Timing of Surgical Antibiotic Prophylaxis and the Risk of Surgical Site Infection
Timing of Surgical Antibiotic Prophylaxis and the Risk of Surgical Site Infection
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DOI：
10.1001/jamasurg.2013.134
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发表时间：
2013-07-01
期刊：
影响因子：
16.9
通讯作者：
Itani, Kamal M. F.
中科院分区：
文献类型：
--
作者：
Hawn, Mary T.;Richman, Joshua S.;Itani, Kamal M. F.
外科手术预防性抗生素使用的时机是由医疗保险和医疗补助服务中心外科护理改进项目赞助的国家强制性和公开报告的质量指标。许多研究未能证明遵守外科护理改进项目预防性抗生素及时给药措施与减少手术部位感染（SSI）有关。目的探讨预防性抗生素使用时机与SSI的发生是否相关。回顾性队列研究使用2005 - 2009年国家退伍军人事务部关于骨科、结直肠、血管和妇科手术预防性抗生素使用时间的患者水平数据。国家退伍军人事务外科护理改进项目数据来自112家退伍军人事务医院和匹配的退伍军人事务外科质量改进项目数据。患者接受髋关节或膝关节置换术、结肠直肠手术、动脉血管手术和子宫切除术的患者。干预措施：与手术切口时间相关的预防性抗生素给药时机。评估预防性抗生素药物、手术切口预防性抗生素时机以及患者和手术风险变量的数据，以评估其与术后30天内发生复合浅表或深部切口SSI的关系。使用非线性广义加性模型来检验抗生素使用时间与SSI之间的关系。结果32459例手术中，预防性抗生素在手术切口前中位数28分钟（四分位数间距17-39分钟）给予，1497例（4.6%）发生SSI。与在切口前60分钟内给药的手术相比，在切口前60分钟以上的手术中观察到更高的SSI发生率（未经调整的比值比[OR] = 1.34; 95% CI, 1.08-1.66），但在切口后没有（未经调整的比值比[OR] = 1.26; 95% CI, 0.92-1.72）。在未调整的广义加性模型中，我们观察到预防性抗生素使用时间与SSI之间存在显著的非线性关系（P = 0.01）。在调整了患者、程序和抗生素变量的广义加性模型中，没有观察到预防性抗生素使用时间与SSI之间的显著关联。盐酸万古霉素与骨科手术中较高的SSI发生率相关（调整后OR = 1.75; 95% CI, 1.16-2.65）。头孢唑啉钠和喹诺酮联合厌氧剂与结直肠手术SSI事件较少相关（头孢唑啉：调整OR = 0.49; 95% CI, 0.34-0.71；喹诺酮：调整OR = 0.55; 95% CI, 0.35-0.87）。结论和相关性SSI风险因患者和手术因素以及抗生素特性而异，但与预防性抗生素使用时间无显著相关性。虽然坚持及时的预防性抗生素措施并不是糟糕的护理，但几乎没有证据表明这是更好的护理。
IMPORTANCE Timing of prophylactic antibiotic administration for surgical procedures is a nationally mandated and publicly reported quality metric sponsored by the Centers for Medicare and Medicaid Services Surgical Care Improvement Project. Numerous studies have failed to demonstrate that adherence to the Surgical Care Improvement Project prophylactic antibiotic timely administration measure is associated with decreased surgical site infection (SSI).OBJECTIVE To determine whether prophylactic antibiotic timing is associated with SSI occurrence.DESIGN Retrospective cohort study using national Veterans Affairs patient-level data on prophylactic antibiotic timing for orthopedic, colorectal, vascular, and gynecologic procedures from 2005 through 2009.SETTING National Veterans Affairs Surgical Care Improvement Project data from 112 Veterans Affairs hospitals and matched Veterans Affairs Surgical Quality Improvement Program data.PATIENTS Patients undergoing hip or knee arthroplasty, colorectal surgical procedures, arterial vascular surgical procedures, and hysterectomy.INTERVENTION Timing of prophylactic antibiotic administration with respect to surgical incision time.MAIN OUTCOMES AND MEASURES Data for prophylactic antibiotic agent, prophylactic antibiotic timing with respect to surgical incision, and patient and procedure risk variables were assessed for their relationship with the occurrence of a composite superficial or deep incisional SSI within 30 days after the procedure. Nonlinear generalized additive models were used to examine the association between antibiotic timing and SSI.RESULTS Of the 32 459 operations, prophylactic antibiotics were administered at a median of 28 minutes (interquartile range, 17-39 minutes) prior to surgical incision, and 1497 cases (4.6%) developed an SSI. Compared with procedures with antibiotic administration within 60 minutes prior to incision, higher SSI rates were observed for timing more than 60 minutes prior to incision (unadjusted odds ratio [OR] = 1.34; 95% CI, 1.08-1.66) but not after incision (unadjusted OR = 1.26; 95% CI, 0.92-1.72). In unadjusted generalized additive models, we observed a significant nonlinear relationship between prophylactic antibiotic timing and SSI when considering timing as a continuous variable (P = .01). In generalized additive models adjusted for patient, procedure, and antibiotic variables, no significant association between prophylactic antibiotic timing and SSI was observed. Vancomycin hydrochloride was associated with higher SSI occurrence for orthopedic procedures (adjusted OR = 1.75; 95% CI, 1.16-2.65). Cefazolin sodium and quinolone in combination with an anaerobic agent were associated with fewer SSI events (cefazolin: adjusted OR = 0.49; 95% CI, 0.34-0.71; quinolone: adjusted OR = 0.55; 95% CI, 0.35-0.87) for colorectal procedures.CONCLUSIONS AND RELEVANCE The SSI risk varies by patient and procedure factors as well as antibiotic properties but is not significantly associated with prophylactic antibiotic timing. While adherence to the timely prophylactic antibiotic measure is not bad care, there is little evidence to suggest that it is better care.