[我們以前是教人手術預防性抗生素要劃刀前一小時IV給予，這篇報導是說，劃刀前給，感染機率比一小時前給，還要少，9% vs 14.5%]
Give Preop
Antibiotics Just Before the Incision: Study
Aug 19, 2013
By James E. Barone MD
NEW YORK (Reuters
Health) Aug 19 - The best time to give preoperative prophylactic antibiotics is
within 18 minutes of making the incision, new findings suggest.
The National Surgical
Infection Prevention Project advises that antibiotics be given within the hour
before incision. But Dr. Colleen G. Koch, who headed the new research, told
Reuters Health, "While current antibiotic administration guidelines are
based on simplicity and rough cut-offs, there may be substantial opportunity to
further refine antibiotic timing to reduce postoperative infections."
Indeed, it's been
unclear in previous studies whether specific times within that 60-minute window
offer any advantage.
"Many healthcare
systems have adopted the practice of administering antibiotics in the operating
room just prior to incision, but there has been concern that this practice does
not allow for sufficient circulation of the drug. The study supports the safety
and effectiveness of this practice," Dr. Mary T. Hawn, vice-chair of
surgery at the University of Alabama at Birmingham, told Reuters health in an
email.
For the new analysis,
published online June 18 in the Journal of the American College of Surgeons,
Dr. Koch and colleagues at the Cleveland Clinic looked at data from more than
4,400 various general surgery cases done from 2006 to 2012. Patients were
excluded if they had ongoing infections or missing data, or if they received
vancomycin or had procedures lasting more than four hours. If patients had
multiple procedures, only the first operation was included.
The interval from the
start of the antibiotic infusion to the incision was obtained from the
anesthesia record. Ultimately, 4,239 patients (95.1%) received antibiotics
within the recommended 60 minutes before incision.
Overall, the primary
composite endpoint -- any wound disruption, superficial, deep or organ space
surgical site infection, or sepsis -- occurred in 444 patients (10%), including
9% of the 3,140 patients who got antibiotics within 30 minutes before incision
and 11.7% of the 1,099 who were medicated between 30 and 60 minutes in advance
(p=0.01).
The 214 patients who
received their antibiotics either more than 60 minutes before the incision, or
more than 60 minutes afterward, had 31 infections (14.5%).
The relationship
between timing of antibiotics and infection was nonlinear and
"bowl-shaped," with the lowest risk of infection near the time of
incision, the authors said.
"Investigations
on antibiotic timing consistently display a 'bowl-shaped' relationship of
timing and infection risk, however, studies vary on the where the nadir risk
lies in relationship to surgical incision," Dr. Koch said in an email.
"Of note, we never reach a nadir of 'zero' risk for postoperative
infectious complications."
Dr. Hawn added,
"This is an important paper and confirms the findings from many other
reports that giving antibiotics close to incision, even if it results is giving
them a few minutes after incision, is better than giving them closer to one
hour prior to incision."
Patients with
infections had a median hospital length of stay of seven days, vs. three days
for those without infections (p<0.001).
Using 1500 bootstrap
datasets of random sampling of patients and replacement and logistic regression
of each dataset, the ideal timing of antibiotic administration was estimated to
be four minutes before incision (95% bootstrap CI 0-18 minutes).
"Bootstrapping
allows the authors to estimate the accuracy and reliability of their
findings," said Dr. Hawn. "In essence, it allowed them to create
multiple populations within their study population to ensure that the findings
were consistent in random subgroups of patients."
From those data, the
authors calculated that an 11.3% reduction in the rate of infections would have
resulted if antibiotics had been given four minutes before surgery in all
cases.
Dr. Kamal Itani,
Chief of Surgery at the VA Boston Health Care System, had a few concerns about
the study.
The mix of several
general surgical operations might be a problem, he said, "because the
effect of timing for a colorectal surgery might be different from the timing
for a breast or hernia operation."
With regard to
including wound dehiscence and organ space infections in the composite
endpoint, Dr. Itani added, "Those two complications are more likely to be
due to technical issues rather than antibiotic prophylaxis."
Also, he said,
"The relationship between timing and SSI should have taken into
consideration other important risk factors such as complexity of the operation,
its duration as well as specific patient risk factors."
"I think the
data are interesting and highlight the difficulty of translating a practice
that is effective into a quality metric," said Dr. Hawn. "Giving
antibiotics two minutes after incision may be better than 60 minutes before, but
the former is publicly reported as poor quality."
"Our analysis
suggests there is indeed an opportunity to improve upon the current guideline
metric in the setting of general surgical patients," said Dr. Koch.
Drs. Koch, Hawn and
Itani all favor giving prophylactic antibiotics after induction of anesthesia
or within minutes of the time of incision. Dr. Koch said, "Caregivers are
more cognizant of timing, however, no formal policy has been set based on the
observational study design."
J Am Coll Surg 2013.
Antibiotics Just Before the Incision: Study
Health) Aug 19 - The best time to give preoperative prophylactic antibiotics is
within 18 minutes of making the incision, new findings suggest.
Infection Prevention Project advises that antibiotics be given within the hour
before incision. But Dr. Colleen G. Koch, who headed the new research, told
Reuters Health, "While current antibiotic administration guidelines are
based on simplicity and rough cut-offs, there may be substantial opportunity to
further refine antibiotic timing to reduce postoperative infections."
unclear in previous studies whether specific times within that 60-minute window
offer any advantage.
systems have adopted the practice of administering antibiotics in the operating
room just prior to incision, but there has been concern that this practice does
not allow for sufficient circulation of the drug. The study supports the safety
and effectiveness of this practice," Dr. Mary T. Hawn, vice-chair of
surgery at the University of Alabama at Birmingham, told Reuters health in an
email.
published online June 18 in the Journal of the American College of Surgeons,
Dr. Koch and colleagues at the Cleveland Clinic looked at data from more than
4,400 various general surgery cases done from 2006 to 2012. Patients were
excluded if they had ongoing infections or missing data, or if they received
vancomycin or had procedures lasting more than four hours. If patients had
multiple procedures, only the first operation was included.
start of the antibiotic infusion to the incision was obtained from the
anesthesia record. Ultimately, 4,239 patients (95.1%) received antibiotics
within the recommended 60 minutes before incision.
composite endpoint -- any wound disruption, superficial, deep or organ space
surgical site infection, or sepsis -- occurred in 444 patients (10%), including
9% of the 3,140 patients who got antibiotics within 30 minutes before incision
and 11.7% of the 1,099 who were medicated between 30 and 60 minutes in advance
(p=0.01).
received their antibiotics either more than 60 minutes before the incision, or
more than 60 minutes afterward, had 31 infections (14.5%).
between timing of antibiotics and infection was nonlinear and
"bowl-shaped," with the lowest risk of infection near the time of
incision, the authors said.
on antibiotic timing consistently display a 'bowl-shaped' relationship of
timing and infection risk, however, studies vary on the where the nadir risk
lies in relationship to surgical incision," Dr. Koch said in an email.
"Of note, we never reach a nadir of 'zero' risk for postoperative
infectious complications."
"This is an important paper and confirms the findings from many other
reports that giving antibiotics close to incision, even if it results is giving
them a few minutes after incision, is better than giving them closer to one
hour prior to incision."
infections had a median hospital length of stay of seven days, vs. three days
for those without infections (p<0.001).
datasets of random sampling of patients and replacement and logistic regression
of each dataset, the ideal timing of antibiotic administration was estimated to
be four minutes before incision (95% bootstrap CI 0-18 minutes).
allows the authors to estimate the accuracy and reliability of their
findings," said Dr. Hawn. "In essence, it allowed them to create
multiple populations within their study population to ensure that the findings
were consistent in random subgroups of patients."
authors calculated that an 11.3% reduction in the rate of infections would have
resulted if antibiotics had been given four minutes before surgery in all
cases.
Chief of Surgery at the VA Boston Health Care System, had a few concerns about
the study.
general surgical operations might be a problem, he said, "because the
effect of timing for a colorectal surgery might be different from the timing
for a breast or hernia operation."
including wound dehiscence and organ space infections in the composite
endpoint, Dr. Itani added, "Those two complications are more likely to be
due to technical issues rather than antibiotic prophylaxis."
"The relationship between timing and SSI should have taken into
consideration other important risk factors such as complexity of the operation,
its duration as well as specific patient risk factors."
data are interesting and highlight the difficulty of translating a practice
that is effective into a quality metric," said Dr. Hawn. "Giving
antibiotics two minutes after incision may be better than 60 minutes before, but
the former is publicly reported as poor quality."
suggests there is indeed an opportunity to improve upon the current guideline
metric in the setting of general surgical patients," said Dr. Koch.
Itani all favor giving prophylactic antibiotics after induction of anesthesia
or within minutes of the time of incision. Dr. Koch said, "Caregivers are
more cognizant of timing, however, no formal policy has been set based on the
observational study design."
沒有留言:
張貼留言