals )
4-Number of infections reduced by approximately 20%

26.  There is improvement in stopping prophylactic antibiotic within 24 Hours it
was 0% increased to 45% and in 25% of files injectable antibiotic was stopped
but shifted to oral antibiotic which is useless to the patients form and 30% not
stopped we will continue our plan to improve and to reach our target.
 This project was for 6 months from 15-12-1433 to 15-6-1434 and we reach our
target in 6 months but we continue monitoring of prophylactic antibiotic for
another 8 months because antibiogram was bad with multiresistance
bacteria and we need to improve it for patient safety

ACT

27.  In Month 11/1435 out of 50 surgical cases who
received prophylactic antibiotics, 85% were stopped
after 24 hours.
 Month 7 and 8 1435 out of 50 surgical cases received
prophylactic antibiotic 90% were stopped within 24
hours
Review on Current Status

28. 103
42
31
24 23
19
14 13
10
77
18
14 14 12
32
11 9
6
0
20
40
60
80
100
120
Number of infection before policy(positive
cultures)
Number of infections (positive cultures) After
appling policy

29. 0
5
10
15
20
25
blood c&s Urine Sputum Wound swab
0
2.8
19
3.2
6.9 6.5
24
6.5
pseudomonas percent
Before
After

30. It was noticed that all bacterial infection reduced except pseudomonas
aerogenosa increased and may be because all surgeons used rocephine
injection and it is mainly for gram negative infection so we informed them to
use cephazoline or mefoxine instead of rocephin as prophylactic antibiotic but
the sensitivity of pseudomonas in the new antibiogram improved by 20 %for
ciftazidime and incresed for impinam from 60% to 75%
- For acitobacter it was multiresistance maximum 13% sensitive to impinam the
sensitivity increased by 253% now and for gentamycine sensitivity increased
from8% to 33% this means by 412% increase in sensitivity

31. 0%
45%
85%
90%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Month 12/1433 Month 6/1434 Month 11/1434 Month 8/1435
Percent og prophylactic antibiotic stooped within 24 hours
Percent og prophylactic antibiotic stooped
within 24 hours

32. Why do people get infectious diseases?
From the organism’s perspectives
The number of organisms
The virulence of these organisms
From the host’s perspective
Innate immunity
acquired immunity
Antibody-mediated
cell-mediated

34.  THANK YOU