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8/4/2004

New Antimicrobial Advisory Released for Prophylaxis in Surgery

Christina Benner

Pharmacists have more evidence to defend their decisions on preventing postoperative infections: an advisory statement by the Surgical Infection Prevention (SIP) work group.

Surgical site infections (SSIs) are the second most common cause of nosocomial infections after catheter-associated urinary tract infections, according to a 1996 Centers for Disease Control and Prevention (CDC) study.

The goal of the SIP work group is to decrease the morbidity and mortality associated with SSIs by improving the selection and timing of preventive antimicrobials. Sponsored by the CDC and the Centers for Medicare and Medicaid Services (CMS), this national quality improvement project focuses on antimicrobial prophylaxis for 11 surgical procedures commonly performed on Medicare beneficiaries.

Published in the June 15 issue of Clinical Infectious Diseases, SIP's advisory statement reviews areas of agreement among the most recently published guidelines for surgical antimicrobial prophylaxis, addresses inconsistencies, and discusses issues not currently addressed in published guidelines.1

The group made general recommendations to hospitals to help them increase the number of patients (1) who receive a prophylactic antimicrobial in the hour before surgical incision (two hours prior with vancomycin or fluoroquinolone prophylaxis), (2) given a prophylactic antimicrobial consistent with current recommendations, and (3) whose prophylactic antimicrobial was discontinued within 24 hours after surgery. Antimicrobial selection for patients with a b-lactam allergy was also addressed.

ASHP's representative to the project, Keith Olsen, professor of pharmacy at the University of Nebraska Medical Center in Omaha, said, "The document that was just published in Clinical Infectious Diseases was not meant to replace more comprehensive, well-referenced reviews and guidelines like ASHP's." SIP's advisory statement, he explained, is "supposed to be a more concise document that would correspond with CMS's goals and objectives for the entire project and would allow hospitals to take the guidelines and implement them into their institutions."

Released in 1999 and accepted in 2000 by the federally supported National Guideline Clearinghouse, the ASHP Therapeutic Guidelines on Antimicrobial Prophylaxis in Surgery serve as a reference for the advisory statement.2 ASHP is 1 of 14 societies, including the American College of Surgeons and the Society of Thoracic Surgeons, to participate in the SIP work group.

Both ASHP and SIP's recommendations support timely administration of antimicrobials to prevent infection and short duration to prevent antimicrobial resistance.

While ASHP's guidelines include pediatric recommendations, the SIP statement, because of its focus on older patients, does not address the pediatric population.

Olsen said pharmacists have a number of opportunities to promote rational antimicrobial prophylaxis for surgical procedures. Medication scheduling and delivery to the operating room are tasks pharmacists could oversee, he suggested. Since there is potential cost savings for institutions that use appropriate antimicrobial prophylaxis, Olsen also encouraged pharmacists to participate in committees and adopt the advisory statement.

1. Bratzler DW, Houck PM, for the Surgical Infection Prevention Guidelines Writers Workgroup. Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project. Clin Infect Dis. 2004; 38:1706-15.

2. American Society of Health-System Pharmacists. ASHP therapeutic guidelines on antimicrobial prophylaxis in surgery. Am J Health-Syst Pharm. 1999; 56:1839-88.