DYNAMIC DUO Catherine Rehnert, RN, MSN (left), and Marian LeCoultre, RN, BSN, CNOR, helped improve antibiotic administration practices at St. Luke's University Health Network.

One out of every 24 patients develops a surgical site infection, according to current literature, and antibiotic selection and timing are key first steps to reducing the risk. In 2009, however, our compliance rate for delivering the appropriate antibiotic hovered around 92%. Good, not great, so we monitored our surgical team's performance and discovered inconsistency in selecting the right medication was a major issue. The essential elements of our improved antibiotic delivery program highlighted here have kept our compliance rate at 100% since July 2010, and we're confident it won't slip again.

1. Staff education
Have a representative from your facility's pharmacy department (or perhaps an outside pharmaceutical consultant if you manage a small surgery center) talk with the surgical team about the importance of antibiotic selection and on-time administration.

We linked the inconsistencies in our delivery process to a lack of physician and staff knowledge about proper antibiotic selection. The surgical team needed to learn which antibiotics are appropriate for which surgeries, so our hospital's pharmacist Cathleen A. Zanghi, PharmD, led an excellent presentation about choosing between the different combinations of initial antibiotics based on patient characteristics and surgery types (see "Know Your Antibiotic Classes" on page 10).

Certain antibiotics attack harmful bacteria in specific areas of the body, so matching the right medication to where the surgery will be performed is of paramount importance. Patients undergoing GYN procedures, for example, require different prophylaxis doses than orthopedic patients.

Dr. Zanghi also informed us that cefazolin is effective for most clean procedures because of its activity against Staphylococci and Streptococci. Procedures that may involve exposure to bowel anaerobes, on the other hand, require combined doses of cefazolin, metronidazole and ertapenem. Dr. Zanghi shared that most patients who are allergic to penicillin can be treated with cefazolin because reactions are infrequent, but attending physicians have final say in these situations, and the pharmacy department will continue to call for clarification if questions arise about proper dosing.

Staying up to date on the latest antibiotic delivery regulations and guidelines should be an ongoing goal to ensure your staff properly performs this important first step in SSI prevention (see "New Antimicrobial Prophylaxis Guidelines Released"). Hang an information bulletin board in a high-traffic area where you can post the latest information pertaining to antibiotic administration, including related measures of the Surgical Care Improvement Project (SCIP).

UPDATED RECOMMENDATIONS
New Antimicrobial Prophylaxis Guidelines Released

A multi-society collaboration resulted in updated clinical guidelines for antimicrobial prophylaxis, including the optimal time for administering pre- and intra-operative antibiotic doses (for lengthy procedures), weight-based dosing for obese patients and breakdowns of antimicrobial prophylaxis for various surgical procedures. Among the key ground covered by the Society of Health-System Pharmacists, the Infectious Diseases Society of America, the Surgical Infection Society and the Society for Healthcare Epidemiology of America:

HIGH STAKES According to the CDC, SSIs account for nearly 10% of deaths caused by hospital-acquired infections, adding $10,000 to $25,000 to the cost of caring for each affected patient.

• Timing. The optimal time for administration of pre-op doses is within 60 minutes of the surgical incision. This is a more specific time frame than the previously recommended "at induction of anesthesia." Some agents, such as fluoroquinolones and vancomycin, require administration 1 to 2 hours before surgery; the administration of these agents should therefore begin within 120 minutes of the surgical incision.

• Weight-based doses. Obesity has been linked to an increased risk for SSI and the pharmacokinetics of antibiotics may be altered in obese patients, so dosage adjustments based on body weight may be warranted for these patients. In the obese, and especially in the morbidly obese, serum and tissue concentrations of some drugs may differ from those in normal-weight patients. Body fat percentage is a more sensitive and precise measurement of SSI risk than body mass index.

• Re-dosing. Administer prophylactic agents to ensure adequate levels remain in blood and tissue for the interval during which the surgical site is open. For all patients, intraoperative re-dosing is needed to ensure adequate blood and tissue concentrations if the procedure's duration exceeds 2 half-lives of the drug or excessive blood loss occurs during the procedure.

On the Web:

• See the full multi-society report in the American Journal of Health-System Pharmacy: tinyurl.com/bu4rm3m

• Check out key recommendations in the report's pocket guide: tinyurl.com/btjnh2z

— Daniel Cook

TIMING IS EVERYTHING Antibiotics must be administered within 60 minutes before the surgical incision, or within 120 minutes if vancomycin is given.

2. Frontline champions
Form a process improvement team consisting of a quality improvement leader, pre-op nurses, a pharmacy rep and the managers and educators of the surgical services department. The team should serve as champions of your antibiotic delivery efforts. They'll become the frontline experts and be available if questions or issues arise throughout the day related to antibiotic selection or administration.

3. Proper selection
Select the proper antibiotic based on the common pathogens you're targeting and the types of procedures patients are scheduled to undergo. Antibiotics must be profiled and available before patients arrive in pre-op. (Our pharmacy puts needed doses in our department's automated medication storage and dispensing cabinet.)

Post SCIP's antibiotic delivery algorithm (tinyurl.com/d3mc3ao) in your pre-op holding areas to provide staff with visual reminders of which antibiotic are appropriate for various procedures and patients. The algorithm will prove invaluable to pre-op nurses and perhaps be even more informative for nurses who fill in during sick days and vacations.

Before any antibiotic is hung, have staff check the posted algorithm. If the prescribed antibiotic doesn't match the suggested type, have them consult with the surgeon or anesthesia provider to have it changed.

4. Perfect timing
Antibiotics must be administered within 60 minutes of the surgical incision, or within 120 minutes if vancomycin or a quinolone is given. Pre-op nurses should retrieve medications and hang them next to patients, but shouldn't start the drips — that should be left for the anesthesia providers as they move patients to the ORs. When vancomycin is the recommended dose, pre-op nurses should start drips in the holding area before patients are moved for surgery.

Administering vancomycin at the appropriate time demands excellent communication between the pre-op staff and the surgical team. As a general rule, start the medication when the surgeon is closing the previous patient's incision to ensure the drug drips for more than an hour.

Make a note in the patient's operative report if an airway issue, positioning difficulty or other unforeseen circumstance delays the expected start time of the case and throws off the proper timing of the antibiotic administration.

SELECTION GUIDE
Know Your Antibiotic Classes

Aminoglycosides
Common types: gentamicin, tobramycin, kanamycin
Targets: gram-negative bacteria, E. coli, Klebsiella, P. aeruginosa, some gram-positive aerobes (Enterococcus)
Uses: prophylaxis for GI procedures

Carbapenems
Common types: Ertapenem, imipenem/cilastatin and meropenem
Targets: Both gram-positive and gram-negative bacteria, and anaerobic organisms (not suited for MRSA or P. aeruginosa)
Uses: prophylaxis of surgical site infection for elective colorectal surgery

Cephalosporins: First Generation
Common types: cefazolin, cephalexin, and cefadroxil
Targets: mainly gram-positive organisms: endogenous Staphylococci and Streptococci, and group A beta-hemolytic Streptococcus (shows greater beta-lactamase resistance than penicillin)
Uses: Bowel surgery if used with metronidazole and orthopedic surgery (shows good penetration into bone and surrounding tissues)

Cephalosporins: Second Generation
Common types: cefaclor, cefoxitin
Targets: gram-positive bacteria and some gram-negative species: E. coli, Proteus mirabilis, Klebsiella, Haemophilus, Moraxella and anaerobes
Uses: Procedures involving exposure to bowel anaerobes

Cephalosporins: Third Generation
Common types: ceftriaxone, ceftazidime
Targets: some gram-positive bacteria, even more gram-negative species: E. coli, Proteus mirabilis, Klebsiella, Haemophilus, Moraxella and anaerobes
Uses: orthopedic surgery (especially if infection is already present in bone or joint) and GYN indications

Glycopeptide
Common type: vancomycin
Targets: Staphylococcal and Streptococcal species (gram-positive) as IV formulation; C. diff. orally
Uses: high-risk surgery with identifiable risk factors for MRSA infection post-operatively such as diabetes, renal disease and recent hospitalization (also option for penicillin/cephalosporin allergic patients undergoing cardiac, GYN, vascular and orthopedic procedures)

Monobactam
Common type: aztreonam
Targets: mainly gram-negative coverage
Uses: esophageal procedures; can be used with clindamycin for penicillin/cephalosporin allergic patients undergoing billiary surgery

WISE CHOICE Understanding the pathogens that antibiotics target will help ensure the right dose is given to the right patient.

Penicillin
Common types: amoxicillin, ampicillin, nafcillin, piperacillin, oxacillin and meropenem
Targets: Mainly gram-positive bacteria, and some gram-negative coverage (H. pylori, E. coli, Proteus mirabilis)
Uses: prophylaxis for GI procedures and endocarditis

Quinolones
Common types: ciprofloxacin, levofloxacin, moxifloxacin
Targets: broad spectrum (gram-negative bacteria more than gram-positive)
Uses: beta-lactam allergic patients, patients undergoing genitourinary, ophthalmic, GI, cardiac and orthopedic procedures*

* Quinolones have been associated with development of serious and fatal hypoglycemia, especially in elderly and diabetic patients, but can occur in non-diabetic patients as well. The medications can interfere with development of cartilage in patients younger than 18 years.

— Cathleen A. Zanghi, PharmD

Dr. Zanghi ([email protected]) is a pharmacist at St. Luke's University Health Network in Allentown, Pa.