Wise use of perioperative antibiotics

AORN Journal,  June, 2005  by Donna J. Plonczynski

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The article "Wise use of perioperative antibiotics" is the basis for this AORN Journal independent study. The behavioral objectives and examination for this program were prepared by Rebecca Holm, RN, MSN, CNOR, clinical editor, with consultation from Susan Bakewell, RN, MS, BC, education program professional, Center for Perioperative Education.

Participants receive feedback on incorrect answers. Each applicant who successfully completes this study will receive a certificate of completion. The deadline for submitting this study is June 30, 2008.

Complete the examination answer sheet and learner evaluation found on pages 1277-1278 and mail with appropriate fee to

AORN Customer Service

c/o Home Study Program

2170 S Parker Rd, Suite 300

Denver, CO 80231-5711

or fax the information with a credit card number to (303) 750-3212.

You also may access this Home Study via AORN Online at http://www.aorn.org/journal/homestudy/default.htm.

BEHAVIORAL OBJECTIVES

After reading and studying the article on perioperative use of antibiotics, nurses will be able to

1. describe patients' physiological responses to the presence of bacteria,

2. explain antibiotic effectiveness related to the pharmacotherapeutic property of mutation prevention,

3. discuss current theories of how long antibiotics should be administered after surgery,

4. describe the new guidelines published in the Medical Letter for surgical infection prophylaxis, and

5. identify how perioperative nurses help reduce surgical site infections through wise use of antibiotics.

Hospital-acquired infections are a major concern for perioperative nurses. Nearly 27 million people have surgery every year, and approximately 500,000 will acquire nosocomial surgical site infections (SSIs) of varying severity. (1) Patients who acquire infections experience longer hospital stays and higher morbidity and mortality rates. In addition, their care is more costly. (2)

Although infection rates are affected by patient factors and the type and length of surgery performed, (3) patients undergoing high-risk procedures who receive inadequate antibiotic prophylaxis before surgery have 2.32 times greater risk of acquiring an SSI compared to those who receive adequate antibiotic prophylaxis. (4) Correct antibiotic prophylaxis has been shown to reduce SSIs and hospital costs. (5) The purposes of this article are to discuss antibiotic effectiveness and resistance and present the latest research and guidelines regarding antibiotic prophylaxis to prevent SSIs in surgical patients.

INNATE AND ACQUIRED RESPONSES

Any surgical break in the skin barrier allows bacteria from the skin, air, and environment to enter a surgical site even if colonization does not progress to a clinical infection. (6) A patient's response to the presence of bacteria is classified as either innate or acquired. Innate factors, such as how well a patient's neutrophils and macrophages function, are responsible for eradicating foreign substances in the body. Innate immunological factors differ between individuals and within each individual and are affected by the aging process. (7)

Acquired factors that can impair a patient's immune response include chronic diseases (eg, diabetes, Cushing's disease), medications (eg, corticosteroids, blood transfusions), and certain conditions (eg, malnutrition, hypothermia). In addition to the normal aging of the population, longevity of adults with multiple chronic illnesses is resulting in an increased risk of SSIs.

ULTIMATE WEAPON OR SURGICAL RISK?

Less than 80 years after their introduction in 1935, antibiotics evolved from the ultimate weapon against the primary causes of morbidity and mortality to a significant surgical risk factor. Antibiotic overuse has been responsible for the development of bacteria that resist eradication. (8) Undergoing surgery has been shown to increase a hospitalized patient's risk of acquiring an antibiotic-resistant infection by 62%. (9) These worrisome bacteria include amikacin-resistant Pseudomonas aeruginosa, methicillin-resistant Staphylococcus aureus (MRSA), and vancomycin-resistant enterococci. Judicious antibiotic use in the OR is warranted, however, because of the increase in higher-risk surgical patients and the rising rate of microbial resistance to antibiotics.

To address the significance of infection and microbial resistance, the Centers for Disease Control and Prevention has developed an education program for health care facilities. The program's four tenets are to

* prevent infection,

* use antibiotics wisely,

* diagnose and treat infections accurately, and

* prevent further transmission of the infection. (10)

An SSI may occur because a patient's defense mechanisms are weakened or as a result of the amount and virulence of the bacteria and the patient's wound characteristics. (6) As a result of differing infection control procedures in health care facilities (eg, most notably antibiotic administration practices), rates of infection (11) and antibiotic resistance differ by hospital (12) and by country. (13) Wise use of antibiotics is one of the methods by which perioperative nurses affect the rate of SSIs for their patients, (14) particularly because many patient risk factors for infection are nonmalleable. (15) Understanding appropriate antibiotic choice, dose, and timing is indispensable knowledge to protect surgical patients. In addition to administering antibiotics, perioperative team members help control the rate of SSIs by