Improving the prescription of antibiotics, focus on surgical prophylaxis.

Abstract

This thesis comprises several studies on the implementation of guidelines for antimicrobial use in prophylaxis as well as in therapy. The main part focuses on the data of the CHIPS-study; a quality improvement project of surgical prophylaxis in the Netherlands promoting prudent use of antibiotics and implementing the national guideline for prophylaxis of the Ducth Working Party of Antibiotic Policy (SWAB). Thirteen hospitals, in four surgical disciplines, participated in the study. Audits in the hospitals showed that in general the willingness to adhere to local guidelines for prophylaxis was good, although adherence to guidelines for timing was problematic. Implementation of the SWAB-guideline for prophylaxis resulted in significant improvements: increased use of narrow spectrum antibiotics, shorter duration of prophylaxis and correct timing. A significant decrease in total antimicrobial use and costs was achieved while maintaining efficacy in terms of preventing surgical site infections (SSI). Barriers for change varied per parameter of surgical prophylaxis and between hospitals and surgical specialties. There was no magic improvement strategy and identifying key players for change was essential for success. In total hip arthroplasty it was shown that, although not statistically significant, timing of prophylaxis seems to be the most relevant prophylaxis parameter that influences patient outcome in terms of SSI. Timely administration of antibiotics also effects patient outcome in antibiotic therapy, and an intervention study in an University Hospital showed that the delay between the order and administration of the first dose of the antibiotic could be signifcantly shortened. In conclusion important improvements in the quality of surgical prophylaxis and therapy could be achieved and, even in a country with a history of prudent antibiotic use, cost savings could be obtained in prophylaxis while maintaining efficacy in terms of prevention of SSI