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Gyssens, I.C.

Hal, G. van

Knape, J.T.A.

Meer, J.W.M. van der

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The anaesthetist as determinant factor of quality of surgical antimicrobial pro­
phylaxis. A survey in a university hospital
• I .C .  G y s s e n s ,  J .T .A .  K n a p e , G . Van Hal and  ) .W .M . van  d e r M eer
Introduction
Antimicrobial drugs account for 13-37% of the drug 
budget in European hospitals; 30%  of the antimicro­
bial use is for prophylaxis [1]. The timing of surgical 
prophylaxis and its organizational aspects have rarely 
been analysed. Recently, suboptimal timing of antibi­
otic prophylaxis was found to be associated with a 
significant higher rate of wound infections in a large 
series [2]. Intravenous administration of the drug dur­
ing induction of anaesthesia within 30 min before 
incision is a generally accepted standard [3]. In this 
practice, anaesthetists administer the antibiotic. In 
the University Hospital of Nijmegen, ± 1600 opera­
tions/month are performed on inpatients in 7 operat­
ing departments. An estimated 30% of patients are 
receiving perioperative prophylaxis with antimicrobial 
drugs. Prophylaxis is almost exclusively started in the 
operating room. In the first phase of our quality-of- 
use study of surgical antimicrobial prophylaxis, we 
had measured deficient timing of prophylaxis in 2 out 
of 3 of these operating departments [4]. The results 
were discussed with the surgeons. The anaesthetists 
seemed to play a major role in the timing of surgical 
prophylaxis, but their point of view was not known. 
Because a large staff of 44 anaesthetists rotated in a 
working schedule in all operating departments, we 
wanted to interview all of them by means of an 
inquiry. In preparation of the implementation of new 
guidelines by the department of clinical pharmacy, 
we studied the anaesthetists' perception of the organ­
ization of prophylaxis in the surgical departments and 
their views on optimizing practice. In order to evalu­
ate administration cost, we also asked the anaesthe­
tists about their usual methods of administered anti­
microbial prophylaxis.
M ethods
All 44 staff members (seniors and residents) of the 
department of anaesthesiology who were performing 
anaesthesias were sent a pre-numbered questionnaire 
by internal mail. The forms were distributed and col­
lected by a senior staff member of the department of 
anaesthesiology, who added an introductory letter, 
and urged on nonresponders for three weeks. The 
forms were then returned so that anonymity was pre­
served.
The form contained three blocks of precoded ques­
tions on four pages. To fill in the form, only a few min­
utes were required. Anaesthetists were asked for their 
usual ways of administration of intravenous antimi­
crobial drugs for prophylaxis, i.e. by bolus injection of 
3-5 min or i.v. infusion over 15-30 min, and the rea­
sons for their choice in terms of safety, time, habit and 
cost. They were asked questions about the transmis­
sion of the antibiotic order by the surgeon and its 
relation to the timing of the operation in 7 operating 
departments of the hospital, both for scheduled and
I.C. Cyssens, J.T.A. Knape, C. Van Hal and J.W.M. van der Meer. 
The anaesthetist as determinant factor of quality of surgical 
antimicrobial prophylaxis. A survey in a university hospital. 
Pharm World Sci 7997;7 9(2): 89-92.
© 1997 Kluwer Academic Publishers. Printed in the Netherlands.
I.C. Gyssens: Dept, of General Internal Medicine, University 
Hospital Nijmegen, and Dept of Clinical Microbiology, 
University Hospital Rotterdam, Dr. Molewaterplein 40, 3015 
GD Rotterdam, The Netherlands (correspondence). 
j.T.A. Knape: Department of Anaesthesiology, University 
Hospital Nijmegen, presently: Institute of Anaesthesiology, 
University Hospital Utrecht, The Netherlands.
J.W.M. van der Meer: Dept, of General Internal Medicine, 
University Hospital Nijmegen, The Netherlands.
G. Van Hal: Department of Epidemiology, University of 
Antwerp, Belgium.
K eyw ords
Anaesthesiology
Antibiotics
Cost
Hospital
Pharmacy
Surgical prophylaxis 
A bstract
In actual surgical antimicrobial prophylaxis, the anaesthetist 
administers the drugs at induction of anaesthesia. In the first 
phase of our quality-of-use intervention study on 
antimicrobial drugs in a large university hospital, information 
on the practice of antimicrobial prophylaxis was needed. The 
staff of 44 anaesthetists was interviewed by means of a 
questionnaire. Response rate was 36/44 (82%). The 
anaesthetists' method of administering surgical prophylaxis 
was rather uniform and inexpensive: cephalosporins were 
almost exclusively administered by bolus method. The main 
reason was that infusion was more cumbersome (range 77- 
85%). Communication between surgeon and anaesthetist 
was reported to be poor, and in two out of three operating 
departments, orders of prophylaxis transmitted at or after 
induction accounted for more than 80%. Seventy-seven 
percent of the responders asked the surgeon if prophylaxis 
was necessary if they were in doubt; 20%  responded that 
they checked it systematically. The data collected by the 
inquiry proved useful in the process of optimizing surgical 
prophylaxis in our hospital.
Accepted October 1996
emergency procedures. Space was allowed for com ­
ments. Finally, they were asked for their attitude 
toward measures to improve the organization of anti­
microbial preoperative prophylaxis. Absolute and rel­
ative frequencies of responses to the questionnaire 
were tabulated.
R esults
Thirty-nine (87% ) staff members returned the form. 
Three returned the form blank. Thirty-six forms of 
responders (82% ) were used for analysis. Considering 
the age classes younger than 35 years (n=24, mostly 
residents), 35-45 years (n= 14, mostly staff members), 
and older than 45 years (r?=6, senior staff members), 
no difference in age (<35 yr, 35-45 yr, >45 yr) could 
be found between responders and non-responders 
(chi-square, p = 0.88).
Way of administration
All anaesthetists but one administered prophylactic 
cefazolin and penicillins only by bolus injections 
(97% ) (Table 1). Gentamicin was administered only
by bolus injection in 62%.
The main reasons for this choice seemed to be 
practicality (range 77-85%) and habit (range 65- 
94% ) (Table 2). Although 48%  considered i.v. infu­
sion safer for gentamicin, this view did not always 
determine their choice of administration: 29%  gave 
gentamicin solely by i.v. infusion (Table 1). A differ­
ence in cost was not a major issue; on the average, 
33%  thought there was no difference and 42%  had 
no opinion on the subject.
Communication of prophylactic orders
Table 3 shows the different ways in which the 
anaesthetist was informed about the need for adm in­
istration of preoperative antibiotics for the three 
departments where the timing had been recorded. 
The questionnaire gave five possible kinds of commu­
nications, and one unknown'. Also multiple replies 
were given. In the operating department of surgery 
(SURG), replies indicated that the majority of orders 
were transmitted at earliest at or after induction: 
27.5/31 (89%). In the operating department of 
orthopaedic surgery (ORTH), about half the replies
Table 1 Usual way of administration of prophylactic antibiotics by anaesthetists
Frequency distribution (%) of replies
Ampicillin Flucloxacillin Cefazolin Cefuroxime Gentamicin
(n =35) (n=33) (n=35) (r?=34) (n=34)
Bolus injection 34 (97) 32 (97) 34 (97) 27 (79) 21 (62)
i.v. infusion 0 0 0 4 (12) 10 (29)
Both methods 1 (3) 1 (3) 1 (3) 3 (9) 3 (9)
Table 2 Reasons for choice of i.v. administration by anaesthetists
Frequency distribution (%) of replies
Ampicillin Flucloxacillin Cefazolin Cefuroxime Gentamicin
Safety (n= 33)
i.v. bolus safer 0 0 0 0 0
i.v. infusion safer 3 (9) 2 (6) 4 (12) 6 (18) 16 (49)
no difference 20 (61) 21 (64) 19 (58) 17 (52) 9 (27)
no opinion 10 (30) 10 (30) 10 (30) 10 (30) 8 (24)
Time (n=30)
i.v. infusion more cumbersome 25 (85) 23 (77) 23 (77) 23 (77) 23 (77)
bolus more cumbersome 0 0 2 (6) 1 (3) 0
no difference 5 (15) 7 (23) 5 (17) 6 (20) 7 (23)
Habit (n=32)
always bolus method 30 (94) 26 (81) 28 (88) 25 (78) 21 (65)
always i.v. infusion 0 0 2 (6) 2 (6) 6 (19)
varying methods 2 (6) 2 (6) 2 (6) 4 (13) 4 (13)
no opinion 0 4 (13) 0 1 (3) 1 (3)
Cost (n= 32)
bolus is more expensive 0 0 1 (3) 0 0
i.v. infusion is more expensive 8 (25) 8 (25) 7 (22) 7 (22) 8 (25)
no difference 10 (31) 11 (34) 10 (31) 12 (37) 11 (34)
no opinion 14 (44) 13 (41) 14 (44) 13 (41) 13 (41)
Table 3 Communication between surgeon and anaesthetist concerning antimicrobial prophylaxis
Scheduled operations Emergency operations
Operating department
Number of anaesthetists responding
SURG
33
ORTH
32
ORL
34
SURG
29
ORTH
29
ORL
28
Replies of early communication 
a. antimicrobial drug sent with the patient to the 
operating room 0 4 24 0 0 5
b. order preoperatively written in medical chart 0 0 0 0 1 0
c. order transmitted orally before the patient is in the o.r. 2 9 0 2 5 2
combinations of a, b or c 1 4 5 4 2 2
Replies of late communication
d. order transmitted orally at induction of anaesthesia 10 9 1 6 11 3
e. asked for by the anaesthetist at/after induction 9 1 1 13 6 7
combinations of d and e 8 1 0 2 0 1
Other combinations 1 2 1 0 0 0
f. unknown 2 2 2 2 4 8
SURG = Surgery, ORTH = Orthopaedic Surgery, ORL = Otorhinolaryngology
indicated also late communication. However, in the 
operating department of otorhinolaryngology (ORL), 
29.5/32 (92% ) of the replies indicated that the drug 
was sent with the patient.
The question on communication between the sur­
geon and the anaesthetist was repeated for emergen­
cy (unscheduled) operations (Table 3). The majority 
of orders was transmitted at earliest at or after induc­
tion of anaesthesia: in this situation not much differ­
ence was observed between the operating depart­
ments.
Contribution to quality
The questions and replies of this part of the question­
naire are presented in Table 4. One fifth of the 
responders would systematically ask the surgeon at
induction about the need for prophylactic antimicro­
bial drugs. Thirty-nine percent assumed that no pro­
phylaxis was necessary if the surgeon did not inform 
them. Nevertheless, more than three quarters would 
ask him if in doubt.
Standardizing measures
Ninety-one percent of the responding anaesthetists 
agreed that written information in the record was 
necessary for the individual patient. Three thought 
that oral information would suffice. Five anaesthetists 
(three staff members, two residents) wrote comments 
on the deficient communication and two suggested 
that the policy of operating department ORL (preop- 
eratively written order) be adopted.
Table 4 Point of view of anaesthetists on contribution to quality and standardizing measures of surgical
prophylaxis
Frequency distribution (%) of replies
Agree Do not agree
If the surgeon does not inform you of the need for perioperative
prophylaxis for a patient, this means that:
You systematically ask the surgeon for it (n=35) 7 (20) 28 (80)
No prophylaxis is necessary (n=28) 11 (39) 17 (61)
You ask the surgeon if you are in doubt (r?=35) 27 (77) 8 (23)
Oral information that is passed from the surgeon to the anaesthetist
regarding perioperative prophylaxis concerning an individual patient is in
your opinion:
Not necessary if written information is available (n=27) 14 (52) 13 (48)
Necessary (n=32) 25 (78) 7 (22)
Written information from the surgeon in the record of the patient
regarding perioperative prophylaxis is in your opinion:
Not necessary because oral information is sufficient (n=27) 3 (11) 24 (89)
Necessary (n= 34) 31 (91) 3 (9)
D iscu ssion
Although anaesthetists play a crucial role in the prac­
tice of antimicrobial drug prophylaxis in surgery in 
most hospitals, they consider it the responsibility of 
the surgeon, and no studies have been performed on 
organizational aspects. The present inquiry informed 
the department of clinical pharmacy about the weak 
points in the organization. The inquiry identified 
operating departments where communication 
between surgeon and anaesthetist on antimicrobial 
drug prophylaxis was good and others where it was 
particularly poor. There was an association between 
the relative frequencies of replies of late' communi­
cation for the operating departments SURG, ORTH 
and ORL in the inquiry, and the delayed administra­
tion (after surgical incision) recorded in those depart­
ments during the quality-of-use study [4].
Furthermore, anaesthetists seemed to play an 
important role in reminding the surgeon of prophy­
laxis, as three quarters stated that they checked it if in 
doubt. However, such reminders occurred late in or 
after induction of anaesthesia, again resulting in a 
delay of prophylaxis.
The variety of replies concerning communication 
of prophylaxis within some operating departments 
probably reflect a diversity of practices due to the 
absence of protocols. In the unit ORL which had a 
standardized policy of sending the prophylactic anti­
biotic with the patient, replies were rather uniform. 
The diversity of practices in the other departments 
was identified as a negative critical factor impeding 
quality. We advocated a hospital-wide uniformity in 
the administration procedure of surgical antimicrobial 
prophylaxis. Almost all anaesthetists had a favourable 
reaction to the policy of pre-operatively written drug 
orders by the surgeon. We subsequently implement­
ed a pre-operative patient checklist that included the 
need for antimicrobial prophylaxis. The inquiry 
informed us that our plans to implement the least 
expensive way of administration of prophylactic anti­
biotics, i.e., bolus injection [6], corresponded with the 
actual practice of the anaesthetists. Although cost fac­
tors were not perceived by the majority of the 
responding anaesthetists, we learned that other 
motives such as practicality made bolus injection 
already the preferred way of administration for pro­
phylactic beta lactams. Concerning gentamicin, there 
was a common but erroneous belief that slow i.v. 
infusion would reduce the risk for toxicity. However, 
gentamicin can be safely injected over 3-5 min [7], 
and, both from a pharmacodynamic and pharmacoki­
netic point of view, there are indications that high 
initial peak concentrations are most effective and not 
associated with higher toxicity [8].
The information provided by this inquiry proved 
useful in an educational setting during the implemen­
tation of new guidelines [5]. Antibiotic committees, 
consisting of consultant microbiologists, clinical phar­
macists, infectious disease physicians and clinicians 
should involve anaesthetists in new strategies to 
improve surgical prophylaxis.
1 Hekster YA, Barrett CW. Formulary antibiotic surveillance pro­
gram. J Pharm Clin 1 987;6:335-42.
2 Classen DC, Evans RS, Pestotnik SL, Horn SD, Menlove RL, 
Burke JP. The timing of prophylactic administration of antibi­
otics and the risk of surgical-wound infection. N Engl j Med 
1992;326:281-6.
3 Abramowicz M. Antimicrobial prophylaxis in surgery. Med 
Letter 1 989;31 (806):105-8.
4 Gyssens IC, Geerligs IE), Nannini-Bergman MG, Knape JTA, 
Hekster YA, Van der Meer JWM. Optimising the timing of 
antimicrobial drug prophylaxis in surgery: an intervention 
study. J Antimicrob Chemother 1 996;38:301 -8.
5 Gyssens IC, Geerligs IEJ, Dony JMJ, Van der Vliet )A, Van 
Kampen A, Van den Broek Pj, Hekster YA, Van der Meer ]WM. 
Optimising the quality of antimicrobial drug use in surgery: 
an intervention study, j Antimicrob Chemother 1996, in 
press.
6 Gyssens IC, Lennards CA, Hekster YA, Van der Meer JWM. The 
cost of antimicrobial chemotherapy. A method for cost evalu­
ation. Pharm Weekbl [Sci] 1991 ;1 3(6):248-53.
7 Mendelson J, Portnoy J, Dick V, Black M. Safety of the bolus 
administration of gentamicin. Antimicrob Agents Chemother 
1976; 9:633-8.
8 Gilbert DN. Once-daily aminoglycoside therapy. Antimicrob 
Agents Chemother 1991;35:399-405.
A ck n ow led gem en ts
We thank Ruurd de Graaf, Dept, of Medical Statistics, 
University of Nijmegen, for his help with the analysis 
of the data.


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