Application of antimicrobial prophylaxis and discontinuing antimicrobial after operation in clean surgeries can be cost saving and prevent surgical site infections in a country with limited resources?

Background: Continuing use of antimicrobial (AMB) after operation is found in most of operations in Viet nam. In almost hospitals, about 96.7% operation patients receive AMB as therapy for an average of 6.5 days after operations with little compliance to published AMB guidelines.

Objective: Evaluate the incidence of surgical site infections (SSIs) in clean operations that were given AMB as prophylaxis without continuing AMB after operations and estimate the cost saving in these patients.

Methods: Prospective, cohort study conducted from from Feb 2009 to May 2009 at Cho Ray hospital, a tertiary hospital of Vietnam. Cost analysis was based on data derived from financial records. Cost saving were evaluated by comparing with the control patients who match with age, sex, operation classification but were given AMB as therapy.

Results: Nighty eight selected surgical patients who have not been operated before admitting and classified as clean wound were included in the study. Their mean age was 43.1 (SD 17.9) years (range, 2 to 84 years), and 36 (44.4%) were male. Specific underlying conditions were recorded in 11 patients (13.1%), and included cancer (n=2), liver or kidney disease (n =1), hypertension (n=6), cardiac diseases (n=2), under steroid (n=1). Seven (8.3%) of the patients were admitted for trauma-related injuries. The median ASA score of the patients was 1. AMB were given 30 minutes before operation, repeated one further dose if operation duration exceed 3 hours. The AMB chosen was Ampicilline/Sulbactam or Amoxicillin/ Acid Clavuanic for general surgery and vascular surgery, Cephalosporin third generation for neurosurgery, urology and orthopedics.One patients had superficial incisional SSI, the SSI incidence rate thus was 1.0%. The mean (SD) cost for patients using AMB as prophylaxis were $247(32), the mean (SD) cost for patients continuing AMB long after operation were $425(48), thus the cost saving was $178 per case.

Conclusions: Almost surgeons in Vietnam believe that AMB use as prophylaxis were not appropriate to their patients due to the unsafe hospital environment and limited resources in patient care and infection control. As a consequence, surgeons tend to prescribe widespread AMB long after operations with the hope that this can reduce SSIs.  However, this study confirm that continuing AMB after clean surgeries is ineffective in reducing SSI and cost saving. The incidence of SSIs in this study is 1%, even much lower than the incidence of SSIs reported in the annual surveys of this hospital which range from 2.8 to 3.4% in 2009. Further studies to improve the prescription of AMB in surgical patients in this setting are necessary.