Skipping Antibiotic Guidelines Ups Trauma Surgical Infections

LAKE BUENA VISTA, FLA. – Just 49.3% of patients undergoing emergency trauma laparotomy received antibiotics in accordance with the Surgical Care Improvement Project guidelines in a multicenter, retrospective analysis of 306 patients.

"Many of the non-SCIP patients received the wrong antibiotic or antibiotics for too long after their index operation," lead author Brian P. Smith said at the annual meeting of the Eastern Association for the Surgery of Trauma.

Moreover, compliance with the guidelines slashed surgical site infection rates from 32.9% among patients with noncompliant antibiotic management to 16.6% (P less than .001).

The Surgical Care Improvement Project (SCIP) established surgical antibiotic prophylaxis guidelines as part of a collaborative effort by the Centers for Medicare and Medicaid Services and the Centers for Disease Control and Prevention to reduce surgical complications. While these antibiotic prophylaxis guidelines have become well established in patients undergoing elective operative procedures, they have never been studied in trauma patients undergoing emergency surgery, said Dr. Smith, a surgical resident at Temple University Hospital in Philadelphia.*

He reported on an analysis involving 306 trauma patients who survived for more than 4 days after undergoing emergency laparotomy within 2 hours of admission at two level 1 trauma centers during 2007 and 2008. Patients were compared on the basis of adherence to the following SCIP guidelines: prophylactic antibiotic given, antibiotic received within 1 hour prior to incision, correct antibiotic selection, and discontinuation of antibiotic within 24 hours after surgery.

Their mean age was 32 years, 70% had penetrating wounds, 44% had enteric injuries, and 20% had preoperative hypotension.

In all, 155 patients received noncompliant perioperative antibiotic management. Of these, 55% received no prophylaxis or incorrect antibiotics, 46% received antibiotics outside of the recommended 60-minute window, and 54% received them beyond the 24-hour limit, Dr. Smith said.

"It’s important to note these because they represent simple practice maneuvers that can be changed to help improve antibiotic stewardship in our trauma patients," he said.

The SCIP group spent significantly fewer days than the non-SCIP group in the ICU (mean 4 days vs. 7 days; P = .02) and in the hospital (mean 14 days vs. 19 days; P = .01), although no significant difference in mortality was detected (3% vs. 6%; P = .41).

Notably, Injury Severity Score was higher at admission in the non-SCIP group at 16 vs. 13 in the SCIP group (P = .03). Prehospital transfer time, which could influence the prolongation of antibiotics before surgery, was not available.

In a multivariate regression analysis that adjusted for such confounding factors as age, Injury Severity Score, shock, presence of enteric injury, transfusion requirements, damage control surgery, surgery duration, and hospital, complete adherence to the four SCIP guidelines independently decreased the risk of a surgical site infection (odds ratio, 0.448).

The non-SCIP group had significantly more enteric injuries than the SCIP group (52% vs. 35%; P = .027), and the rate of prolonged antibiotics was higher in patients with enteric injuries, compared with those without enteric injuries (38.6% vs. 19.4%; P = .001), Dr. Smith pointed out.

"This suggests the possibility that the extent of antibiotics rather than the enteric injuries themselves explained the wound infection rates in these two groups," he said.

Discussant Dr. John Santaniello, a critical care surgeon from Loyola University Chicago, Maywood, Ill., said the authors need to further elucidate antibiotic usage in patients with enteric injuries to distinguish true SCIP prophylaxis violations from empiric treatment for contamination.

He also questioned why the authors included only four of the six SCIP measures, omitting preoperative skin preparation and intraoperative normothermia maintenance, which have been shown to reduce surgical wound infections.

Dr. Smith said missing data and difficulty in abstracting data from handwritten records kept them from analyzing these two measures.

Attendee Dr. Patrick Reilly, chief of traumatology, surgical critical care, and emergency surgery at the University of Pennsylvania in Philadelphia, questioned how SCIP compliance was defined in a damage-control patient, and asked whether the investigators have a routine way of closing the skin when the fascia can be closed in these patients.

"For a number of years, we have had a practice – we don’t really call it a practice management guideline because we don’t really have any evidence for it – where we leave the skin open if we close the fascia, at least initially, because we’ve realized a high incidence of wound infections regardless of what antibiotic regimen we use," Dr. Reilly said.

Dr. Smith responded that they used the time from the index operation as the cut-point for SCIP compliance in the damage-control setting, but acknowledged that in many practices, patients receive another dose of antibiotics when they return to the operating room for a second look or washout.

Preliminary data on skin management in damage-control patients is being analyzed, but "we suspect, as you do at your institution, that it is probably the management of the skin in the setting of the fascial closure that may contribute to surgical site infections and are looking at a future study," he said.

Finally, when asked how the results have changed practice at Temple University, Dr. Smith said they’d like to believe they are using only 24 hours’ worth of antibiotics in the setting of prophylaxis but lack the evidence to confirm this. He pointed out that although more than a decade has passed since the Eastern Association for the Surgery of Trauma published its own antibiotic guidelines, more than 50% of surgeons in the study were not in compliance.

"Certainly, there is always room for improvement in how we treat our patients," he added.

Dr. Smith and Dr. Santaniello reported no conflicts of interest. Conflict of interest information for Dr. Reilly was not available.

*Correction, 2/22/2012: An earlier version of this article misidentified the lead author of the study.

LAKE BUENA VISTA, FLA. – Just 49.3% of patients undergoing emergency trauma laparotomy received antibiotics in accordance with the Surgical Care Improvement Project guidelines in a multicenter, retrospective analysis of 306 patients.

"Many of the non-SCIP patients received the wrong antibiotic or antibiotics for too long after their index operation," lead author Brian P. Smith said at the annual meeting of the Eastern Association for the Surgery of Trauma.

Moreover, compliance with the guidelines slashed surgical site infection rates from 32.9% among patients with noncompliant antibiotic management to 16.6% (P less than .001).

The Surgical Care Improvement Project (SCIP) established surgical antibiotic prophylaxis guidelines as part of a collaborative effort by the Centers for Medicare and Medicaid Services and the Centers for Disease Control and Prevention to reduce surgical complications. While these antibiotic prophylaxis guidelines have become well established in patients undergoing elective operative procedures, they have never been studied in trauma patients undergoing emergency surgery, said Dr. Smith, a surgical resident at Temple University Hospital in Philadelphia.*

He reported on an analysis involving 306 trauma patients who survived for more than 4 days after undergoing emergency laparotomy within 2 hours of admission at two level 1 trauma centers during 2007 and 2008. Patients were compared on the basis of adherence to the following SCIP guidelines: prophylactic antibiotic given, antibiotic received within 1 hour prior to incision, correct antibiotic selection, and discontinuation of antibiotic within 24 hours after surgery.

Their mean age was 32 years, 70% had penetrating wounds, 44% had enteric injuries, and 20% had preoperative hypotension.

In all, 155 patients received noncompliant perioperative antibiotic management. Of these, 55% received no prophylaxis or incorrect antibiotics, 46% received antibiotics outside of the recommended 60-minute window, and 54% received them beyond the 24-hour limit, Dr. Smith said.

"It’s important to note these because they represent simple practice maneuvers that can be changed to help improve antibiotic stewardship in our trauma patients," he said.

The SCIP group spent significantly fewer days than the non-SCIP group in the ICU (mean 4 days vs. 7 days; P = .02) and in the hospital (mean 14 days vs. 19 days; P = .01), although no significant difference in mortality was detected (3% vs. 6%; P = .41).

Notably, Injury Severity Score was higher at admission in the non-SCIP group at 16 vs. 13 in the SCIP group (P = .03). Prehospital transfer time, which could influence the prolongation of antibiotics before surgery, was not available.

In a multivariate regression analysis that adjusted for such confounding factors as age, Injury Severity Score, shock, presence of enteric injury, transfusion requirements, damage control surgery, surgery duration, and hospital, complete adherence to the four SCIP guidelines independently decreased the risk of a surgical site infection (odds ratio, 0.448).

The non-SCIP group had significantly more enteric injuries than the SCIP group (52% vs. 35%; P = .027), and the rate of prolonged antibiotics was higher in patients with enteric injuries, compared with those without enteric injuries (38.6% vs. 19.4%; P = .001), Dr. Smith pointed out.

"This suggests the possibility that the extent of antibiotics rather than the enteric injuries themselves explained the wound infection rates in these two groups," he said.

Discussant Dr. John Santaniello, a critical care surgeon from Loyola University Chicago, Maywood, Ill., said the authors need to further elucidate antibiotic usage in patients with enteric injuries to distinguish true SCIP prophylaxis violations from empiric treatment for contamination.

He also questioned why the authors included only four of the six SCIP measures, omitting preoperative skin preparation and intraoperative normothermia maintenance, which have been shown to reduce surgical wound infections.

Dr. Smith said missing data and difficulty in abstracting data from handwritten records kept them from analyzing these two measures.

Attendee Dr. Patrick Reilly, chief of traumatology, surgical critical care, and emergency surgery at the University of Pennsylvania in Philadelphia, questioned how SCIP compliance was defined in a damage-control patient, and asked whether the investigators have a routine way of closing the skin when the fascia can be closed in these patients.

"For a number of years, we have had a practice – we don’t really call it a practice management guideline because we don’t really have any evidence for it – where we leave the skin open if we close the fascia, at least initially, because we’ve realized a high incidence of wound infections regardless of what antibiotic regimen we use," Dr. Reilly said.

Dr. Smith responded that they used the time from the index operation as the cut-point for SCIP compliance in the damage-control setting, but acknowledged that in many practices, patients receive another dose of antibiotics when they return to the operating room for a second look or washout.

Preliminary data on skin management in damage-control patients is being analyzed, but "we suspect, as you do at your institution, that it is probably the management of the skin in the setting of the fascial closure that may contribute to surgical site infections and are looking at a future study," he said.

Finally, when asked how the results have changed practice at Temple University, Dr. Smith said they’d like to believe they are using only 24 hours’ worth of antibiotics in the setting of prophylaxis but lack the evidence to confirm this. He pointed out that although more than a decade has passed since the Eastern Association for the Surgery of Trauma published its own antibiotic guidelines, more than 50% of surgeons in the study were not in compliance.

"Certainly, there is always room for improvement in how we treat our patients," he added.

Dr. Smith and Dr. Santaniello reported no conflicts of interest. Conflict of interest information for Dr. Reilly was not available.

*Correction, 2/22/2012: An earlier version of this article misidentified the lead author of the study.

LAKE BUENA VISTA, FLA. – Just 49.3% of patients undergoing emergency trauma laparotomy received antibiotics in accordance with the Surgical Care Improvement Project guidelines in a multicenter, retrospective analysis of 306 patients.

"Many of the non-SCIP patients received the wrong antibiotic or antibiotics for too long after their index operation," lead author Brian P. Smith said at the annual meeting of the Eastern Association for the Surgery of Trauma.

Moreover, compliance with the guidelines slashed surgical site infection rates from 32.9% among patients with noncompliant antibiotic management to 16.6% (P less than .001).

The Surgical Care Improvement Project (SCIP) established surgical antibiotic prophylaxis guidelines as part of a collaborative effort by the Centers for Medicare and Medicaid Services and the Centers for Disease Control and Prevention to reduce surgical complications. While these antibiotic prophylaxis guidelines have become well established in patients undergoing elective operative procedures, they have never been studied in trauma patients undergoing emergency surgery, said Dr. Smith, a surgical resident at Temple University Hospital in Philadelphia.*

He reported on an analysis involving 306 trauma patients who survived for more than 4 days after undergoing emergency laparotomy within 2 hours of admission at two level 1 trauma centers during 2007 and 2008. Patients were compared on the basis of adherence to the following SCIP guidelines: prophylactic antibiotic given, antibiotic received within 1 hour prior to incision, correct antibiotic selection, and discontinuation of antibiotic within 24 hours after surgery.

Their mean age was 32 years, 70% had penetrating wounds, 44% had enteric injuries, and 20% had preoperative hypotension.

In all, 155 patients received noncompliant perioperative antibiotic management. Of these, 55% received no prophylaxis or incorrect antibiotics, 46% received antibiotics outside of the recommended 60-minute window, and 54% received them beyond the 24-hour limit, Dr. Smith said.

"It’s important to note these because they represent simple practice maneuvers that can be changed to help improve antibiotic stewardship in our trauma patients," he said.

The SCIP group spent significantly fewer days than the non-SCIP group in the ICU (mean 4 days vs. 7 days; P = .02) and in the hospital (mean 14 days vs. 19 days; P = .01), although no significant difference in mortality was detected (3% vs. 6%; P = .41).

Notably, Injury Severity Score was higher at admission in the non-SCIP group at 16 vs. 13 in the SCIP group (P = .03). Prehospital transfer time, which could influence the prolongation of antibiotics before surgery, was not available.

In a multivariate regression analysis that adjusted for such confounding factors as age, Injury Severity Score, shock, presence of enteric injury, transfusion requirements, damage control surgery, surgery duration, and hospital, complete adherence to the four SCIP guidelines independently decreased the risk of a surgical site infection (odds ratio, 0.448).

The non-SCIP group had significantly more enteric injuries than the SCIP group (52% vs. 35%; P = .027), and the rate of prolonged antibiotics was higher in patients with enteric injuries, compared with those without enteric injuries (38.6% vs. 19.4%; P = .001), Dr. Smith pointed out.

"This suggests the possibility that the extent of antibiotics rather than the enteric injuries themselves explained the wound infection rates in these two groups," he said.

Discussant Dr. John Santaniello, a critical care surgeon from Loyola University Chicago, Maywood, Ill., said the authors need to further elucidate antibiotic usage in patients with enteric injuries to distinguish true SCIP prophylaxis violations from empiric treatment for contamination.

He also questioned why the authors included only four of the six SCIP measures, omitting preoperative skin preparation and intraoperative normothermia maintenance, which have been shown to reduce surgical wound infections.

Dr. Smith said missing data and difficulty in abstracting data from handwritten records kept them from analyzing these two measures.

Attendee Dr. Patrick Reilly, chief of traumatology, surgical critical care, and emergency surgery at the University of Pennsylvania in Philadelphia, questioned how SCIP compliance was defined in a damage-control patient, and asked whether the investigators have a routine way of closing the skin when the fascia can be closed in these patients.

"For a number of years, we have had a practice – we don’t really call it a practice management guideline because we don’t really have any evidence for it – where we leave the skin open if we close the fascia, at least initially, because we’ve realized a high incidence of wound infections regardless of what antibiotic regimen we use," Dr. Reilly said.

Dr. Smith responded that they used the time from the index operation as the cut-point for SCIP compliance in the damage-control setting, but acknowledged that in many practices, patients receive another dose of antibiotics when they return to the operating room for a second look or washout.

Preliminary data on skin management in damage-control patients is being analyzed, but "we suspect, as you do at your institution, that it is probably the management of the skin in the setting of the fascial closure that may contribute to surgical site infections and are looking at a future study," he said.

Finally, when asked how the results have changed practice at Temple University, Dr. Smith said they’d like to believe they are using only 24 hours’ worth of antibiotics in the setting of prophylaxis but lack the evidence to confirm this. He pointed out that although more than a decade has passed since the Eastern Association for the Surgery of Trauma published its own antibiotic guidelines, more than 50% of surgeons in the study were not in compliance.

"Certainly, there is always room for improvement in how we treat our patients," he added.

Dr. Smith and Dr. Santaniello reported no conflicts of interest. Conflict of interest information for Dr. Reilly was not available.

*Correction, 2/22/2012: An earlier version of this article misidentified the lead author of the study.