Antibiotic Compliance Falls Short in Gynecologic Surgery

Norra MacReady

November 12, 2013

Surgeons have a poor track record when it comes to adhering to published guidelines for the use of perioperative antibiotics in gynecologic procedures, the authors of a new study say.

"Although use of antibiotics is high (87%) for women who should receive antibiotics, antibiotics are being increasingly administered to women who are likely to receive little benefit from the drugs," lead author Jason D. Wright, MD, and colleagues report in an article published online November 6 and in the December print issue of Obstetrics & Gynecology.

"The widespread misuse of perioperative antibiotics for gynecologic surgery suggests that strategies to better-align practice patterns with evidence-based recommendations are urgently needed," they warn.

During the last 40 years, the American College of Obstetricians and Gynecologists (ACOG) has developed guidelines that recommend perioperative antibiotics for high-risk procedures such as hysterectomy, urogynecologic surgery, hysterosalpingogram, and abortion, Dr. Wright, from the Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York City, and coauthors explain. For lower-risk procedures such as laparoscopy, tubal sterilization, hysteroscopy, and laparotomy, ACOG recommends that perioperative antibiotics be avoided.

National efforts also have been made to promote appropriate use of antibiotics in gynecologic procedures. Nevertheless, information on the actual adherence to these recommendations is sparse, prompting the authors to perform a population-based analysis of guideline-based use of antibiotics in women undergoing surgical gynecologic procedures.

The authors drew their information from the Perspective database, which contains data from more than 500 hospitals throughout the United States. The information in the database includes detailed clinical and demographic data. In 2006, the database captured nearly 5.5 million hospital discharges, representing about 15% of all hospitalizations in the United States. For this study, Dr. Wright and coauthors analyzed the use of antibiotics among women who were at least 18 years of age and who underwent inpatient or outpatient gynecologic surgery between 2003 and the first quarter of 2010.

They identified 1,036,403 women, of whom 545,332 underwent procedures for which antibiotics were recommended. Antibiotics were administered appropriately to 475,180 (87.1%) of those patients, whereas 12,451 (2.3%) received antibiotics not recommended in the guideline and 57,901 (10.6%) received no antibiotic prophylaxis at all.

In contrast, of the 491,071 women who underwent procedures for which antibiotics were not recommended, 197,226 (40.2%) received antibiotics anyway, with their use increasing from 33.4% in 2003 to 43.7% in 2010 (P < .001).

Surgical volume was an important predictor of guideline adherence, with high-volume surgeons being less likely both to omit antibiotics recommended by the guidelines and to prescribe antibiotics that were not indicated compared with lower-volume surgeons. "These data suggest that adherence to best practice perioperative guidelines may, at least in part, explain the lower costs incurred by higher-volume gynecologic surgeons," the authors write.

Other factors associated with antibiotic use included geography (patients in the Eastern United States were more likely to receive antibiotics regardless of procedure type), number of comorbid conditions (also associated with greater unindicated use of antibiotics), and patient age, with older women more likely than their younger cohorts to receive a prolonged course of antibiotics. Nonteaching hospitals were 25% less likely to administer antibiotics in cases for which they were recommended compared with teaching hospitals.

After controlling for infectious complications, antibiotic administration was prolonged beyond 24 hours for 26.7% of patients, in violation of Surgical Care Improvement Project guidelines.

Study limitations include the possible misclassification of prophylaxis in some cases and the inability to account for the possibility that antibiotic use may have been appropriate in some cases, despite the guideline recommendations.

"The odds of receiving inappropriate care remain about 1 in 10, and most patients would rightfully consider that rate unacceptable," Sean C. Dowdy, MD, from the Department of Gynecologic Oncology at the Mayo Clinic, Rochester, Minnesota, writes in an accompanying editorial .

"It is estimated that 30% of health care expenditures in the United States are unnecessary, and the 40% of patients who received unnecessary or prolonged courses of antibiotics are but one example of this," Dr. Dowdy adds. What makes these findings even more troubling is that "when considered in the larger context of the complexity of medical care, the decision to administer and discontinue antibiotics is perhaps the simplest aspect of surgery."

Dr. Dowdy urged the use of interventions such as checklists, procedure-specific standing orders, collaboration among all surgical team members, and judicious use of technology to improve guideline compliance and quality of care.

The authors and Dr. Dowdy have disclosed no relevant financial relationships.

Obstetrics Gynecol. 2013;122:1143-1153. Article abstract, Editorial extract

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