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Klin Padiatr 2016; 228(03): 139-144
DOI: 10.1055/s-0042-104415
Original Article
© Georg Thieme Verlag KG Stuttgart · New York

Clinical Practice Audit: Perioperative Antibiotic Prophylaxis in Paediatric Cancer Patients with Broviac Catheter Implantation

Audit zur klinischen Praxis: Antibiotische Prophylaxe bei kinderonkologischen Patienten zum Zeitpunkt der Broviac-Katheter Implantation
K. Weiss
1   Paediatric Hematology and Oncology, Children’s Hospital Medical Center, Homburg, Germany
,
A. Simon
1   Paediatric Hematology and Oncology, Children’s Hospital Medical Center, Homburg, Germany
,
N. Graf
1   Paediatric Hematology and Oncology, Children’s Hospital Medical Center, Homburg, Germany
,
J. Schöpe
2   Institute for Medical Biometry, Epidemiology and Medical Informatics, Univeristy Hospital Saarland, Homburg, Germany
,
C. M. Meier
3   Pediatric Surgery, Medical School of the Saarland University, Homburg, Germany
› Author Affiliations
Further Information

Publication History

Publication Date:
20 April 2016 (online)

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Abstract

Background: Perioperative antimicrobial prophylaxis (PAP) is an important target for internal audits, concerning the judicious use of antibiotics. Paediatric oncology patients face an increased risk of surgical site infection (SSI) after implantation of long term central venous catheters (CVAD).

Patients: All Patients<18 years admitted to the paediatric oncology centre (POC) with implantation of a CVAD.

Methods: Systematic audit in 2 groups: retrospective (Jan 01, 2012 – March 31, 2014) and prospective (April 01, 2014 – March 31, 2015) referring to an internal PAP guideline, invented in Jan 2014. Surveillance of SSI up to 30 days after the operation.

Results: In total, 97 CVAD implantations were analysed in 89 paediatric oncology patients (Broviac in 94%). The detailed analysis of PAP revealed lower Cefuroxim doses than requested (30 vs. 50 mg/kg). In addition, Cefotaxim was used in 1 case and in 3 cases Clindamycin was given without a medical history of Penicillin hypersensitivity. In the retrospective audit group PAP was administered in 22% for≤24 h); this was the case in 91% of the prospective group (p<0.001). No SSI was detected.

Conclusion: This first comprehensive audit of PAP in a German POC outlines significant opportunities for improvement in terms of correct dosing, correct choice of the antibiotic, and shorter duration of PAP. In addition our results illustrate the challenges of optimising standard workflows in clinical practice.

Zusammenfassung

Hintergrund: Die perioperative Antibiotikaprophylaxe (PAP) ist ein Ansatzpunkt für die Verbesserung des rationalen Antibiotikaeinsatzes in der klinischen Praxis durch interne Audits. Kinderonkologische Patienten haben ein erhöhtes Risiko für postoperative Wundinfektionen (surgical site infection, SSI).

Patienten: Alle≤18 Jahre alten Patienten eines kinderonkologischen Zentrums mit Broviac oder Port Implantation (durch die Kinderchirurgie).

Methoden: Systematisches Audit in zwei Gruppen: retrospektiv (1. Jan 2012 – 31. März 2014) und prospektiv (01. April 2014 – 31. März 2015). Bezug nehmend auf einen internen Standard zur PAP, der im Januar 2014 vereinbart wurde. Surveillance von SSI in den ersten 30 Tagen nach der Operation.

Ergebnisse: Insgesamt wurden 97 CVAD Implantationen bei 89 kinderonkologischen Patienten analysiert (94% Broviac). Die detaillierte Analyse der PAP ergab zu niedrige Dosierungen (Cefuroxim 30 statt 50 mg/kg). In einem Fall wurde Cefotaxim zur PAP gegeben. In 3 Fällen wurde Clindamycin ohne anamnestische Hinweise auf eine Penicillinallergie verabreicht. Während in der retrospektiv auditierten Gruppe die PAP in 22% der Fälle nach 24 Stunden beendet wurde, lag dieser Anteil in der prospektiv auditierten Gruppe bei 91% (p<0,001). Bei keinem Patienten wurde eine SSI diagnostiziert.

Schlussfolgerung: Dieses erste umfassende Audit der PAP bei kinderonkologischen Patienten bei Implantation eines Broviac oder Port Katheters zeigt wichtige Ansatzpunkte für eine Verbesserung der klinischen Praxis (korrekte Dosierung, Verzicht auf Cefotaxim oder Clindamycin und kürzere Gesamtdauer). Außerdem zeigt die Analyse organisatorische Herausforderungen bei Änderung interdisziplinärer Arbeitsabläufe.

Key words

paediatric oncology - broviac - port - antimicrobial prophylaxis - quality improvement in health care

Schlüsselwörter

Kinderonkologie - Broviac - Port - perioperative Antibiotikaprophylaxe - Qualitätsverbesserung im Gesundheitswesen
 

  • References

  • 1 Bratzler DW, Dellinger EP, Olsen KM et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm 2013; 70: 195-283
    CrossrefPubMedGoogle Scholar
  • 2 Cabana MD, Rand CS, Powe NR et al. Why don’t physicians follow clinical practice guidelines? A framework for improvement. JAMA 1999; 282: 1458-1465
    CrossrefPubMedGoogle Scholar
  • 3 Carr E, Jayabose S, Stringel G et al. The safety of central line placement prior to treatment of pediatric acute lymphoblastic leukemia. Pediatr Blood Cancer 2006; 47: 886-888
    CrossrefPubMedGoogle Scholar
  • 4 Charani E, Castro-Sanchez E, Sevdalis N et al. Understanding the determinants of antimicrobial prescribing within hospitals: the role of “prescribing etiquette”. Clin Infect Dis 2013; 57: 188-196
    CrossrefPubMedGoogle Scholar
  • 5 Ciofi Degli Atti M, Spila Alegiani S, Raschetti R et al. Surgical antibiotic prophylaxis in children: adherence to indication, choice of agent, timing, and duration. Eur J Clin Pharmacol 2015; 71: 483-488
    CrossrefPubMedGoogle Scholar
  • 6 Ciofi Degli Atti ML, Raponi M, Tozzi AE et al. Point prevalence study of antibiotic use in a paediatric hospital in Italy. Euro Surveill. 2008; 13
    PubMedGoogle Scholar
  • 7 Furtwangler R, Laux C, Graf N et al. Impact of a modified Broviac maintenance care bundle on bloodstream infections in paediatric cancer patients. GMS hygiene and infection control 2015; 10 Doc15
    PubMedGoogle Scholar
  • 8 Gerber JS, Kronman MP, Ross RK et al. Identifying Targets for Antimicrobial Stewardship in Children’s Hospitals. Infect Control Hosp Epidemiol 2013; 34: 1252-1258
    CrossrefPubMedGoogle Scholar
  • 9 Gonzalez G, Davidoff AM, Howard SC et al. Safety of central venous catheter placement at diagnosis of acute lymphoblastic leukemia in children. Pediatr Blood Cancer 2012; 58: 498-502
    CrossrefPubMedGoogle Scholar
  • 10 Gurses AP, Marsteller JA, Ozok AA et al. Using an interdisciplinary approach to identify factors that affect clinicians’ compliance with evidence-based guidelines. Crit Care Med 2010; 38: S282-S291
    CrossrefPubMedGoogle Scholar
  • 11 Handrup MM, Moller JK, Frydenberg M et al. Placing of tunneled central venous catheters prior to induction chemotherapy in children with acute lymphoblastic leukemia. Pediatr Blood Cancer 2010; 55: 309-313
    CrossrefPubMedGoogle Scholar
  • 12 Hawkins RB, Levy SM, Senter CE et al. Beyond surgical care improvement program compliance: antibiotic prophylaxis implementation gaps. Am J Surg 2013; 206: 451-456
    CrossrefPubMedGoogle Scholar
  • 13 Hing WC, Yeoh TT, Yeoh SF et al. An evaluation of antimicrobial prophylaxis in paediatric surgery and its financial implication. J Clin Pharm Ther 2005; 30: 371-381
    CrossrefPubMedGoogle Scholar
  • 14 Junqueira BL, Connolly B, Abla O et al. Severe neutropenia at time of port insertion is not a risk factor for catheter-associated infections in children with acute lymphoblastic leukemia. Cancer 2010; 116: 4368-4375
    CrossrefPubMedGoogle Scholar
  • 15 Kim CS, Spahlinger DA, Kin JM et al. Lean health care: what can hospitals learn from a world-class automaker?. J Hosp Med 2006; 1: 191-199
    CrossrefPubMedGoogle Scholar
  • 16 Klinger G, Carmeli I, Feigin E et al. Compliance with Surgical Antibiotic Prophylaxis Guidelines in Pediatric Surgery. Eur J Pediatr Surg 2015; 25: 199-202
    Article in Thieme ConnectPubMedGoogle Scholar
  • 17 Kronman MP, Hersh AL, Gerber JS et al. Identifying Antimicrobial Stewardship Targets for Pediatric Surgical Patients. J Pediatric Infect Dis Soc 2015; in press
    PubMedGoogle Scholar
  • 18 McLean TW, Fisher CJ, Snively BM et al. Central venous lines in children with lesser risk acute lymphoblastic leukemia: optimal type and timing of placement. J Clin Oncol 2005; 23: 3024-3029
    CrossrefPubMedGoogle Scholar
  • 19 Penel N, Neu JC, Clisant S et al. Risk factors for early catheter-related infections in cancer patients. Cancer 2007; 110: 1586-1592
    CrossrefPubMedGoogle Scholar
  • 20 Pichichero ME. Use of selected cephalosporins in penicillin-allergic patients: a paradigm shift. Diagn Microbiol Infect Dis 2007; 57: 13S-18S
    CrossrefPubMedGoogle Scholar
  • 21 Pronovost P, Weast B, Rosenstein BJ et al. Implementing and Validating a Comprehensive Unit-based Safety Program. J Patient Safety 2005; 1: 33-40
    CrossrefPubMedGoogle Scholar
  • 22 Rangel SJ, Fung M, Graham DA et al. Recent trends in the use of antibiotic prophylaxis in pediatric surgery. J Pediatr Surg 2011; 46: 366-371
    CrossrefPubMedGoogle Scholar
  • 23 Robert Koch-Institut. Bekanntmachung des Robert Koch-Institutes: Surveillance nosokomialer Infektionen sowie die Erfassung von Krankheitserregern mit speziellen Resistenzen und Multiresistenzen. Fortschreibung der Liste der gemäß §+4 Abs. 2 Nr. 2 Buchstabe b in Verbindung mit §+23 Abs. 4 IfSG zu erfassenden nosokomialen Infektionen und Krankheitserreger mit speziellen Resistenzen und Multiresistenzen. Bundesgesundheitsblatt – Gesundheitsforschung - Gesundheitsschutz 2013; 56: 580-583
    PubMedGoogle Scholar
  • 24 Scottish Intercollegiate Guidelines Network. Antibiotic prophylaxis in surgery – SIGN 104 – A national clinical guideline. 2014 July 2008, updated April 2014
    PubMedGoogle Scholar
  • 25 Simon A, Beutel K, Trautmann M et al. Evidenzbasierte Empfehlungen zur Anwendung dauerhaft implantierter, zentralvenöser Zugänge in der pädiatrischen Onkologie. mhp Verlag; Wiesbaden: 2013. Vierte überarbeitete Auflage
    Google Scholar
  • 26 Simon A, Graf N, Furtwangler R. Results of a Multicentre Survey Evaluating Clinical Practice of Port and Broviac Management in Paediatric Oncology. Klin Padiatr 2013; 225: 145-151
    Article in Thieme ConnectPubMedGoogle Scholar
  • 27 Singer SJ, Falwell A, Gaba DM et al. Identifying organizational cultures that promote patient safety. Health care management review 2009; 34: 300-311
    CrossrefPubMedGoogle Scholar
  • 28 Taylor HA, Pronovost PJ, Faden RR et al. The ethical review of health care quality improvement initiatives: findings from the field. Issue Brief (Commonw Fund) 2010; 95: 1-12
    PubMedGoogle Scholar
  • 29 van de Wetering MD, van Woensel JB. Prophylactic antibiotics for preventing early central venous catheter Gram positive infections in oncology patients. Cochrane Database Syst Rev 2007; DOI: 10.1002/14651858.CD003295.pub2. [doi]: CD003295
    PubMedGoogle Scholar
  • 30 Versporten A, Sharland M, Bielicki J et al. The antibiotic resistance and prescribing in European Children project: a neonatal and pediatric antimicrobial web-based point prevalence survey in 73 hospitals worldwide. Pediatr Infect Dis J 2013; 32: e242-e253
    CrossrefPubMedGoogle Scholar