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Do We Comply? Monitoring Antibiotic Prophylaxis In Pediatric Spine Surgery

Saturday, October 20, 2012: 1:07 PM
Melrose (Hilton Riverside)
Matthew D. Riedel, BA1, Hiroko Matsumoto, MA1, Meghan Murray, BA2, Lisa Covington, RN2, Lisa Saiman, MD, MPH2, Joshua E. Hyman, MD, FAAP1, Benjamin D. Roye, MD, MPH, FAAP1, David P. Roye Jr., MD1 and Michael G. Vitale, MD, MPH, FAAP1, (1)Division of Pediatric Orthopaedic Surgery, Department of Orthopaedic Surgery, Columbia University Medical Center, New York, NY, (2)Department of Infection Prevention and Control, Columbia University Medical Center, New York, NY

Purpose

Much attention has been focused on optimizing multimodal prophylactic strategies in order to reduce surgical site infections (SSI). With recent literature suggesting perioperative antibiotic prophylaxis as a key modifiable factor affecting SSIs, it is important to determine how compliant physicians are with established regimens. The purpose of this study is to review compliance with established pediatric spine antibiotic prophylaxis protocol at a tertiary children’s spine program.

Methods

This was a retrospective review of compliance to an established perioperative antibiotic regimen for all patients undergoing spine surgery from January 2009 through September 2011 at our institution. Electronic anesthetic charts were reviewed the to identify the specific antibiotic regimen ordered, compliance with this regimen, and whether or not an SSI occurred.

Results

507 spine surgeries were identified and included in the study. Current protocol consists of dual antibiotic treatment with cefazolin (30 mg/kg +/- 10%) and tobramycin (2.5 mg/kg +/- 10%), in cases of drug allergy or prior infection (MRSA, etc.) vancomycin (15 mg/kg +/- 10%) is substituted for cefazolin. Cefazolin and tobramycin are given <60min prior to incision, vancomycin <120min. Cefazolin is redosed every 4 hours +/- 15min, tobramycin and vancomycin every 8 hours +/- 15min. Cefazolin was used in 91.3% of cases, tobramycin 97.6%, & vancomycin 7.5%. Compliance with all antibiotics was lower than expected. In patients receiving cefazolin: 82.5% received the correct pre-operative dose (per weight), 91.6% with the correct timing. This decreased to 79.2% & 83.7%, respectively, in those requiring one re-dose, and 70.5% & 62.3% in those requiring a 2nd re-dose. For tobramycin: these numbers, respectively, were 78.6% & 91.3%, 70.3% & 56.3%, and 100% & 0%. For vancomycin: 52.6% & 94.7%, 40% & 60%, no 2nd re-doses were required. The timing of first antibiotic doses were more than 90% accurate for all antibiotics, however this dropped precipitously with 2nd and 3rd doses. Dosing for all antibiotics was poor however when re-dosed, correct doses were given less than 80% of the time for all antibiotics. This information is summarized in the Table 1. The study was not adequately powered to detect a correlation between adherence to antibiotic protocol and SSIs as only 15 SSIs occurred in this cohort of 507 surgeries.

Table. 1

Perioperative Antibiotic Compliance

 

Cefazolin

Tobramycin

Vancomycin

 

Correct Dose

Correct Timing

Correct Dose

Correct Timing

Correct Dose

Correct Timing

Dose 1 (pre-op)

82.5%

91.6%

78.6%

91.3%

52.6%

94.7%

Dose 2

79.2%

83.7%

70.3%

56.3%

40%

60%

Dose 3

70.5%

62.3%

100%

0%

N/A

N/A

Conclusion

Perioperative antibiotic regimen compliance is lower than expected across all antibiotic agents despite multi-disciplinary efforts to establish a standardized protocol at the beginning of the study period. Efforts to increase compliance are necessary to continue to improve modifiable risk factors for SSIs.