Int J Pharm Pharm Sci, Vol 10, Issue 4, 128-131Original Article
PRESCRIPTION PATTERN OF PROPHYLACTIC ANTIMICROBIAL AGENTS USED IN PREOPERATIVE PATIENTS AT A TERTIARY CARE TEACHING HOSPITAL
KALA P.*1, JAMUNA RANI R.2, SANGEETHA RAJA3
1Assistant Professor, 2Professor and Head, 3Assistant Professor, Department of Pharmacology, SRM Medical College Hospital and Research Centre, SRM University, Potheri, Tamil Nadu, India, 603203
Email: [email protected]
Received: 06 Feb 2018 Revised and Accepted: 15 Mar 2018
ABSTRACT
Objective: This study was designed to analyze the prescription pattern of prophylactic antimicrobial agents used in preoperative patients.
Methods: A descriptive observational study was done at a tertiary care teaching hospital in Potheri from July to December 2013 after obtaining of Institutional Ethics Committee clearance.
Results: Total 284 patients were included in this study, out of which 141(49.6%) were females and 143(50%) were males. In the department of general surgery, the very commonly used antimicrobial agents were cefotaxime (81%) followed by cefoperazone sodium (42%). In the orthopaedics department, the frequently used antimicrobial agents were cefoperazone and sulbactam (39%) followed by cefazolin (29%). Most commonly used antimicrobial agent was cefotaxime (100%) in gynaecology department.
Conclusion: Antimicrobial prophylaxis is helpful in declining the frequency of post-operative infections. This study explained about the various antimicrobial agents used prior to surgeries. Practitioners must prescribe an antibiotic based on their hospital antibiotic policy.
Keywords: Prophylaxis, Antimicrobial agents, Antibiotics, Surgery, Antibiotic policy
© 2018 The Authors. Published by Innovare Academic Sciences Pvt Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/)
DOI: http://dx.doi.org/10.22159/ijpps.2018v10i4.25164
INTRODUCTION
Prophylactic Antibiotic refers to “prevention of infection and its complication by using antimicrobial agents prior to any surgical procedures”. In spite of numerous available aseptic precautions, antimicrobial agents, advanced sterilization procedures and operative techniques, the Surgical Site Infection (SSI) is one of the most important crises in the field of surgery [1]. The definition of surgical site infection is that, the occurrence of infection at or near the surgical site within 30 d or a year followed by any surgical procedure [2]. Around two million cases had developed a surgical site infection worldwide [3]. SSI is the second most common nosocomial infection and cause of many post-operative complications [4]. The rate of morbidity and mortality are more in SSI and it increases the expense and duration of hospital stay for the surgical patients [5, 6]. SSI also produces delayed wound healing, augmented use of antibiotics and multidrug antibiotic resistance [7]. The causes for the SSI could be due to poor hygiene, existing infection, anaemia, diabetes, obesity and improper techniques which can be overcome by proper prophylactic antibiotic usage [8]. Surgeries like coronary bypass, hip and knee prosthesis and exploratory abdominal surgeries showed higher rates of SSI [9]. The commonest pathogens isolated were Staphylococcus aureus, Escherichia coli, Klebsiella sp. Coagulase-negative Staphylococci, Pseudomonas aeruginosa, Proteus mirabilis [8]. Prophylaxis could be defined based on timing of administration of antimicrobial agents and categorized as early operative where it was scheduled before one hour of incision, pre-operative prophylaxis when it was given less than two hours prior to incision and peri-operative prophylaxis,if it was planned at the time of surgery and postoperative prophylaxis given after the completion of surgery [10]. Prophylactic antibiotics should be stopped within 24 h of surgery and within 48 h in cardiothoracic surgeries [5]. The commonest prophylactic antimicrobial agents used are, first and second-generation cephalosporins and vancomycin in patients who are hypersensitive to β-lactam antibiotics [11, 12]. The criteria for a prophylactic antibiotic are, good efficacy against infective microorganisms, achievement of sufficient local tissue levels, minimal side effects and relatively at a lower cost (13). The aim of the present is to identify the common antimicrobial agents used prophylactically in various surgeries.
MATERIALS AND METHODS
The present study was a descriptive observational study done at SRM Medical College Hospital and Research Centre which was carried out from July to December 2013 after obtaining the Institutional Ethics Committee clearance (415/IEC/2013). Patients, undergoing surgery in the department of general surgery, orthopaedics and gynaecology were included in this study based on inclusion and exclusion criteria’s. After getting the oral informed consent from the patient, the data like age, gender, date of admission, diagnosis, co-morbid conditions, date and type of surgery, name and details of prophylactic antimicrobial agents given were analyzed and entered in individual proforma. Follow-up was done for any evidence of postoperative infections. Data were analyzed using SPSS version 17.0 and results were expressed as a percentage.
RESULTS
A total of 284 patients were included in the study, out of which 141(49.6%) were females and 143(50.4%) were males. In the department of general surgery, the surgeries performed frequently were appendicectomy (21%) followed by hernioplasty (17%), abdominal meshplasty (15%), haemorrhoidectomy (13%), cholecystectomy (9%), lipoma and granuloma excision (7%). In the above conditions, the commonest antimicrobial agents used were cefotaxime (81%) followed by cefoperazone sodium (42%), ceftriaxone (25%), amoxicillin with clavulanate (20%) and metronidazole (14%) (table 1, fig. 1).
In the orthopaedics department, surgeries done very often were Open Reduction and Internal Fixation-ORIF (43%), plate and screw fixation (21%), laminectomy and discectomy (10%). In these, the commonest antimicrobial agents used were cefoperazone with sulbactam (39%), cefazolin (29%), cefoperazone sodium (28%), gentamicin (25%) and cefuroxime (20%) (table 2, fig. 2).
Table 1: Types of surgeries and antimicrobial agents used in the department of general surgery
| Name of surgery | No. of cases N=148 | Name of Antimicrobial agent |
| Hernioplasty | 29(17%) | Cefotaxime(75%) Cefoperazonesodium(10%) Ceftriaxone and Tazobactam(06%) Ceftriaxone and Sulbactam(06%) |
| Haemorrhoidectomy | 21(13%) | Cefotaxime(71%) Ceftriaxone and Tazobactam(19%) |
| Abdominal meshplasty | 24(15%) | Cefotaxime(62%) Ceftriaxone and Sulbactam(16%) Ceftriaxone and Tazobactam(08%) |
| Appendicectomy | 34(21%) | Cefotaxime(55%) Metronidazole(14%) Ceftriaxone and Sulbactam(08%) Ciprofloxacin(06%) |
| Cholecystectomy | 09(6%) | Cefotaxime(66%) Cefoperazonesodium(33%) |
| Lipoma and Granuloma excision | 07(4.7%) | Cefotaxime(100%) |
| Skin graft | 06(4%) | Cefotaxime(66%) Cefoperazonesodium(16%) Amoxicillin and Clavulanate(16%) |
| Fibroadenoma excision | 06(4%) | Cefotaxime(100%) |
| Secondary suture | 03(2%) | Cefotaxime(100%) |
| Wound debridement | 04(2.7%) | Ceftriaxone(25%) Cefotaxime(25%) Cefoperazonesodium(25%) Amoxicillin and Clavulanate(25%) |
| Radical Mastectomy | 03(2%) | Cefotaxime(100%) |
| Thyroidectomy | 01(1%) | Cefoperazonesodium(100%) |
| Colectomy | 01(1%) | Cefotaxime(100%) |
Fig. 1: Pattern of antimicrobial agents used in general surgery
Table 2: Types of surgeries and antimicrobial agents used in the department of orthopaedics
| Name of surgery | Number of cases N=67 | Name of Antimicrobial agent |
| Open Reduction and Internal Fixation(ORIF) | 29(43%) | Cefoperazonesodium (31%) Cefoperazone and Sulbactam (27%) Cefazolin (17%) |
| Plate and screw fixation | 14(21%) | Cefoperazonesodium (42%) Cefoperazone and Sulbactam (42%) Cefazolin (21%) |
| Laminectomy and Dissectomy | 07(10%) | Cefoperazone and Sulbactam (85%) |
| Arthrodesis | 05(7%) | Cefoperazonesodium (20%) Cefoperazone and Sulbactam (20%) Cefuroxime (20%) |
| Implant removal | 05(7%) | Cefoperazonesodium (20%) Cefoperazone and Sulbactam (40%) Cefuroxime (20%) |
| Wound debridement | 04(4%) | Cefazolin (50%) Cefoperazone and Sulbactam (25%) Gentamicin (25%) |
Fig. 2: Pattern of antimicrobial agents used in orthopaedics
In the gynaecology department, the common surgeries done were Total Abdominal Hysterectomy with Bilateral Salphingo Oophrectomy-TAHBSO (43%), vaginal hysterectomy (12%), laparotomy hysterectomy (5%) and myomectomy (4%), where the antimicrobial agent prescribed was, only cefotaxime (100%) (table 3).
Table 3: Types of surgeries and antimicrobial agents used in the department of gynaecology
| Name of surgery | No. of cases N=70 | Name of antimicrobial agent |
| TAHBSO | 43(61%) | Cefotaxime(100%) |
| Vaginal hysterectomy | 12(17%) | Cefotaxime(100%) |
| Laparotomy hysterectomy | 05(7%) | Cefotaxime(100%) |
| Myomectomy | 04(5.7%) | Cefotaxime(100%) |
DISCUSSION
The usage of prophylactic antimicrobial agents has significantly reduced the mortality and morbidity in the postoperative patients. Standard antibiotic prophylactic guidelines recommended the use of these agents prior to surgery. Nowadays, it has been made mandatory to use these drugs to minimize the surgical risk due to infection. The present study was done, to find out the pattern of prophylactic antimicrobial agents that were used in the departments of general surgery, orthopaedics and gynaecology. A total of 284 patients were included in the study. All antimicrobial agents were given one hour prior to surgery. The dose was based on the particular antimicrobial agent. In the department of general surgery, the common surgeries performed were appendicectomy (21%) followed by hernioplasty (17%), abdominal meshplasty (15%) and haemorrhoidectomy (13%). In these surgeries, the common antimicrobial agents used were cefotaxime (81%) followed by cefoperazone sodium (42%), ceftriaxone (25%) and amoxicillin with clavulanate (20%). The first three drugs belong to the third generation cephalosporin. Since the third generation cephalosprin is having a wide spectrum activity, it has become a preferred drug to be used as a prophylactic agent. According to Garcia-Rodriguez JA et al.,the frequency of wound infections in the cefotaxime group was less (3.3%) when compared to cefoxitin group(7.6 %) which is a second-generation cephalosporin [14]. Another study by Woodfield stated that, both ceftriaxone and cefotaxime along with metronidazole were highly effective and well comparable in their efficacy [15]. Amoxicillin and clavulanate were mainly used in skin graft and wound debridement in the present study. A study, published in vascular journal explained that, 95% of the organisms cultured from the skin preoperatively were sensitive to amoxicillin/clavulanic acid which has a suitable spectrum and tissue penetration [16]. Ciprofloxacin, ceftriaxone with sulbactam and ceftriaxone with tazobactam were used in appendicectomy, haemorrhoidectomy and hernioplasty surgeries in the present study. The common orthopedic surgeries done were ORIF (43%), plate and screw fixation (21%), laminectomy and dissectomy (10%). In these surgeries the preferred antimicrobial agents used were cefoperazone with sulbactam (39%), cefazolin (29%) and cefoperazone sodium (28%). Since the staphylococcus aureus infection is most common in orthopaedic surgeries, above said antimicrobials were commonly used which was confirmed by the protocol,“Antibiotic Prophylaxis to Prevent Surgical Site Infections” by Alan et al.,. In the present study, cefuroxime was mainly used in implant removal and arthrodesis cases which were also mentioned in the protocol [5]. Injection gentamicin was used in cases like wound debridement against gram negative infection in the present study which was supported by a study done by Adrienne J et al., [17]. The frequent gynaecology surgeries were TAHBSO (43%), vaginal hysterectomy (12%), laproscopic hysterectomy (5%) and myomectomy (4%). In these surgeries, an antimicrobial agent used was cefotaxime (100%). Cefotaxime was the common antimicrobial agent used as a monotherapy and also combined with the other group of antibiotics in most of the surgeries, specified in a study done by peter et al.,[18]. A similar study done by Brethiset al., stated that the use of cefotaxime was 20.7% followed by metronidazole 19.1% [19]. A study by Amol M et al., compared cefotaxime with various groups and defined that, the short course and long course of various antimicrobial therapy did not differ considerably [20]. After the follow-up, none of the patients showed any postoperative infections. The present study emphasized, that the chosen antimicrobials proved to be an effective prophylactic agent.
CONCLUSION
Reduction of surgical site infections decreases the postoperative morbidity, mortality and wastage of healthcare resources. Prolonged operative time, wound class, and wound contamination influence the wound infections. Antimicrobial prophylaxis is helpful in declining the frequency of post-operative infections. This study explains about the various antimicrobial agents used in surgeries. Practitioners must implement antibiotic prophylaxis based on the antibiotic policy.
ACKNOWLEDGEMENT
We thank our Director (Medical), Dean (Medical), Medical Superintendent and HOD of General Surgery, Orthopaedics and Gynaecology for their support and acceptance of this study. We thank Mrs. NS. Chitra, lecturer for the enormous support in manuscript correction.
AUTHORS CONTRIBUTIONS
The research work and manuscript writing were done by Kala, the author. Jamuna Rani and Sangeetha Raja were involved with results analysis and correction of the manuscript.
CONFLICT OF INTERESTS
Declared none
Ethical approval
Approved by Institutional Ethics Committee
REFERENCES
Mahesh CB, Shivakumar S, Suresh BS, Chidanand SP, Vishwanath Y. A prospective study of surgical site infections in a teaching hospital. J Clin Diagnostic Res 2010;4:3114-9.
Mangram AJ, Horan TC, Pearson ML. Guideline for prevention of surgical site infection. Hospital Infection Control Practices Advisory Committee. Infect Controlled Hosp Epidemiol 1999;20:250-78.
Anusha S, Vijaya LD, Pallavi K, Manna PK, Mohanta GP, Manavalan R. An epidemiological study of surgical wound infections in a surgical unit of tertiary care teaching hospital. Indian J Pharm Practice 2010;3:8-13.
Haley RW. The scientific basis for using surveillance and risk factor data to reduce nosocomial infection rates. J Hosp Infect 1995;30:3-14.
Alan R Salkind, Kavitha C Rao. Antibiotic prophylaxis to prevent surgical site infections. American Family Physician 2011;83:585-90.
Bishnu Rath Giri, Hom Prasad Pant, P Ravi Shankar, Chandrasekhara T Sreeramareddy, Pranav Kumar Sen. Surgical site infection and antibiotics use pattern in a tertiary care hospital in Nepal. J Pak Medical Association 2008;58:148-51.
Rizvi M, Rizvi MW, Shaheen. The emergence of coryneform bacteria as pathogens in nosocomial surgical site infections in a tertiary care hospital of North India. J Infect Public Health 2013;6:283–8.
Anand Saxena, Mahendra Pratap Singh, Swagata Brahmachari, Malay Banerjee. Surgical site infection among postoperative patients of tertiary care centre in the central india-a prospective study. Asian J Biomed Pharm Sci 2013;3:41-4.
Rosenthal VD, Richtmann R, Singh S. Surgical site infections, International Nosocomial Infection Control Consortium (INICC) report, data summary of 30 countries, 2005–2010. Infect Control Hosp Epidemiol 2013;34:597–604.
Satyanarayana V. Study of surgical site infections in abdominal surgeries. J Clin Diagnostic Res 2011;5:935-9.
Alphonso N, Anagnostopoulos PV, Scarpace S. Perioperative antibiotic prophylaxis in paediatric cardiac surgery. Cardiol Young 2007;17:12-25.
Maher KO, Van Der Elzen K, Bove EL. A retrospective review of three antibiotic prophylaxis regimens for pediatric cardiac surgical patients. Ann Thorac Surg 2002;74:1195-200.
Dale W Bratzler, E Patchen Dellinger, Keith M Olsen, Trish M Perl, Paul G Auwaerter, Maureen K Bolon, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm 2013;70:195-283.
Garcia Rodriguez JA, Puig LaCalle J, Arnau C, Porta M, Vallve C. Antibiotic prophylaxis with cefotaxime in gastroduodenal and biliary surgery. Am J Surg 1989;158:428-33.
Woodfield JC, Van Rij AM, Pettigrew RA, van der Linden AJ, Solomon C, Bolt D. A comparison of the prophylactic efficacy of ceftriaxone and cefotaxime in abdominal surgery. Am J Surg 2003;185:45-9.
Jonothanj Earnshaw F. Risk factors in vascular surgical sepsis. Annals of the Royal College of Surgeons of England; 1988. p. 70.
Adrienne J Headley. Necrotizing soft tissue infections: a primary care review. Am Family Physician 2003;68:323-8.
Nikhil Peter, Nissycherian, Sagythomas, Snehageorge, Junior sundresh N. Study of prescribing pattern and use of antibiotic in the management of wound infection. Asian J Pharm Clin Res 2017;10:210-3.
CS Brethis, S Thamizharasan, SA Sridevi, B Kalaiselvi, M Balaji Singh, K Vijaykumar. A prospective study of the pattern of use of antimicrobial agents in surgical prophylaxis in a tertiary care centre. Int J Pharm Pharm Sci 2017;9:283-7.
Amol M Valvi, Arun R Mahale, Pankaj N Baravkar. How many antibiotics for cesarean section and hysterectomy: short course versus long course. Int J Reprod Contracept Obstet Gynecol 2014;3:394-7.