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Association of Prophylactic Antibiotic Guideline Non-Adherence with Surgical Site Infections in Patients Receiving
Amit Bardia1, Hung-Mo Lin2, George Michel3
1Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
Objective:
To investigate whether non-adherence to the combined Infectious Disease Society of America (IDSA), the Surgical Infection Society (SIS), and the Society for Healthcare Epidemiology of America (SHEA) guideline based antibiotic choice, timing, and/or dose of vancomycin was associated with Surgical Site infections in surgeries where vancomycin was administered.
Summary Background Data:
Despite the pivotal role of antibiotics in preventing surgical site infections (SSIs), widespread non-adherence to IDSA/SIS/SHEA guidelines especially related to vancomycin for intraoperative antibiotic prophylaxis continues. It is unclear whether this non-adherence is associated with SSIs.
Methods:
In this multicenter observational study, we utilized integrated data from Multicenter Perioperative Outcomes Group (MPOG) registry, the National Surgical Quality Improvement Program (NSQIP) and Michigan Surgical Quality Collaborative (MSQC) registries encompassing 31 academic and community hospitals for surgeries from 01/01/2014 to 08/31/2022. Patients over 18 years of age who underwent non-cardiac procedures involving a skin incision and who were administered Vancomycin were included. The co-primary exposures were non-adherence to IDSA/SIS/SHEA guidelines with respect to choice, dose, or timing, and the primary outcome was NSQIP/MSQC-coded SSI. A hierarchical generalized linear mixed model with surgical patients nested within MPOG institutions was performed.
Results:
A total of 5542 unique cases met the inclusion criteria, 55.5% participants were women, and the mean (SD) age was 60.0 (14.3) years. The incidence of SSI was 5.6% in the cohort. Non-adherence to guideline-based antibiotic choice, dosing and timing was 705 (12.7%), 59 (1.1%) and 197 (3.6%) respectively. In adjusted analysis, non-adherence to antibiotic choice [RR (95% CI): 1.64 (1.17, 2.31), P =0.004], and timing [RR (95% CI): 1.56 (1.01, 2.40), P=0.043] were significantly independently associated with SSI.
Conclusions:
Guideline adherent antibiotic choice (IDSA/SIS/SHEA metric) and time of vancomycin administration (IDSA/SIS/SHEA and SCIP metric) are associated with reduced odds of Surgical Site Infections in patients receiving perioperative vancomycin prophylaxis.
Insights
Non-adherence to antibiotic choice and timing guidelines for vancomycin increases Surgical Site Infection (SSI) risk. Adhering to Infectious Disease Society of America (IDSA), Surgical Infection Society (SIS), and Society for Healthcare Epidemiology of America (SHEA) guidelines reduces SSI rates.
Area of Science:
- Surgical Infection Prevention
- Antibiotic Stewardship
- Clinical Guidelines
Background:
- Surgical Site Infections (SSIs) remain a significant concern despite antibiotic use.
- Non-adherence to established guidelines for vancomycin prophylaxis is common.
- The impact of this non-adherence on SSI rates is not well-defined.
Purpose of the Study:
- To determine if deviations from IDSA/SIS/SHEA guidelines for vancomycin impact SSI risk.
- To analyze the association between vancomycin choice, dose, and timing adherence and SSI development.
- To evaluate the effectiveness of guideline adherence in preventing SSIs.
Main Methods:
- Multicenter observational study using registry data (MPOG, NSQIP, MSQC) from 31 hospitals (2014-2022).
- Included adult patients undergoing non-cardiac procedures with vancomycin administration.
- Assessed non-adherence to vancomycin choice, dose, and timing against guidelines; analyzed SSI as the primary outcome using mixed-effects models.
Main Results:
- 5542 patients included; 5.6% incidence of SSI.
- Non-adherence rates: 12.7% for choice, 1.1% for dose, 3.6% for timing.
- Adjusted analysis showed significant association between non-adherence to choice (RR 1.64) and timing (RR 1.56) and increased SSI risk.
Conclusions:
- Adherence to vancomycin antibiotic choice and administration timing guidelines is associated with lower SSI rates.
- Guideline adherence for perioperative vancomycin prophylaxis is crucial for preventing SSIs.
- Reinforces the importance of strict adherence to IDSA/SIS/SHEA guidelines for vancomycin use in surgery.
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