1. Antibioticaprofylaxe en verbetertraject Inge C. Gyssens MD PhD Hasselt University, Belgium & Radboud University Medical Center, Nijmegen, The Netherlands

2. (2) Hospital: Cochrane Systematic Review First review [2005; Issue 3: CD003543] Included studies up to November 2003 Revised review [2013; Issue 4: CD003543] Included studies up to December 2006 Meta-analysis for ITS EPOC Risk of Bias criteria. Courtesy of Ian M Gould ICG 2014

3. (2) Hospital: Cochrane Systematic Review What interventions? Courtesy of Ian M Gould ICG 2014

4. Barriers to intervention Non acceptance of the principle “Therapeutic freedom of the prescriber” Non acceptance of external interference Fear of: political consequences legal consequences Financial and logistic barriers START WITH AN INVENTORY OF BARRIERS Grimshaw JM et al. Health Technol Assess. 2004;8:1-72. Review: ICG 2014

5. Quality standard for antimicrobial prophylaxis in surgical procedures 1. Indication 2. Choice of drug 3. Duration 4. Timing Bratzler et al. Clinical practice guidelines for surgical prophylaxis. Am J Health-Syst Pharm. 2013; 70:195-283 SIGN guideline Surgical prophylaxis rev. July 2008 http://www.sign.ac.uk/pdf/sign104.pdfhttp://www.sign.ac.uk/pdf/sign104.pdf ICG 2014

6. INDICATION Responsibility of the surgeon/committee

8. Indications for surgical prophylaxis: cost effectiveness Define outcome and expected baseline risk –Surgical site infection (SSI) rate Superficial Deep Organ/space What are the Odds ratios (OR)? What is the number needed to treat to avoid the adverse outcome = number to treat (NNT) http://www.sign.ac.uk/pdf/sign104.pdfhttp://www.sign.ac.uk/pdf/sign104.pdf version July 2008 http://www.sign.ac.uk/pdf/sign104.pdf ICG 2014

9. What is the evidence? Surgical procedures for which prophylaxis is indicated http://www.sign.ac.uk/pdf/sign104.pdfhttp://www.sign.ac.uk/pdf/sign104.pdf http://www.sign.ac.uk/pdf/sign104.pdf version July 2008 http://www.sign.ac.uk/pdf/sign104.pdf Clean operations; the risk of infection is low but the consequences are serious Cataract surgery OR 0.36, NNT 451 Cardiac pacemaker OR 0.26, NNT 38 Total hip arthroplasty OR 0.27, NNT 42 ….. ICG 2014

10. Percentage of patients with clean procedures and antibiotic prophylaxis Semarang Surabaya Bambang Wibowo, Hari Parathon, Gyssens I, unpublished data

11. CHOICE OF PROPHYLACTIC DRUG Responsibility of the committee

12. Antimicrob Chemother 2005;56:1094-1102 Quality improvement of surgical prophylaxis in Dutch hospitals: evaluation of a multi-site intervention by time series analysis Marjo E. van Kasteren, Judith Mannien, Bart-Jan Kullberg, Annette S. de Boer, Nico J. Nagelkerke, Marja Ridderhof, Jan C. Wille and Inge C. Gyssens J Antimicrob Chemother 2005;56:1094-1102 ICG 2014 intervention

13. Largest effect with the restrictive component of the intervention: the change of antibiotic

14. DURATION Responsibility of the committee

16. intervention Antimicrob Chemother 2005;56:1094-1102 Quality improvement of surgical prophylaxis in Dutch hospitals: evaluation of a multi-site intervention by time series analysis Marjo E. van Kasteren, Judith Mannien, Bart-Jan Kullberg et al. J Antimicrob Chemother 2005;56:1094-1102 ICG 2014

17. TIMING Responsibility of the ansthesiologist/committee

18. M.E.E. van Kasteren, J. Manniën, A. Ott, B.J. Kullberg, A.S. de Boer, I.C. Gyssens. Clin Infect Dis 2007;44(7):921-7 Antibiotic Prophylaxis and the Risk of Surgical Site Infections following Total Hip Arthroplasty: Timely Administration Is the Most Important Factor M.E.E. van Kasteren, J. Manniën, A. Ott, B.J. Kullberg, A.S. de Boer, I.C. Gyssens. Clin Infect Dis 2007;44(7):921-7 ICG 2014

19. Timing after intervention ICG 2014

20. Conclusion Many interventions to improve prescribing of prophylaxis have been tried Success is contextual Cultural, socioeconomic and regulatory factors play a role In general, involving the prescribers in crucial decisions is most successful ICG 2014