QUALITY STANDARD FOR ANTIMICROBIAL PROPHYLAXIS IN SURGICAL-PROCEDURES

OBJECTIVE: The objectives of this quality standard are 1) to provide a n implementation mechanism that will facilitate the reliable administr ation of prophylactic antimicrobial agents to patients undergoing oper ative procedures in which such a practice is judged to be beneficial a nd 2) to provide a guideline that will help local hospital committees formulate policies and set up mechanisms for their implementation. Alt hough standards in the medical literature spell out recommendations fo r specific procedures, agents, schedules, and doses, other reports doc ument that these standards frequently are not followed in practice. OP TIONS: We have specified the procedures in which the administration of prophylactic antimicrobial agents has been shown to be beneficial, th ose in which this practice is widely thought to be beneficial but in w hich compelling evidence is lacking, and those in which this practice is controversial. We have examined the evidence regarding the optimal timing of drug administration, the optimal dose, and the optimal durat ion of prophylaxis. OUTCOMES: The intended outcome is more uniform and reliable administration of prophylactic antibiotics in those circumst ances where their value has been demonstrated or their use has been ju dged by the local practicing medical community to be desirable. The re sult should be a reduction in rates of postoperative wound infection w ith a limitation on the quantities of antimicrobial agents used in cir cumstances where they are not likely to help. EVIDENCE: Many prospecti ve, randomized, controlled trails comparing placebo with antibiotic an d comparing one antibiotic with another have been conducted. In additi on, some trials have compared the efficacy of different doses or metho ds of administration. Other papers have reported on the apparent effic acy of administration at different times and on actual practice in spe cific communities. Only a small group of relevant articles found throu gh 1993 are cited herein. When authoritative reviews are available, th ese rather than an exhaustive list of original references are cited. V ALUES: We assumed that reducing rates of postoperative infection was v aluable but that reducing the total amount of antimicrobial agents emp loyed was also worthwhile. The cost of and morbidity attributable to p ostoperative wound infections should be weighed against the cost and p otential morbidity associated with excessive use of antimicrobial agen ts. BENEFITS, HARMS, AND COSTS: More reliable administration of antimi crobial agents according to recognized guidelines should prevent some postoperative wound infections while lowering the total quantity of th ese drugs used. No harms are anticipated. The costs involved are those of the efforts needed on a local basis to design and implement the me chanism that supports uniform and reliable administration of prophylac tic antibiotics. RECOMMENDATIONS: All patients for whom prophylactic a ntimicrobial agents are recommended should receive them. The agents gi ven should be appropriate in light of published guidelines. A short du ration of prophylaxis (usually < 24 hours) is recommended. VALIDATION: More than 50 experts in infectious disease and 10 experts in surgical infectious disease and surgical subspecialties reviewed the standard. In addition, the methods for its implementation were reviewed by the American Society of Hospital Pharmacists. SPONSORS. The Quality Standa rds Subcommittee of the Clinical Affairs Committee of the Infectious D isease Society of America (IDSA) developed the standard. The subcommit tee was composed of representatives of the IDSA (Drs. Gross and McGowa n), the Society for Hospital Epidemiology of America (Dr. Wenzel), the Surgical Infection Society (Dr. Dellinger), the Pediatric Infectious Disease Society (Dr. Krause), the Centers for Disease Control and Prev ention (Dr. Martone), the Obstetrics and Gynecology Infectious Disease s Society (Dr. Sweet), and the Association of Practitioners of Infecti on Control (Ms. Barrett). Funding was provided by the IDSA and the oth er cooperating organizations. The standard is endorsed by the IDSA.