Surgeries Fall Short of Infectious Diseases Society Guidelines One Third of the Time, Study Finds - Yale School of Medicine

Surgical site infections (SSIs) are a serious but often preventable risk patients face when going under the knife. But despite the implementation of measures and surveillance programs to reduce their occurrence, they remain among the main sources of health care-related infections and a major reason for unplanned post-surgery hospital readmissions.

Now, researchers find, variation in the administration of antibiotics during surgery may be a factor in stagnant SSI rates. A collaborative study between Yale School of Medicine and the University of Michigan Medical School found that practices in over a third of surgical procedures in the United States weren't consistent with the Infectious Diseases Society of America's recommendations. The researchers published their findings December 14 in JAMA Network Open.

"This is the first time we've been able to see in a large, nationally-representative sample what really happens in antibiotic administration around the time of surgery," says Robert Schonberger, MD, associate professor of anesthesiology and senior author of the study. "We looked at several hundred thousand surgeries across the country over five years and found an area where current practice falls well short of what patients deserve."

SSIs affect approximately 125,000 surgeries each year, accruing $1.6 billion in additional health care costs. Experts estimate that around half of these cases are avoidable. "When a patient suffers a surgical site infection, sometimes it can be relatively minor. But not infrequently, it can be a major life-changing process incurring multiple extra surgeries, prolonged hospitalizations, sepsis, or even death," says Schonberger.

To reduce the risk of SSIs in health care settings, the Surgical Care Improvement Project (SCIP), a collaboration between the Centers for Medicare & Medicaid Services and the Centers for Disease Control and Prevention, introduced initiatives over the past two decades for standardizing and publicizing rates of appropriate antibiotic administration. Data show that providers' adherence to SCIP guidelines is near 100 percent. However, says Schonberger, the guidance SCIP offers is limited.

"SCIP only looks at the timing of the first dose of antibiotics," he says. "It does not tell us which antibiotic to give in several kinds of cases, how to adjust antibiotics for differences in patient weight, or when, if at all, to re-dose antibiotics during prolonged procedures."

As a result, he continues, a patient may receive the correct timing of an antibiotic, but may not receive the right type or amount, or the antibiotic might not be properly re-dosed. In these instances, although the provider has adhered to SCIP, a patient can still be affected by inappropriate antibiotic administration. To address these factors, the Infectious Diseases Society of America offers more extensive guidelines on antibiotic choice, weight-adjusted dosing, and timing of the first and subsequent doses.

In order to better understand overall adherence to these additional guidelines, the team studied data from 414,851 surgical encounters at 31 hospitals across 21 states. The data came from surgeries on adults 18 or older from 2014 through 2018. They found that although adherence to SCIP guidelines was nearly universal for practices related to the dosing of antibiotics, the specific class of antibiotics and practices around re-dosing were not consistent with what experts feel to be best practice. About a third of the time, the study shows, prevalent practice in the United States was not adherent to the Infectious Disease Society of America's metrics.

"There's a real discordance between what the Infectious Disease Society says we should do and what we actually are doing in national practice," says Schonberger. "The next question proposed is, 'Who is right?'"

Appropriate antibiotic stewardship is not only important for preventing infections, but also keeping antibiotic-resistant organisms from emerging. Schonberger hopes this research will lead to future studies on which care practices are most impactful, which need to change, and improving care practice in accordance with the best data. "Our long-term goal is to develop systems of care improvement, not just around this problem alone, but more broadly around surgical care in general," he says. "We want to bring the best evidence-based practice to the bedside to make care safer."

When asked about his inspiration for his research, Schonberger holds up his own medical ID bracelet "What makes being a provider meaningful is not forgetting that we are all also patients," he says. "I don't just want to provide the best possible care to the patient on my table, but also improve surgical practice for all patients where I can on a broader scale."

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