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JAC Advance Access published online on October 18, 2005
Journal of Antimicrobial Chemotherapy, doi:10.1093/jac/dki374
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© The Author 2005. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy. All rights reserved. For Permissions, please e-mail: journals.permissions@oxfordjournals.org
Received June 15, 2005
Revised September 18, 2005
Accepted September 19, 2005

Original article

Quality improvement of surgical prophylaxis in Dutch hospitals: evaluation of a multi-site intervention by time series analysis

Marjo E. E. van Kasteren 1*, Judith Mannien 2, Bart-Jan Kullberg 1, Annette S. de Boer 2, Nico J. Nagelkerke 2, Marja Ridderhof 3, Jan C. Wille 4, and Inge C. Gyssens 3

1 Department of Internal Medicine, University Medical Centre Nijmegen, Nijmegen, The Netherlands; Nijmegen University Centre for Infectious Diseases, Nijmegen, The Netherlands
2 National Institute for Public Health and the Environment, RIVM, Bilthoven, The Netherlands
3 Department of Medical Microbiology and Infectious Diseases, Division of Infectious Diseases, Erasmus MC University Medical Center Rotterdam, The Netherlands; Department of Internal Medicine, Division of Infectious Diseases, Erasmus MC University Medical Center Rotterdam, The Netherlands
4 Dutch Institute for Healthcare Improvement, CBO Utrecht, The Netherlands

* To whom correspondence should be addressed.
Marjo E. E. van Kasteren, E-mail: M.v.Kasteren{at}elisabeth.nl


  Abstract

Objectives: Misuse of antibiotics in surgical prophylaxis is still quite common. The objectives of this study were to reduce the quantity and improve the quality of surgical prophylaxis and to reduce costs.

Methods: Prospective multi-site study of elective procedures in 13 Dutch hospitals. The quality of prophylaxis was audited before and after an intervention consisting of performance feedback and implementation of national clinical practice guidelines. Process outcome parameters were antibiotic choice, duration, timing, antibiotic volume and costs. Segmented regression analysis was used to estimate the effect size of the intervention. Patient outcome was documented by the incidence of surgical site infections (SSI).

Results: Before the intervention, 1763 procedures were recorded and 2050 thereafter. Antimicrobial use decreased from 121 to 79 DDD (defined daily doses)/100 procedures and costs reduced by 25% per procedure. After the intervention, antibiotic choice was inappropriate in only 37.5% of the cases instead of in 93.5% expected cases had the intervention not occurred. Prolonged prophylaxis was observed in 31.4% instead of 46.8% expected cases and inappropriate timing in 39.4% instead of the expected 51.8%. Time series analysis showed that all improvements were statistically significant (P < 0.01) and that they could be fully attributed to the intervention. The overall SSI rates before and after intervention were 5.4% (95% CI: 4.3-6.5) and 4.6% (95% CI: 3.6-5.4), respectively.

Conclusions: The intervention led to improved quality of surgical prophylaxis and to reduced antibiotic use and costs without impairment of patient outcome.

Keywords: antibiotic prophylaxis; intervention studies; audit; interrupted time series; practice guidelines.
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