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ORIGINAL ARTICLE
Year : 2013  |  Volume : 16  |  Issue : 4  |  Page : 144-147

Timing of prophylactic antibiotic administration in an orthopedic hospital in a developing country


1 Department of Surgery, Division of Orthopaedics and Trauma, College of Health Sciences, Ladoke Akintola University of Technology, Osogbo, Osun State, Nigeria
2 Department of Clinical Services, National Orthopaedic Hospital, Dala, Kano, Kano State, Nigeria

Date of Web Publication21-Jan-2014

Correspondence Address:
Adesina Ajibade
Department of Surgery, Division of Orthopaedics and Trauma, College of Health Sciences, Ladoke Akintola University of Technology, Osogbo, Osun State
Nigeria
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DOI: 10.4103/1118-8561.125555

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  Abstract 

Background: Appropriate timing of administration is crucial to the effectiveness of prophylactic antibiotics in preventing surgical site infection. Poor adherence to perioperative antibiotic prophylaxis recommendations has been documented from developed countries, but there is a paucity of data on this subject from Nigeria. The aim of this study was to assess the timeliness of administration of the first dose of prophylactic antibiotics in orthopedic surgery. Materials and Methods: In this observational study in an orthopedic practice, administration of antibiotics in operations done over a 6-month period was investigated. The main outcome measure was timing of antibiotic administration in relation to skin incision and tourniquet application. Optimum timing was defined as prophylactic antibiotic administration 15-60 min before skin incision or tourniquet application. Univariate analysis was performed using CDC-Epi Info TM Version 3.5.1 (August 2008). Results: There were 102 procedures out of which 95 (93.1%) were performed without a tourniquet. Of these 95 procedures, antibiotics were given before skin incision in 53 (55.8%) procedures and administration was optimum only in 16 (16.8%) procedures. The median induction-incision interval was 19 min (range: 3-45 min). Conclusion: Timing of perioperative antibiotic administration was inadequate. Routine administration at induction of anesthesia may promote optimum timing and can be considered as in any practice where no written perioperative antibiotic protocol exists.

Keywords: Perioperative prophylactic antibiotics, orthopedic practice, surgical site infections


How to cite this article:
Ajibade A, Akinniyi OT. Timing of prophylactic antibiotic administration in an orthopedic hospital in a developing country. Sahel Med J 2013;16:144-7

How to cite this URL:
Ajibade A, Akinniyi OT. Timing of prophylactic antibiotic administration in an orthopedic hospital in a developing country. Sahel Med J [serial online] 2013 [cited 2019 Oct 18];16:144-7. Available from: http://www.smjonline.org/text.asp?2013/16/4/144/125555


  Introduction Top


Appropriate timing of administration is crucial to the well documented effectiveness of prophylactic antibiotics in preventing surgical site infections.[1],[2] It is generally recommended that infusion of the first dose of prophylactic antibiotic should be commenced within 1 h prior to skin incision.[3] Adherence to recommendations is, however, often poor.[4]

In Nigeria, there is paucity of data on antibiotic prophylaxis in orthopedic surgery. We conducted a study to assess the timing of administration of the first dose of prophylactic antibiotics in orthopedic surgery.


  Materials and Methods Top


A 6 month observational study was conducted from June 2011 to November 2011. Patients who had internal fixation, hemiarthroplasty, total joint replacement (hip and knee) or spinal operations with or without the use of implants during the study period were included. Patients who were operated by the authors and those with complete spinal cord injury who qualified for inclusion based on the procedure performed but who had surgery without anesthesia were excluded.

Data that were collected included type of anesthesia, time of induction of anesthesia, timing of administration of the first dose of prophylactic antibiotics in relation to skin incision and tourniquet application, time of skin incision, procedure performed and types of implants used. A nurse anesthetist in the anesthesia team completed the data form.

The perioperative antibiotic order was written by surgeons. Antibiotics were administered by nurse anesthetists through intravenous bolus injection. Ceftriaxone and genticin were the perioperative antibiotics. The time of prophylactic antibiotic administration was the time of completion of administration of the first prophylactic antibiotic. Ceftriaxone was the antibiotic first given in all patients; the time of its administration was used in calculating time intervals.

Time was recorded with the same clock for any particular procedure. Antibiotic incision interval was the time span between administration of prophylactic antibiotics and surgical incision and it applied to procedures in which antibiotic administration preceded surgical incision. In this way, the following 4 time intervals were defined: Antibiotic incision, antibiotic tourniquet, induction incision and induction tourniquet intervals. For patients who had spinal anesthesia the time of administration of the anesthetic agent was taken to be the time of induction of anesthesia. Administration of prophylactic antibiotic 15 60 min before incision or tourniquet application was regarded as optimum timing.

Univariate analysis was performed using CDC Epi InfoTM Version 3.5.1 (August 2008). Frequencies and percentages were computed. Measures of central tendency and spread of time intervals were the median and range respectively.


  Results Top


There were 103 procedures. One procedure was excluded because no time was recorded. Of the remaining 102 procedures [Table 1], 77 (75.5%) were done under general anesthesia; 25 (24.5%), under spinal anesthesia. 95 (93.1%) procedures were performed without using a tourniquet. A thigh tourniquet was used in 7 (6.9%) procedures non pneumatic tourniquet in five procedures, and a pneumatic tourniquet in two total knee replacements. The types of implants used are shown in [Table 2]. No implant was used in the only spinal decompression that was performed. Ceftriaxone was given in all procedures. Genticin was an additional antibiotic in 99 (97.1%) procedures. The former was the first antibiotic given in all procedures; hence, time of its administration was the reference point for computing antibiotic incision and antibiotic tourniquet intervals.
Table 1: Procedures performed

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Table 2: Types of implants used

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Antibiotics were given before incision in 53 (55.8%) of the 95 procedures performed without using a tourniquet with median antibiotic incision interval of 10 min (range = 1.00 47.00 min) and median induction incision interval of 22 min (range = 3.00 45.00 min). Only in 16 (16.8%) of these 95 procedures were antibiotics given 15 60 min before skin incision. [Figure 1] is a bar chart of the antibiotic incision interval with groups of size 15 min in the 53 procedures in which antibiotics were given before skin incision. In 9 (9.5%) and 33 (34.7%) procedures antibiotics were administered at the time of incision and after incision respectively. The median induction incision interval for all 95 procedures was 19.00 min (range = 3.00 45.00 min).

In the seven procedures performed with a thigh tourniquet applied the induction tourniquet intervals were 5 (two procedures), 8, 10, 15, 20 and 25 min. In five procedures in which antibiotics were given before tourniquet application, the antibiotic tourniquet intervals were 2, 8, 10 (in two procedures) and 20 min.


  Discussion Top


Prophylactic antibiotics were given within 60 min before incision only in 55.8% of procedures done without tourniquet application. This is inadequate and similar to the results from developed countries.[5],[6] If antibiotics are administered too near to the time of skin incision, the serum and tissue concentration might not have reached a high enough level for effective prophylaxis. On the other hand, if antibiotics are given more than 60 min before incision, the serum concentration might fall below the minimum inhibitory concentration by the time incision is made, especially if the half life of the antibiotic is short. Based on these considerations and the short half life of the commonly used antibiotics (cloxacillin, clindamycin and cefuroxime) in Sweden at the time of their study, Stefánsdóttir et al.[4] considered antibiotic administration 15 45 min before skin incision or tourniquet inflation as adequate. They found that only in 45% of operations performed in their center and 57% of randomly selected procedures from the Swedish Knee Arthroplasty Register were antibiotics administered within 15 45 min before incision. Keeping the upper range of optimum timing at 60 min because of the relatively longer half life of ceftriaxone [Table 3], we observed that antibiotics were administered within 15 60 min before incision in only 16.8% of the procedures performed without a tourniquet and about 24.5% of the subset in which antibiotics were given before skin incision [Figure 1]. This demonstrates the inappropriateness of timing of perioperative antibiotic prophylaxis in our practice.
Table 3: Elimination half-lives of relevant antibiotics in normal adults

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Figure 1: Antibiotic incision interval in 53 procedures performed without a tourniquet

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In analyzingthe timing of prophylactic antibiotic administration in orthopedic surgery, procedures performed with the use of tourniquet should be considered separately. This is because antibiotics must reach the tissues before tourniquet application. In the current study, the number of such procedures is, however, too small to assess timing of perioperative antibiotic administration.

Administration of prophylactic antibiotics at the time of induction of anesthesia is safe and produces adequate tissue concentration of antibiotics.[3] It also ensures that antibiotics are administered before skin incision. We found that the median induction incision interval was greater than the median antibiotic incision interval for the 53 procedures performed without tourniquet and with antibiotics given before incision. Furthermore, the median induction incision interval was 19 min for all 95 procedures performed without a tourniquet. These findings appear to suggest that giving prophylactic antibiotics routinely at induction of anesthesia may promote optimum timing.

A possible source of bias in this study is Hawthorne effect, the improvement in performance that occurs when subjects are aware that they are being observed. This could relate to the surgeon or to the anesthetists.If surgeons knew what the study was about they could specify when prophylactic antibiotics should be given and this might ensure appropriate timing of administration. Consequently, procedures performed by the authors were excluded to limit bias from the first source. The second source was even more important because it was one of the attending nurse anesthetists that completed the data form. If this source of bias was in operation during data collection, our results could be considered an overestimation, rather than underestimation, of timeliness of administration of prophylactic antibiotics at the center. This would further indicate the inappropriateness of timing of prophylactic antibiotic administration observed.


  Conclusion Top


Timing of administration of prophylactic antibiotics was inadequate. Routine administration at induction of anesthesia may promote optimum timing and can be considered as in any practice where no written perioperative antibiotic protocol exists.


  Acknowledgment Top


We are grateful to the nurse anesthetists in National Orthopedic Hospital, Dala, Kano for their help in data collection.

 
  References Top

1.Fletcher N, Sofianos D, Berkes MB, Obremskey WT. Prevention of perioperative infection. J Bone Joint Surg Am 2007;89:1605-18.  Back to cited text no. 1
[PUBMED]    
2.Prokuski L. Prophylactic antibiotics in orthopaedic surgery. J Am Acad Orthop Surg 2008;16:283-93.  Back to cited text no. 2
[PUBMED]    
3.Bratzler DW, Houck PM, Surgical Infection Prevention Guidelines Writers Workgroup, American Academy of Orthopaedic Surgeons, American Association of Critical Care Nurses, American Association of Nurse Anesthetists, et al. Antimicrobial prophylaxis for surgery: An advisory statement from the National Surgical Infection Prevention Project. Clin Infect Dis 2004;38:1706-15.  Back to cited text no. 3
    
4.Stefánsdóttir A, Robertsson O, W-Dahl A, Kiernan S, Gustafson P, Lidgren L. Inadequate timing of prophylactic antibiotics in orthopedic surgery. We can do better. Acta Orthop 2009;80:633-8.  Back to cited text no. 4
    
5.Bratzler DW, Houck PM, Richards C, Steele L, Dellinger EP, Fry DE, et al. Use of antimicrobial prophylaxis for major surgery: Baseline results from the National Surgical Infection Prevention Project. Arch Surg 2005;140:174-82.  Back to cited text no. 5
[PUBMED]    
6.Classen DC, Evans RS, Pestotnik SL, Horn SD, Menlove RL, Burke JP. The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection. N Engl J Med 1992;326:281-6.  Back to cited text no. 6
[PUBMED]    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]


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