Surgical antimicrobial prophylaxis: preventing infection or increasing resistance?

Using antibiotics to prevent surgical site infections is the most common indication for antimicrobial use in Australian hospitals. However, there are high rates of inappropriate use.

40% of prescriptions for surgical prophylaxis were found to be inappropriate in the 2015 National Antimicrobial Prescribing Survey. This is problematic because it contributes to overuse of antibiotics, and exposes patients to potential adverse effects.

During World Antibiotic Awareness Week (13–19 November), a special release article from Australian Prescriber urges health professionals to conserve the usefulness of antibiotics by practising appropriate antimicrobial prescribing during surgery.

One of the authors, Professor Karin Thursky, Director of the National Centre for Antimicrobial Stewardship, says a common finding is that patients are continued on oral antibiotics after surgery. There may be several reasons for this, but it may be driven by individual surgeons’ beliefs that it helps reduce risk of infection.

“All surgical procedures carry a risk of infection. There is good evidence for how and when antibiotics are required to prevent post-surgical infection. What we are seeing though is a wide variation in practice which may not provide any additional benefit to the patient, and may in fact cause harm. Use of any antibiotics must be balanced against their potential risks, including allergic reactions, antibiotic-associated Clostridium difficile and antibiotic resistance,” says Professor Thursky.

“For minor procedures undertaken in general practice, prophylaxis before or during surgery is often not indicated and post-procedural prophylaxis, especially the use of topical antimicrobials, is rarely indicated yet often prescribed.”

“Antimicrobial prophylaxis is more likely to be needed for procedures where surgical site infections tend to be high, such as colorectal surgery, or where the consequences of infection are significant (eg cardiac valve surgery).”

The authors urge that efforts need to be made to maximise the quality of surgical antimicrobial prophylaxis prescribing in accordance with the Therapeutic Guidelines or locally endorsed prophylaxis guidelines.

In a more recent survey (2016) specifically looking at surgical antimicrobial prophylaxis, there were concerns about inappropriate procedural and post-procedural prescribing in Australian hospitals. Where guidelines were available, 41% of procedural and 62% of post-procedural prophylaxis was not concordant with those guidelines.

The key elements of appropriate prophylaxis include considering the correct indication, antimicrobial, drug dose, route, timing of administration and duration.

“It’s important for GPs to remember they have a significant role to play in ensuring the appropriate use of antibiotics. Patients are usually back into the community after their operation or procedure, and GPs will manage their post-operative progress. Understanding the role of antibiotics in the absence of a documented infection is important,” Professor Thursky points out.

6 ways to achieve best-practice surgical antimicrobial prophylaxis in general practice

1. Do not prescribe surgical antimicrobial prophylaxis without an appropriate indication.
   
2. Avoid topical antimicrobials for surgical procedures.
   
3. Use the Therapeutic Guidelines for specific information regarding optimal drug, dose, route and timing.
   
4. Query long-term use of post-procedural antibiotics with the initial prescriber or surgical team.
   
5. Avoid prescribing ongoing supply of topical and oral antimicrobials without a clear indication from the initial prescriber.
   
6. Monitor for surgical complications such as superficial, deep and organ space infections, and discuss with the surgeon or treating hospital.
   

For dentists

For dental procedures, guidelines recommend that antimicrobial prophylaxis may be appropriate for surgery on immunocompromised patients, and for surgical removal of a bone-impacted tooth or periapical surgery in patients with a history of recurring infections.

Endocarditis prophylaxis may be required for a range of dental procedures in specific patients.

To read more about antibiotic prophylaxis in dentistry, see the article in the current issue of Australian Prescriber.

ENDS

Experts are available for media interview.

Media contacts:
Eve Hanks on (02) 8217 9249, 0419 618 365 or ehanks@nps.org.au
Juliet Pisani-Forde on (02) 8217 8667 or jpisaniforde@nps.org.au

World Antibiotic Awareness Week is an annual, global event to raise awareness about the serious health issue of antibiotic resistance. Our aim is to reduce antibiotic resistance and educate Australians about the steps they can take to preserve the power of antibiotics. Visit nps.org.au/waaw to learn more about the week or contact our media advisers for more information.

Australian Prescriber is an independent peer-reviewed journal providing critical commentary on therapeutic topics for health professionals. It is published by NPS MedicineWise, an independent, not-for-profit organisation for quality use of medicines funded by the Australian Government Department of Health. Australian Prescriber is published every two months and is available online at nps.org.au/australianprescriber.