Inappropriate antibiotic prescribing common in elective surgeries, study finds
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Key takeaways:
- A study of more than 500,000 inpatient elective surgeries found that antibiotic prophylaxis guidelines were not followed 41% of the time.
- The adjusted odds of adherence fell by 8% in 2020 compared with 2019.
A large study conducted at more than 800 hospitals found that antibiotic prophylaxis guidelines were not followed in more than two-fifths of inpatient elective surgeries.
The data, published in Clinical Infectious Diseases, were from a range of surgeries. The researchers found that inappropriate vancomycin use was “by far” the largest contributor to nonadherence, used in 77% of nonadherent regimens and 31% of all surgeries. Vancomycin use increased the risk for acute kidney injury (AKI), even when used for a single day, and the risk increased even more when vancomycin was added to cefazolin.
“We were quite surprised by the results of our study,” Stephanie Cabral, MD, a second-year postgraduate clinician at Beth Israel Deaconess Medical Center in Boston, told Healio. “This nonadherence rate is highly problematic, and specifically, the high rate of noncompliant vancomycin use is concerning. The guidelines were carefully designed based on prior research to maximize surgical site infection prevention while minimizing the risk of prophylaxis-associated events.”
Cabral said that prior work suggests vancomycin does not reduce the risk for surgical site infection, which means “there are a lot of U.S. patients who are receiving an extra medication that may increase their risk of adverse events without offering much, if any, clinical benefit.”
Cabral and colleagues conducted a retrospective cohort study of 521,091 inpatient elective surgeries — craniotomy, hip replacement, knee replacement, spinal procedure and hernia repair — performed between Jan. 1, 2019, and Dec. 31, 2020, at 825 hospitals. Patients included in the trial had a mean age of 65 and 43% were male.
Of the analyzed procedures, 59% were adherent to prophylaxis guidelines endorsed by the American Society of Health-System Pharmacists. The adjusted odds of adherence decreased by 8% in 2020 compared with 2019, according to the study.
After controlling for age, sex, comorbidities, procedure, treatment with other nephrotoxic agents and MRSA status, the data showed patients receiving a combination of vancomycin and cefazolin had a 19% greater risk for developing AKI during hospitalization compared with patients receiving cefazolin alone.
Vancomycin, the researchers wrote, is being overused by U.S. providers in patients who have not been diagnosed with MRSA or are at high risk for it — although they note that the cohort’s 1.4% MRSA prevalence may be an underestimate.
According to Cabral, in the 10 years since the guidelines were endorsed and published “there has been very little tracking in the ensuing decade to find out whether hospitals have been adhering to these recommendations.”
Previous surveys have found that hospitals have been slow to adopt some guidelines, including for reasons that include physician skepticism and institutional priorities, as well as that some physicians simply are not aware of them.
The goal of the analysis, Cabral said, was to provide a more comprehensive understanding of adherence rates, and specifically which regimens are being given incorrectly, in order to better inform future efforts at both antimicrobial stewardship and surgical site infection prevention.
“Overall, our study underscores that adherence to surgical antimicrobial prophylaxis is suboptimal and is primarily driven by noncompliant vancomycin use,” Cabral said. “Our data also suggest that modifying the guidelines to more clearly specify when vancomycin should and should not be used could be valuable in order to improve the overall risk/benefit profile of antimicrobial prophylaxis.”
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