Nursing, Antibiotics and Infection - Research Paper Example

? NURSING It has freshly come to the interest of medical experts that it is possible to give antibiotics prior tosurgical procedures as a way of minimizing infection to orthopedic patients. In this particular research study, the clinical question of whether giving antibiotics within 1 hour before surgical incision to pre-operative orthopedic patients decreases the rate of infection as compared to those who do not receive antibiotics within the 1 hour will be addressed. A number of articles will also be used. The significance of this question will also be addressed in the course of this study. A summary will then be provided of the types of studies retrieved in addition to an algorithm of the research. Key findings will be highlighted, citing studies that have contributed most to the subject matter. The study will also include any strengths, weaknesses or gaps in the Literature part of it where a few examples will be provided. A conclusion will be provided at the end of the study. Key Words: Orthopedics, antibiotics, infection. 1.0. STATEMENT OF THE PROBLEM 1.1. Clinical Question Does Giving Antibiotics within 1 Hour before Surgical Incision to Pre-Operative Orthopedic Patients Decrease Rate of Infection Compared to Patients Who Do Not Receive Antibiotics within 1 Hour? 1.2. PICO 1.2.1. Problem/Patient Patients who were sampled for this particular study where those with previous ailments and included patients who are allergic to penicillin. Such patients were administered 600mg of clindamycin (Kim et al., 2010). All 317 patients were undergoing various surgical initiatives such as total knee arthroplasty, total hip arthroplasty and spine surgery (Jamsen et al., 2010). Before the main intervention was carried out, a number of the patients cited a few concerns regarding the whole process. For instance, if the intervention was going to be successful, what would happen if they did not come out of the surgical process? They were, however, assured of success and this made them rest easy. Some of the characteristics indicated above regarding the patients such as previous ailments or current medications should be considered while searching for evidence. 1.2.2. Intervention A medical intervention is usually the main concern for patients or clients. All patients in the study will be subjected to a surgical ‘time-out’ protocol as a way of preventing wrong-site surgery. The protocol will be carried out in the course of a 7-day period where the patients will be administered prophylactic intravenous antibiotics at least an hour before surgical incision. Anesthesiologists will also routinely administer these antibiotics to the patients before or shortly after induction of anesthesia (Maksimovic et al., 2008). Time interval between administering antibiotics and performing the incision is, as a result, of the patients being positioned, prepared and draped, where the longest time interval taken will be in total hip arthroplasty procedures (Gillespie & Walenkamp, 2010). In the course of the intervention, identifiers will also be put in use as a means of authenticating the correct patient together with the correct surgical site/side, including the patient’s name, date of birth, and the surgeon’s initials in the operative area as well as a signed operative consent form (Jamsen et al., 2010). As mentioned earlier, there are those patients with previous medical issues and those without. For those patients with, for instance, a history of penicillin or cephalosporin allergy, the administration of 600mg of clindamycin will be done, while those without any previous medical conditions will be administered 1g of cefazolin (Burke, 2001). Upon completion of these procedures, the time of preoperative antibiotic administration, time of incision, type of surgery as well as specific antibiotic will be obtained for each of the patients from the time out verification sheets and patient charts, where this information will then be identified (Rosenberg, 2008). The time from antibiotic administration to surgical incision will be calculated again for each of the patients, for the group en bloc and also for the major groupings of spine procedures, total hip and total knee procedures (Lundine et al. 2010). 1.2.3. Comparison Group In the course of the study, compliance during the period was compared to compliance during a 3-month period before the institution of this particular intervention as well as compliance for 18 months after institution of this protocol. Chi-square Analysis is the alternative that will be considered when comparing compliance with suitable timing of antibiotic prophylaxis for those patients undergoing knee or hip arthroplasty (Maksimovic et al., 2008). This analysis will also be carried out to compare the outcomes with the use of compliance checklist and compliance observed in a recent large survey. 2.0. LITERATURE SEARCH STRATEGY 2.1. Search strategy Twelve articles were used all together in the search and they included: Burnett, R. S., Aggarwal, A., Givens, S. A., McClure, J. T., Morgan, P. M., & Barrack, R. L. (2009). Prophylactic antibiotics do not affect cultures in the treatment of an infected TKA: A prospect trial. ClinOrthopRelat Res., 468(1), 127-134. Jamsen, E., Furnes, O., Engesaeter, L. B., Konttinen, Y. T., Odgaard, A., Stefansdottir, A., & Lidgren, L. (2010). Prevention of deep infection in joint replacement surgery. AcaOrthop, 81(6), 660 – 666. Rosenberg, A. et al. (2008). Ensuring appropriate timing of antimicrobial prophylaxis. The Journal of Bone and Joint Surgery, Incorporated, 90, 226-32. Stefansdottir, A., Robertsson, O., W-Dahl, A., Kiernan, S., Gustafson, P., & Lidgren, L. (2009). Inadequate timing of prophylactic antibiotics in orthopedic surgery. We can do better. ActaOrthop, 80(6), 633-638. DeBeer, J., Petruccelli, D., Rotstein, C., Weening, B., Royston, K., & Winemaker, M. (2009). Antibiotic prophylaxis for total joint replacement surgery: Results of a survey of Canadian orthopedic surgeons. Can J Surg. 52(6), 229-234. Maksimovic, J., Markovic-Denic, L., Bumbasirevic, M., Marinkovic, J., & Vlajinac, H. (2008). Surgical site infections in orthopedic patients: Prospective cohort study. Croat Med J., 49(1), 58-65. Kim, B., Moon, S. H., Moon, E. S., Kim, H. S., Park, J. O., Cho I. J., & Lee, H. M. (2010). Antibiotic microbial prophylaxis for spinal surgery: Comparison between 48 and 72-Hour AMP protocols. Asian Spine J., 4(2), 71-76. Lundine, K. M., Nelson, S., Buckley, R., Putnis, S., & Duffy, P. J. (2010). Adherence to perioperative antibiotic prophylaxis among orthopedic trauma patients. Can J Surg., 53(6), 367-372. Prokuski, L. (2008). Prophylactic antibiotics in orthopaedic surgery. J Am Acad Orthop Surg, 16(5), 283-293. Burke, J. P. (2001). Maximizing appropriate antibiotic prophylaxis for surgical patients: An update from LDS Hospital, Salt Lake City. Clin Infect Dis., 33(2), 78-83. Prtak, L.E., & Ridgway, E.J. (2009). Prophylactic antibiotics in Surgery. Surgery, 27(10), 431-434. Gillespie, W., & Walenkamp, G. (2010). Antibiotic prophylaxis for surgery for proximal femoral and other closed long bone fractures. Cochrane Database Syst Rev., 2 (3), CD000244 2.2. Summary statements about the quality of the literature this have to be done 2.2.1. Key Words in these articles were: Nosocomial SSIs, prophylactic antibiotic administration, arthroplasty, orthopedic, procedures, penicillin, risk reduction, infection, clinical trials, and placebo. 2.2.2. Inclusion and Exclusion Criteria In any given study, there are those studies that are considered relevant to users and those that are not. Included studies are those that are considered relevant while excluded studies are not so relevant to the studies carried out. In this particular study, there were inclusions and exclusions criteria. 5 of the studies conducted met the inclusion criteria and these were DeBeer et al. (2009), Prokuski (2008), Maksimovic et al. (2008), Prtak and Ridgway (2009) and Lundine et al. (2010). Since the publication of the review, 23 completed trials have been identified that may have actually met the inclusion criteria. Two other studies (Burnett et al., 2010; Stefansdottin et al., 2009) were excluded because either they were carrying out different studies from the main topic of this particular study or participants had already sustained open fracture prior to the administration of the antibiotics. The remaining 3 studies were found to be ongoing and are more likely to be eligible for inclusion in this particular study, once the data is made available. 3.0. SUMMARY OF MAJOR FINDINGS The review presented in this study is a confirmation of the value of antibiotic prophylaxis in dipping the jeopardy of infection if administered 1 hour prior to surgical incision. To the researcher’s knowledge, a reliable method of ensuring compliance with a suitable timing of prophylactic antibiotics was not in existence before this particular study. However, by carrying out the ‘time out’ verification of antibiotic administration before surgical incision and documentation, the operating room staff was reminded to ensure that antibiotics are administered in a timely fashion (Kim et al., 2010). Like any other review, the literature contained a gap with regard to measurement issues. Patient charts are usually reviewed for core measures, which are determined in random samples of all the cases carried out. One particular patient possessed no record of antibiotic administration in the OR and did not have a time out sheet in his chart. It was assumed that he had not been given the first dose of antibiotics until the preoperative period. This incident reinforces the impression that the patient would have received the antibiotics in a timely fashion, had the appropriate procedure been followed. Irrespective of the weaknesses of individual studies, gathering together accumulated evidence tends to support the hypothesis of the ability of antibiotics to reduce surgical site infection if administered an hour before (Burke, 2001). 3.1.1. Major themes or findings: Key findings During the intervention period, the average time between antibiotic administration and the surgical incision was 25±10 minutes for all the patients (Burnett et al., 2010). The intervention proved effective in making sure that the antibiotics were given within 1 hour prior to surgical incision in 312 of 317 patients. For patients receiving the antibiotics prior to the incision, the administration time was 25±10 while for those undergoing total knee arthroplasty was 23±8 minutes (Maksimovic et al., 2008). Patients undergoing spine surgery had an average time of 25±10 minutes while that of patients undergoing total hip arthroplasty was 28±10 minutes (Jamsen et al., 2010). It was observed that in the 3-month preceding the study phase, only 65% of the total patients undergoing total hip or total knee arthroplasty had been administered prophylactic antibiotics within 1 hour before surgical incision (Lundine et al., 2010). For the 18-months study period, a whooping 97% of the total patients undergoing the same hip and knee procedures had been administered the antibiotics within an hour before the incision (Burnett et al., 2010). These outcomes proved that it was better to administer the prophylactic antibiotics 1 hour prior to a surgical incision in an effort of reducing or minimizing infection. 4.0. CONCLUSIONS AND RECOMMENDATIONS From the review, it can thus be concluded that antibiotic prophylaxis is an effective intervention for reducing the rate of infection if administered to patients 1 hour prior to surgical incision. It has also been observed that single dose intravenous antibiotic is not considered inferior to many dose regimens, especially if the tissue levels tend to exceed the minimum inhibitory amount in a 12-hour period. Those responsible for the administration of the antibiotics on a day to day basis confirm that the protocol is viewed as an effective instrument that has assisted them in providing adequate patient care. In the course of the review, a concern arose in that behavior tends to transform individuals who are aware they are being observed, and thus the change may only be on a temporal basis. All in all, compliance was constantly high even after the study period. It is recommended that since the time out procedure for the wrong site surgery is already being implemented nationwide, addition of the verification of antibiotic administration is capable of ensuring that antibiotics are administered at the required time an hour before surgical incision. 4.1. Implications of the Clinical Question The clinical question under consideration is highly crucial in the understanding of the implication of antibiotic prophylaxis as an effective intervention for reducing the rate of infection if administered to patients 1 hour prior to surgical incision. The major implication of the finding is in the sense that it will enhance my research work in the sense that the recommendations made will pave way for other research work. With respect to this, my practice work will be enhanced with more knowledge and experience acquisition assured. REFERENCES Burke, J. P. (2001). Maximizing appropriate antibiotic prophylaxis for surgical patients: An update from LDS Hospital, Salt Lake City. Clin Infect Dis., 33(2), 78-83. Burnett, R. S., Aggarwal, A., Givens, S. A., McClure, J. T., Morgan, P. M., & Barrack, R. L. (2009). Prophylactic antibiotics do not affect cultures in the treatment of an infected TKA: A prospect trial. ClinOrthopRelat Res., 468(1), 127-134. DeBeer, J., Petruccelli, D., Rotstein, C., Weening, B., Royston, K., & Winemaker, M. (2009). Antibiotic prophylaxis for total joint replacement surgery: Results of a survey of Canadian orthopedic surgeons. Can J Surg., 52(6), 229-234. Gillespie, W. & Walenkamp, G. (2010). Antibiotic prophylaxis for surgery for proximal femoral and other closed long bone fractures. Cochrane Database Syst Rev., 2(3), CD000244. Jamsen, E., Furnes, O., Engesaeter, L. B., Konttinen, Y. T., Odgaard, A., Stefansdottir, A., & Lidgren, L. (2010). Prevention of deep infection in joint replacement surgery. AcaOrthop, 81(6), 660-666. Kim, B., Moon, S. H., Moon, E. S., Kim, H. S., Park, J. O., Cho I. J., & Lee, H. M. (2010). Antibiotic microbial prophylaxis for spinal surgery: Comparison between 48 and 72-hour AMP protocols. Asian Spine J., 4(2), 71-76. Lundine, K. M., Nelson, S., Buckley, R., Putnis, S., & Duffy, P. J. (2010). Adherence to perioperative antibiotic prophylaxis among orthopedic trauma patients. Can J Surg., 53(6), 367-372. Maksimovic, J., Markovic-Denic, L., Bumbasirevic, M., Marinkovic, J., & Vlajinac, H. (2008). Surgical site infections in orthopedic patients: Prospective cohort study. Croat Med J., 49(1), 58-65. Prokuski, L. (2008). Prophylactic antibiotics in orthopaedic surgery. J Am Acad Orthop Surg, 16(5), 283-293. Prtak, L.E., & Ridgway, E.J. (2009). Prophylactic antibiotics in surgery. Surgery, 27(10), 431-434. Rosenberg, A., et al. (2008). Ensuring appropriate timing of antimicrobial prophylaxis. The Journal of Bone and Joint Surgery, Incorporated, 90, 226-32. Stefansdottir, A., Robertsson, O., W-Dahl, A., Kiernan, S., Gustafson, P., & Lidgren, L. (2009). Inadequate timing of prophylactic antibiotics in orthopedic surgery. We can do better. ActaOrthop, 80(6), 633 – 638. Algorithm of Search {n=2} {n=458} {n=2} {n=17} {n=3} {n=4} {n=44} {n=425} {n=99} {n=8} FIGURE 1: Algorithm EVIDENCE TABLE AUTHORS/ STUDY STUDY AIM/ PURPOSE DESIGN SAMPLE/SAMPLING APPROACH VARIABLES AND MEASURES/ RELIABILITY AND VALIDITY KEY FINDINGS QUALITY: |Personal GRADE | conclusion STRENGTHS | about LIMITATIONS | article 1.Burke (2001 To investigate failure to administer initial dose of antibiotic within the 2-hour window before incision A retrospective review Sample chosen from the LSD Hospital This study proved reliable and valid for the study being carried out Effective use of antimicrobial prophylaxis needs constant monitoring of and feedback on patterns of use Great difficulties | The article related to | was quite helpful in changing | the study as it systems of care | contained the | necessary | information | regarding the | subject matter 2.Burnett, et al. (2009) To determine whether prophylactic preoperative antibiotics affect results of cultures obtained intraoperatively A retrospective review Enrolled 25 patients with 26 infected Total Knee Arthroplasty This particular study was not as reliable or valid to the main study being carried out as it only focused on one major condition (TKA) Preoperative prophylactic antibiotics did not affect results of intraoperative cultures. Outcomes were | This positive and a | particular article new realization| was not as made, that of not | helpful to withholding | the study as antibiotics before | expected surgical incision| 3.DeBeer, et al. (2009) To investigate the role of perioperative antibiotic prophylaxis in Total Joint Replaement surgery A prospective cohort study Survey carried out on 590 practicing orthopedic surgeons performing TJR The study was unreliable and invalid for use in the main study being conducted Response rate was 70% Current antibiotic prophylaxis regimens differ widely among surgeons Did not contain| This article the necessary| did not provide information needed| all the to carry out the| necessary main study| information Focused mainly| needed for the on clinical practice| study rather than the| clinical question on| the main study| 4.Jamsen, et al. (2010) To investigate the prevention of deep infection of joint replacement surgery A prospective randomized cohort study 2137 operations performed on TKAs This particular study was partially reliable and partially valid for the main study being conducted as it showed what happens to a wound if antibiotic prophylaxis is not administered Colored areas represented 98% confidence interval for the cumulative revision rates of different time periods No antibiotic | Since this prophylaxis was| particular administered and| articles therefore the results | focused on would not assist in | a specific the main study| topic, it was only | partially helpful to |the study 5.Kim, et al. (2010) To evaluate the efficacy of a 48-hour antibiotic microbial prophylaxis protocol as compared to a 72-hour one A prospective randomized cohort study 548 patients who underwent spinal surgery Classified into 2 groups, where AMP for one group was employed for 72 hours post operatively, and the other group 48 hours postoperatively The study was reliable and valid AMP for 48 hours is as efficient as AMP for 72 hours No significant difference in infection rate between the 2 groups Strongly support | This article the main study | greatly assisted |the researcher in | finding the | information |needed for the | study 6.Lundine, et al. (2010) To assess whether patients receive their antibiotic prophylaxis as prescribed A retrospective review 205 patient charts were used and a national survey sent to all surgeon members regarding antibiotic prophylaxis in the locale of surgical treatment for closed fractures Valid and reliable for the main study being conducted Adherence to multi-dose “postoperative antibiotic regimens” is poor. Meta analysies | All the failed to show the | information superiority of | needed for multidose regimens | reference as compared to | in this research single dose | study was found in prophylaxis | this article 7.Maksimovic, et al. (2008) To estimate the incidence rate and risk factor of Surgical Site Infections (SSIs) A prospective cohort study Study conducted at the teaching hospital in Belgrade Patient data collected on surgical procedures, preoperative preparations for patients and underlying disease status Valid and reliable for the main study being conducted Surgical site infections present in 63 of 277 patients after operation Presence of a high |This article incidence of SSIs |proved useful in orthopedic | to the main study patients in Serbia | as compared to | developed and | developing nations | 8.Prtak & Ridgway (2009) To investigate use of surgical prophylaxis in an evidence-based manner A prospective cohort study Tests carried out on patients with postoperative illness Reliable and valid for the main study being conducted Patients were administered antibiotic prophylaxis prior to surgery and this reduced the risk of SSIs Factors such as| This particular antimicrobial| article proved spectrum, patient| helpful to the risk factors and| main study allergies were | being carried out taken into| consideration| 9.Prokuski (2006) To investigate the use of prophylactic antibiotics in orthopedic surgery A prospective randomized cohort study Patients with hip and knee arthroplasty and spine surgery were selected for the administration of antibiotic prior to surgical incision Very reliable and valid for the main study being carried out Correct antimicrobial agent was selected and the drug administered an hour prior to surgical incision Beneficial effect of prophylactic antibiotics were maximized while reducing adverse effects Giving antibiotics |This article within 1 hour | was relevant to before surgical| the study as it incision proved | contained beneficially effective| materials in reducing the |that could be rate of infection | used in this | study 10.Stefansdottir, et al. (2009) To determine how routines with preoperative prophylactic antibiotics are working A prospective cohort study 114 cases treated and the time of administration of preoperative prophylactic antibiotic prior to incision recorded This particular study was reliable and valid Administration of the prophylactic antibiotic prior to surgical incision was effective in reducing the rate of infection Timing of | This article was preoperative | quite relevant to antibiotic | the main study as it prophylaxis is | provided data inadequate | regarding routines Need to sharpen | of antibiotics routines of | administration administration of | and how antibiotics | effective they are 11. Gillespie & Walenka, (2010) To determine whether the prophylactic antibiotic administration in patients undergoing hip surgery or closed fractures reduces infections Randomized/ quasi randomized control trials 23 studies conducted and 8447 samples analyzed Valid and reliable for main study conducted Antibiotic prophylaxis is vital for the patients undergoing closed fracture surgery Strongly support the article Read More