A global evidence-based bundle for surgical antibiotic prophylaxis

Francesco M. Labricciosa, MD, Specialist in Hygiene and Preventive Medicine

Recommending a bundle with evidence-based measures for surgical antibiotic prophylaxis (SAP), easily applicable and helpful to improve antibiotic prescribing practices among surgeons worldwide. This is the aim of a narrative review just published in Antibiotics by Massimo Sartelli and colleagues.

Surgical site infections (SSIs) represent the most common healthcare-associated infections occurring in surgical patients. Therefore, all procedures aiming to prevent SSIs should be integrated before, during, and after surgery.

SAP is one of the most important measures to prevent SSIs. Nevertheless, many surgeons erroneously believe that SAP is peripheral to their clinical practice. But actually, surgeons play a central role in prevention SSIs.

Indeed, approximately 15% of all antibiotics in hospitals are prescribed for SAP. Using antibiotics appropriately, both for therapy and prophylaxis, is essential to improve treatment effectiveness and patient safety, reduce the risk of antibiotic-associated infections (e.g., Clostridioides difficile infection), and the selection and spread of antibiotic-resistant bacteria.

Several guidelines have been published regarding SSIs prevention, but measures stated in these guidelines are not self-implementing. Bundles are among the most used methods to adapt guidelines in local contexts, and improve acceptance and adherence to best practices.

As observed by the authors, bundles implemented as stand-alone interventions or as part of multimodal strategies were associated with decreased SSI rates.

For these reasons, an international working group of 30 physicians has been established by the Global Alliance for Infections in Surgery. The authors aimed to define a global evidence-based bundle for the appropriate SAP administration, and evaluated the evidence supporting it.

This bundle includes five different actions that may affect adequate SAP administration.

***A global evidence-based bundle for surgical antibiotic prophylaxis*** *[Adapted from Figure 1 in Ref. 1]*

In administering antibiotics for any indication, including for SAP, surgeons should always be responsible for handling antibiotics with care. Indeed, inappropriate prescriptions of these precious medications, as well as poor implementation of infection prevention and control measures, are contributing to the development and spread of bacterial antimicrobial-resistance.

The authors hope this bundle can be easily applied everywhere, and help to improve antibiotic prescribing practices among surgeons worldwide.

Reference

Sartelli M, Coccolini F, Labricciosa FM, Al Omari AH, Bains L, Baraket O, et al. Surgical Antibiotic Prophylaxis: A Proposal for a Global Evidence-Based Bundle. Antibiotics. 2024; 13(1):100.

Infection prevention and management in surgery: a global declaration

Francesco M. Labricciosa, MD, Specialist in Hygiene and Preventive Medicine

In a paper recently published in the World Journal of Emergency Surgery, seven surgical societies around the world shared an important declaration.

The authors – expert physicians representing the societies involved in this alliance – highlighted the threat posed by antimicrobial resistance (AMR), and the importance to prevent and manage infections appropriately across the surgical pathway.

The Global Alliance for Infections in Surgery (GAIS), the World Society of Emergency Surgery (WSES), the Surgical Infection Society (SIS), the Surgical Infection Society-Europe (SIS-E), the World Surgical Infection Society (WSIS), the American Association for the Surgery of Trauma (AAST), and the Panamerican Trauma Society (PTS) participated in the realization of this document.

The goal was to raise awareness among surgeons about AMR by focusing on the importance of actively participating in this challenge.

Surgeons really play a pivotal role in prevention and management of infections in their daily practice. Indeed, they are primarily responsible for preventing hospital-acquired infections, particularly surgical site infections. Moreover, they are prescribers of antibiotics, both for prophylaxis and therapy.

Nevertheless, among them adequate infection prevention and control (IPC) measures, and appropriate antibiotic prescribing practices are often disregarded. Why?

In healthcare facilities around the world, cultural, contextual, and behavioural determinants can influence surgeons’ clinical practice. Furthermore, other factors – such as the fear of clinical failure, time pressure, or organizational contexts – can limit their adherence to IPC procedures and antibiotic prescribing practices.

According to the authors, surgeons in hospital settings should be aware of their role and responsibility, and follow the fundamental principles for correct infection prevention and management across the surgical pathway.

***Fundamental principles for correct infect*****ion prevention and management across the surgical pathway**
*[Adapted from Figure 1 in Ref. 1].*

Changing clinical behaviour is extremely challenging.

A collaborative and multidisciplinary approach is paramount to optimize individual patients’ outcomes and overall healthcare delivery. Each healthcare provider of the team has to participate, and be responsible for its own contribution to patient care.

The authors concluded calling all surgeons around the world to take part in this global cause, by pledging support for this declaration, and accepting responsibility for maintaining the effectiveness of current and future antibiotics.

Reference

Sartelli M, Coccolini F, Ansaloni L, Biffl WL, Blake DP, Boermeester MA, Coimbra R, Evans HL, Ferrada P, Gkiokas G, et al. Declaration on infection prevention and management in global surgery. World J Emerg Surg. 2023 Dec 6;18(1):56.

Optimal antibiotic use in hospital settings: ten golden rules

Francesco M. Labricciosa, MD, Specialist in Hygiene and Preventive Medicine

An important article has been recently published in the World Journal of Emergency Surgery.

A position paper, developed by an international multidisciplinary task force of experts, the WARNING collaborators, whose objective is to raise awareness of antimicrobial resistance (AMR), and improve antibiotic prescribing practices worldwide.

This document outlines ten axioms, or “golden rules”, that healthcare professionals should follow in their clinical practice for the appropriate use of these medications in hospital settings.

Antibiotics are life-saving medications, and therefore ensuring their correct prescription is an essential aspect of good clinical practice. The excessive and inappropriate antibiotic use is a main driver of AMR. However, in many regions of the world, there is not only overuse and misuse of antibiotics but also underuse. It is paramount to narrow the gap between excess and access.

As a matter of fact, optimising antibiotic prescribing implies improved treatment effectiveness and patient safety, minimises the risk of antibiotic-associated infections (e.g., Clostridioides difficile infection), and the selection and spread of antibiotic-resistant bacteria in patients within and across hospitals, countries, and globally.

In January 2023, the Global Alliance for Infections in Surgery established an international multidisciplinary task force to write and share a document on the need for appropriate use of antibiotics in hospitals to curb the spread of AMR.

Overall, 295 healthcare professionals with different backgrounds from 115 countries joined the WARNING (Worldwide Antimicrobial Resistance National/International Network Group) project.

In the final document, the ten golden rules for optimal antibiotic use in hospital settings have been described. They focus not only on the appropriate prescription of antibiotics, but also on the importance of Infection Prevention and Control, source control, monitoring and surveillance tools, education and awareness, and Antimicrobial Stewardship Programs.

**The 10 golden rules for optimal antibiotic use in hospital settings** [Adapted from Figure 1 in Ref. 1].

This document confirms the mission of the Global Alliance for Infections in Surgery, promoting standards of care in managing infections in surgery through a multidisciplinary and cohesive approach.

As the authors conclude, the appropriate use of antibiotics should be integral to good clinical practice, and these precious medications should be considered as a public good on the verge of scarcity.

Therefore, it is a global collective responsibility to preserve antibiotics, and avoid future deaths caused by multidrug resistant infections.

Reference

Worldwide Antimicrobial Resistance National/International Network Group (WARNING) Collaborators. Ten golden rules for optimal antibiotic use in hospital settings: the WARNING call to action. World J Emerg Surg. 2023 Oct 16;18(1):50.

Francesco M. Labricciosa, MD, Specialist in Hygiene and Preventive Medicine

Why the Global Alliance for Infections in Surgery?

Infections in surgery are an important cause of morbidity and are frequently associated with poor prognosis, particularly in high-risk patients.

Given the complexity of the treatment of infections in surgical patients a multi-disciplinary approach should be crucial, although it is not always possible in real-life clinical practice.

The Global Alliance for Infections in Surgery is an independent alliance promoted in 2016 by the World Society of Emergency Surgery (WSES) for a cohesive and global approach to promoting research and education in the field of surgical infections.

The Global alliance for Infections in Surgery aims to involve all professionals involved in this battle, including infection control specialists and healthcare specialists, infectious diseases specialists, hospital pharmacologists, microbiologists, intensivists and surgeons.

The mission of Infections in Surgery is to educate health care providers promoting the standards of care in managing surgical infections worldwide.

WSES