Improving the Use of Prophylactic Antibiotics

Abstract & Commentary

Synopsis: Instituting a policy for prophylactic antibiotics can increase their appropriate use.

Source: DiLuigi AJ, et al. J Reprod Med. 2004;49:949.

Diluigi and colleagues in Rhode Island compared the outcomes of 400 patients undergoing hysterectomy with 686 hysterectomy cases performed prior to the institution of a policy for prophylactic antibiotics. Abdominal, vaginal, and laparoscopic cases were included, with the primary aspects being rates and timing of preoperative antibiotic administration as well as postoperative febrile morbidity. The rate of antibiotic administration went from 50% to 91%. Febrile morbidity was 14% prior to the policy, and 11% afterwards. Because of the well-established body of literature that supports the use of antibiotics prior to hysterectomy, the authors demonstrate that implementing a policy within an institution may be needed to improve the practice of evidence-based medicine.

Comment by Frank W. Ling, MD

Take note. Each of our hospitals can make a difference in how medicine is practiced. Given good data, how medicine is practiced can be affected by good hospital policy. This study is both simple and imposing. It is simple because it shows a simple outcome: you can markedly increase the appropriate use of antibiotics prior to hysterectomy. The implications for each of us at each of our hospitals are imposing: we can improve the way that evidence-based medicine is practiced if we choose to do so.

This publication is the second part of a Quality Improvement Initiative at Women and Infants Hospital. DiLuigi et al had already determined that only half of the patients were getting antibiotics prior to hysterectomy. By policy, patients were now to get cefazolin 2 gm (clindamycin 900 mg if allergic to penicillin or cephalosporin). The attending physician had to actively cancel the order for the patient not to receive the antibiotic. Not surprisingly, the patients who did not receive the antibiotics had a higher rate of febrile morbidity. These numbers were too small, however, to be analyzed separately. Those with fever, however, were hospitalized significantly longer.

It is well-established that the goal of administering antibiotics is to achieve tissue and blood levels prior to the procedure. Additional doses have been recommended if blood loss exceeds 1500 cc or the surgical time exceeds 1-2 half-lives of the antibiotic. Despite sound scientific literature, use of prophylactic antibiotics remains spotty. These data from 2000 should make us notice what is happening in our respective hospitals.

I am certainly a proponent of quality of care, but also a proponent of a physician’s ability to make clinical decisions independently. In this case, I am comfortable suggesting an application of this study that could be useful in all of our hospitals. As a simple review, the hospital can see if prophylactic antibiotics are being used prior to hysterectomy—be they abdominal, vaginal, or laparoscopic. The medical staff’s active participation will make this a painless and potentially useful review. If there is room for improvement, a protocol might be considered, something as simple as routine orders for pre-operative antibiotics before any hysterectomy that the attending surgeon must actively cancel in order for the protocol not to apply. Short of a protocol, the physicians, acting as a group, might make a recommendation that prophylactic antibiotics be used. Then, only if there remains a discrepancy between appropriate use and real use, would the department consider implementing a protocol.

The goal here is quality of patient care. Something as simple as prophylactic antibiotics prior to hysterectomy would seem to be a no-brainer. In one of the hospitals where I do surgery, I don’t have to worry whether a patient fulfills the criteria for sequential compression boots. There is a protocol in place and they are applied before I even pre-op the patient in the holding area. My life is simpler and I’m glad the medical staff took these steps. What about other examples? I know that antibiotics have been shown efficacious for Cesarean deliveries for sure. A protocol for that wouldn’t be a bad idea. My urogynecology partner recommends that prophylactic antibiotics be used anytime a sling is used for incontinence. The data to support this are few, but this is what he does. Maybe a protocol for that is still a ways away.

I think you get the point. Look around at your practice, your hospital, your environment. Would your patients and those of the other OB/GYN physicians benefit from the collective wisdom of all the doctors and the literature? This article would provide a model by which significant changes can be made in a painless and effective fashion.

Frank W. Ling, MD, Women’s Health Specialists, PLLC, Memphis, Tennessee, is Associate Editor for OB/GYN Clinical Alert.