USE OF ANTIMICROBIALS IN SURGICAL WOUNDS AND PROCEDURES

To oppose the use of antimicrobial agents in surgical wounds and procedures not based on evidence; further,

To encourage further research to assess the efficacy, safety, and risks of resistance development of antimicrobials used in surgical wounds and procedures; further,

To foster evidence-based recommendations on the use of antimicrobial agents in surgical wounds and procedures and on how to prepare those agents according to appropriate sterile practices; further,

To advocate that antimicrobial stewardship programs review and monitor the use of antimicrobial agents in surgical wounds and procedures; further,

To encourage pharmacists to educate prescribers on adverse outcomes and reactions associated with the use of antimicrobials in surgical wounds and procedures; further,

To support clear and consistent documentation of antimicrobial agents used for surgical wounds and procedures in the electronic health record.

Rationale

The addition of antimicrobials to irrigation solutions during surgical procedures in an effort to prevent surgical site infections has been a long-standing surgical practice. Antibiotics are the most common additives to surgical irrigation fluids, but recent data has shown no clinical benefit compared with saline irrigation, likely due to the mechanism of antibiotics needing a longer exposure time than is allowed during irrigation. Further, the use of topical antibiotics in the open surgical wound is often not monitored and has not been subject to any evidence-based standardization of care. When mixing practices were surveyed across hospitals and health systems, most respondents from facilities in which the solutions were mixed in the operating room (OR) were unaware of who was doing the mixing; of those who were aware, surgical scrub technicians or OR nurses were the individuals most often reported to be doing the mixing.

The results of numerous surveys of surgeons has indicated that the practice of using topical antibiotics intraoperatively, in both irrigation fluids and powders, is widespread. This practice stemmed from the belief that applying antibiotics locally would minimize toxicity and resistance. However, newer data suggest that there is a potential for toxicities and systemic exposure leading to resistance associated with these practices. Because of this, the Infectious Diseases Society of America, Society for Healthcare Epidemiology of America, Surgical Infection Society, American Society of Health-System Pharmacists, World Health Organization, American College of Surgeons, and the International Consensus on Orthopedic Infections all recommend against the use of topical antimicrobial irrigation. Despite these recommendations, this practice is still prevalent throughout hospitals and health systems. Complicating the picture is that neither the Joint Commission nor the Centers for Medicare and Medicaid Services have addressed the use of topical antibiotics.

Due to the risks of topical use and the lack of evidence supporting it, this practice should be an essential part of antimicrobial stewardship programs. All antibiotics sent from pharmacy to the OR, including those intended for topical use, should be documented clearly in the electronic health record, including type and amount used, and should be part of comprehensive surveillance for patient outcomes for surgical site infections, allergic reactions, resistance trends, management of shortages, and toxicity adverse events related to topical surgical administration of antibiotics.