Abstract
Background
Perioperative antimicrobial prophylaxis (PAP) has been identified as an important target for internal audits, concerning the judicious use of antibiotics. Paediatric oncology patients with brain tumours face an increased risk of surgical site infection (SSI) after neurosurgery and receive routine PAP in this setting.
Patients and methods
All patients younger than 18 years admitted to the paediatric oncology centre (POC) with a neurosurgical intervention. Systematic audit of routine clinical data is divided in two groups: retrospective (Jan 01, 2012–March 31, 2014) and prospective (April 01, 2014–March 31, 2015) referring to an internal PAP guideline, invented in Jan. 2014). Surveillance of SSI up to 30 days after the operation with standard criteria (Centres for Disease Control and Prevention, USA).
Results
In total, 53 neurosurgical operations were analysed in 33 paediatric oncology patients. Twelve patients received more than one operation. The detailed analysis of PAP revealed prophylactic cefuroxim doses about 30 mg/kg instead of 50 mg/kg and no repeated dosing in operations lasting longer than 4 h. In addition, Cefotaxim, which is not indicated as PAP in neurosurgery, was used instead of Cefuroxim (or Ampicillin-Sulbactam) in 23 % of all cases in the retrospective and 18 % of all cases in the prospective audit. PAP for more than 3 doses (>24 h) was administered in 66 % in the retrospective group and in 60 % in the prospective group (p = n.s.). In both groups, no SSI was detected.
Discussion
This first comprehensive audit of PAP in paediatric oncology patients undergoing neurosurgery outlines significant opportunities to improve clinical practice in terms of correct dosing, the correct choice of the antibiotic, a correct timing schedule and a shorter duration of PAP. In addition, our results illustrate in detail the challenges in clinical practice when an evidence-based approach to improve a standard workflow has to be implemented.
Similar content being viewed by others
Notes
Centres for Disease Control and Prevention, USA
References
Barker FG 2nd (2007) Efficacy of prophylactic antibiotics against meningitis after craniotomy: a meta-analysis. Neurosurgery 60:887–894 . doi:10.1227/01.neu.0000255425.31797.23discussion 887-894
Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, Fish DN, Napolitano LM, Sawyer RG, Slain D, Steinberg JP, Weinstein RA (2013) Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm 70:195–283. doi:10.2146/ajhp120568
Cabana MD, Rand CS, Powe NR, Wu AW, Wilson MH, Abboud PA, Rubin HR (1999) Why don't physicians follow clinical practice guidelines? A framework for improvement. JAMA 282:1458–1465
Charani E, Castro-Sanchez E, Sevdalis N, Kyratsis Y, Drumright L, Shah N, Holmes A (2013) Understanding the determinants of antimicrobial prescribing within hospitals: the role of "prescribing etiquette". Clin Infect Dis 57:188–196. doi:10.1093/cid/cit2
Ciofi Degli Atti M, Spila Alegiani S, Raschetti R, Arace P, Giusti A, Spiazzi R, Raponi M (2015) Surgical antibiotic prophylaxis in children: adherence to indication, choice of agent, timing, and duration. Eur J Clin Pharmacol 71:483–488. doi:10.1007/s00228-015-1816-0
Ciofi Degli Atti ML, Raponi M, Tozzi AE, Ciliento G, Ceradini J, Langiano T (2008) Point prevalence study of antibiotic use in a paediatric hospital in Italy. Euro Surveill 13
Edwards R, Charani E, Sevdalis N, Alexandrou B, Sibley E, Mullett D, Loveday HP, Drumright LN, Holmes A (2012) Optimisation of infection prevention and control in acute health care by use of behaviour change: a systematic review. Lancet Infect Dis 12:318–329. doi:10.1016/s1473-3099(11)70283-3
Gerber JS, Kronman MP, Ross RK, Hersh AL, Newland JG, Metjian TA, Zaoutis TE (2013) Identifying targets for antimicrobial stewardship in children's hospitals. Infect Control Hosp Epidemiol 34:1252–1258. doi:10.1086/673982
Gurses AP, Marsteller JA, Ozok AA, Xiao Y, Owens S, Pronovost PJ (2010) Using an interdisciplinary approach to identify factors that affect clinicians' compliance with evidence-based guidelines. Crit Care Med 38:S282–S291. doi:10.1097/CCM.0b013e3181e69e02
Hawkins RB, Levy SM, Senter CE, Zhao JY, Doody K, Kao LS, Lally KP, Tsao K (2013) Beyond surgical care improvement program compliance: antibiotic prophylaxis implementation gaps. Am J Surg 206:451–456. doi:10.1016/j.amjsurg.2013.02.009
Hing WC, Yeoh TT, Yeoh SF, Lin RT, Li SC (2005) An evaluation of antimicrobial prophylaxis in paediatric surgery and its financial implication. J Clin Pharm Ther 30:371–381. doi:10.1111/j.1365-2710.2005.00659.x
Hysong SJ, Best RG, Pugh JA (2006) Audit and feedback and clinical practice guideline adherence: making feedback actionable. Implement Sci 1:9. doi:10.1186/1748-5908-1-9
Kiefer M, Antes S, Leonhardt S, Schmitt M, Orakcioglu B, Sakowitz OW, Eymann R (2012) Telemetric ICP measurement with the first CE-approved device: data from animal experiments and initial clinical experiences. Acta Neurochir Suppl 114:111–116. doi:10.1007/978-3-7091-0956-4_20
Kim CS, Spahlinger DA, Kin JM, Billi JE (2006) Lean health care: what can hospitals learn from a world-class automaker? J Hosp Med 1:191–199. doi:10.1002/jhm.68
Klinger G, Carmeli I, Feigin E, Freud E, Steinberg R, Levy I (2015) Compliance with surgical antibiotic prophylaxis guidelines in pediatric surgery. Eur J Pediatr Surg 25:199–202. doi:10.1055/s-0034-1368798
Korinek AM, Baugnon T, Golmard JL, van Effenterre R, Coriat P, Puybasset L (2006) Risk factors for adult nosocomial meningitis after craniotomy: role of antibiotic prophylaxis. Neurosurgery 59:126–133 discussion 126-133
Kronman MP, Hersh AL, Gerber JS, Ross RK, Newland JG, Goldin A, Rangel SJ, Oron AP, Zerr DM (2015) Identifying antimicrobial stewardship targets for pediatric surgical patients. J Pediatric Infect Dis Soc in press. doi:10.1093/jpids/piv022
Lynn J, Baily MA, Bottrell M, Jennings B, Levine RJ, Davidoff F, Casarett D, Corrigan J, Fox E, Wynia MK, Agich GJ, O'Kane M, Speroff T, Schyve P, Batalden P, Tunis S, Berlinger N, Cronenwett L, Fitzmaurice JM, Dubler NN, James B (2007) The ethics of using quality improvement methods in health care. Ann Intern Med 146:666–673
Mattick K, Kelly N, Rees C (2014) A window into the lives of junior doctors: narrative interviews exploring antimicrobial prescribing experiences. J Antimicrob Chemother 69:2274–2283. doi:10.1093/jac/dku093
Miller FG, Emanuel EJ (2008) Quality-improvement research and informed consent. N Engl J Med 358:765–767. doi:10.1056/NEJMp0800136
Pichichero ME (2007) Use of selected cephalosporins in penicillin-allergic patients: a paradigm shift. Diagn Microbiol Infect Dis 57:13S–18S. doi:10.1016/j.diagmicrobio.2006.12.004
Pronovost P, Weast B, Rosenstein BJ, Sexton B, Holzmueller CG, Paine L, Davies R, Rubin H (2005) Implementing and validating a comprehensive unit-based safety program. J Patient Safety 1:33–40
Pronovost PJ, Berenholtz SM, Needham DM (2008) Translating evidence into practice: a model for large scale knowledge translation. BMJ 337:a1714. doi:10.1136/bmj.a1714
Prusseit J, Simon M, von der Brelie C, Heep A, Molitor E, Volz S, Simon A (2009) Epidemiology, prevention and management of ventriculoperitoneal shunt infections in children. Pediatr Neurosurg 45:325–336. doi:10.1159/000257520
Rangel SJ, Fung M, Graham DA, Ma L, Nelson CP, Sandora TJ (2011) Recent trends in the use of antibiotic prophylaxis in pediatric surgery. J Pediatr Surg 46:366–371. doi:10.1016/j.jpedsurg.2010.11.016
Ratilal B, Costa J, Sampaio C (2008) Antibiotic prophylaxis for surgical introduction of intracranial ventricular shunts: a systematic review. J Neurosurg Pediatr 1:48–56. doi:10.3171/ped-08/01/048
Resar RK (2006) Making noncatastrophic health care processes reliable: learning to walk before running in creating high-reliability organizations. Health Serv Res 41:1677–1689. doi:10.1111/j.1475-6773.2006.00571.x
Robert Koch-Institut (2013) Bekanntmachung des Robert Koch-Institutes: Surveillance nosokomialer Infektionen sowie die Erfassung von Krankheitserregern mit speziellen Resistenzen und Multiresistenzen. Fortschreibung der Liste der gemäß § 4 Abs. 2 Nr. 2 Buchstabe b in Verbindung mit § 23 Abs. 4 IfSG zu erfassenden nosokomialen Infektionen und Krankheitserreger mit speziellen Resistenzen und Multiresistenzen. Bundesgesundheitsbl Gesundheitsforsch Gesundheitsschutz 56:580–583
Scheck McAlearney A, Hefner JL, Robbins J, Harrison MI, Garman A (2015) Preventing central line-associated bloodstream infections: a qualitative study of management practices. Infect Control Hosp Epidemiol 36:557–563. doi:10.1017/ice.2015.27
Scottish Intercollegiate Guidelines Network (2014) Antibiotic prophylaxis in surgery - SIGN 104 - A national clinical guideline. July 2008, updated April 2014
Sharma MS, Vohra A, Thomas P, Kapil A, Suri A, Chandra PS, Kale SS, Mahapatra AK, Sharma BS (2009) Effect of risk-stratified, protocol-based perioperative chemoprophylaxis on nosocomial infection rates in a series of 31 927 consecutive neurosurgical procedures (1994-2006). Neurosurgery 64:1123–1130 . doi:10.1227/01.neu.0000345645.51847.61discussion 1130-1121
Simon A, Müller A, Kaiser P, Töpfner N, Berner R, Laws H, Knorr M, Hufnagel M, Beyersdorff A, Heister P, Becker C, Liese J, Tenenbaum T (2013) The Paed IC project—antibiotic stewardship and hospital hygiene to prevent infection with resistant pathogens. Klin Padiatr 225:93–95. doi:10.1055/s-0033-1333761
Singer SJ, Falwell A, Gaba DM, Meterko M, Rosen A, Hartmann CW, Baker L (2009) Identifying organizational cultures that promote patient safety. Health Care Manag Rev 34:300–311. doi:10.1097/HMR.0b013e3181afc10c
Smith MJ, Gerber JS, Hersh AL (2015) Inpatient antimicrobial stewardship in pediatrics: a systematic review. J Pediatric Infect Dis Soc 4:e127–e135. doi:10.1093/jpids/piu141
Taylor HA, Pronovost PJ, Faden RR, Kass NE, Sugarman J (2010) The ethical review of health care quality improvement initiatives: findings from the field. Issue Brief (Commonw Fund) 95:1–12
Valentini LG, Casali C, Chatenoud L, Chiaffarino F, Uberti-Foppa C, Broggi G (2008) Surgical site infections after elective neurosurgery: a survey of 1747 patients. Neurosurgery 62:88–95 . doi:10.1227/01.neu.0000311065.95496.c5discussion 95-86
Versporten A, Sharland M, Bielicki J, Drapier N, Vankerckhoven V, Goossens H (2013) The antibiotic resistance and prescribing in European children project: a neonatal and pediatric antimicrobial web-based point prevalence survey in 73 hospitals worldwide. Pediatr Infect Dis J 32:e242–e253. doi:10.1097/INF.0b013e318286c612
Wacha H, Hoyme U, Isenmann R, Kujath P, Lebert C, Naber K, Salzberger B (2010) Perioperative Antibiotikaprophylaxe–Empfehlungen einer Expertenkommission der Paul-Ehrlich-Gesellschaft für Chemotherapie e.V. Chemotherapie Journal 19:70–84
Woodgate RL, Tailor K, Yanofsky R, Vanan MI (2016) Childhood brain cancer and its psychosocial impact on survivors and their parents: a qualitative thematic synthesis. Eur J Oncol Nurs 20:140–149. doi:10.1016/j.ejon.2015.07.004
Acknowledgment
The authors thankfully acknowledge the outstanding work of all attending physicians and healthcare workers in the Paediatric Oncology Unit at the Children’s Clinic, University Hospital, Homburg / Saar.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
There is no conflict of interest or any ethical conflict.
Additional information
Katja Weiss and Arne Simon contributed equally to this original article.
Rights and permissions
About this article
Cite this article
Weiss, K., Simon, A., Graf, N. et al. Clinical practice audit concerning antimicrobial prophylaxis in paediatric neurosurgery: results from a German paediatric oncology unit. Childs Nerv Syst 33, 159–169 (2017). https://doi.org/10.1007/s00381-016-3279-8
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00381-016-3279-8