One of the most frequent questions people ask me is about when to use antibiotic prophylaxis in performing foot and ankle surgery. I have an entire lecture on this topic. In this lecture, I go through the data, or lack thereof, on the subject and enumerate the clinical situations (i.e. surgery longer than two hours, trauma surgery, immunocompromised hosts, etc.) in which surgeons have traditionally utilized prophylaxis.
More and more, the question posed to me has become: “Warren, my hospital requires me to use prophylactic antibiotics even when I don’t feel they are necessary. They have actually threatened to take away my surgical privileges if I don’t use them. What can I do about that?” Unfortunately, the answer is … not much.
Why is this happening? What has changed? In my opinion, there are two main reasons we have come to be in this situation: The Surgical Care Improvement Project (SCIP) and changes in Centers for Medicare and Medicaid Services (CMS) guidelines that will not reimburse a hospital for a re-admission for a nosocomial infection.1
The CMS change is fairly self explanatory. Hospitals do not get paid if they readmit a patient with a diagnosis of a nosocomial postoperative infection. Therefore, hospitals need to try everything in their power to prove that any infection that does occur is not their fault and the hospital did everything possible to prevent that infection. Chief amongst these is giving prophylactic antibiotics to everyone undergoing surgery. Then when the patient gets infected, the hospital can always claim that the infection was community-acquired and not nosocomial.
The SCIP may not be as well known by the average lower extremity surgeon and is a bit more complicated. Back in 2005, a national initiative developed to attempt to reduce postoperative complication rates by 25 percent in a five-year period. This initiative developed a set of 20 measures. Four of these measures are directly relatable to lower extremity work. These include:
INF-1: Patients need to receive prophylactic antibiotics within one hour prior to surgical incision or two hours if using vancomycin.
INF-2: Patients receive the prophylactic antibiotics recommended for their specific surgical procedure.
INF-3: Discontinue patients’ prophylactic antibiotics within 24 hours after the surgical end time.
INF-6: Surgery patients should have appropriate hair removal with a clippers or depilatory, if at all (no razors).
I think that all readers would agree that this is a lofty and worthy goal. The program is “voluntary” although CMS reduces hospital reimbursement by 2 percent if hospitals fail to report performance on the various measures. It is probably for this reason that the participation rate is around 95 percent of all hospitals.
Now the bad news: the SCIP may not be working.
Stulberg and colleagues published a retrospective cohort analysis of over 400,000 patient discharges between 2006 and 2008.2 They found that when the measures were taken all together in an “all or none” infection prevention score, there was a lower probability of developing a postoperative infection. However, adherence to any individual measure (such as the use of prophylactic antibiotics) was not associated with a significantly lower probability of infection.
There are some other interesting tidbits to take away from this study. The category of “neck, back or extremity surgery” presented with the overall lowest rate of postoperative infection at only 0.19 percent.2 Also, in fairness, although not reaching a level of statistical significance, the use of prophylaxis did decrease the overall risk of infection from 21.0 to 7.5 per 1,000 discharges (unfortunately, the study did not break this out by procedure type). I would also point out that the SCIP protocols do not demand all patients receive antibiotics, just that one provide the “recommended” antibiotic, according to nationally accepted guidelines. Somehow this seems to have morphed into a requirement to administer antibiotics.
So what does this all mean to the lower extremity surgeon? The risk of infection for our surgery remains very low, somewhere probably well below 1.0 percent. In the largest study of its type, Zgonis and colleagues retrospectively looked at charts from 555 patients undergoing elective foot and ankle surgery.3 They found no statistically significant difference in the infection rate in the group that received prophylaxis versus those who did not. The bottom line is that prophylactic antibiotic use is probably not medically necessary in these patients.
Unfortunately, unless you are ready to really “battle city hall,” from a practical standpoint, you are going to continue to be coerced into using antibiotics you suspect are not beneficial.
I find this all rather ironic. In an environment where hospitals are being required to have antimicrobial stewardship programs to effectively decrease antibiotic usage (at the risk of the same possible decrease in reimbursement), those same administrations are telling physicians that they need to use antibiotics that are probably not necessary.
Editor’s note: This blog was originally published at http://www.leinfections.com/antibiotics/scip-surgical-prophylaxis/  and has been adapted with permission from Warren Joseph, DPM, FIDSA, and Data Trace Publishing Company. For more information about the Handbook of Lower Extremity Infections, visit www.leinfections.com/  .
1. Available at http://www.jointcommission.org/surgical_care_improvement_project/  .
2. Stulberg JJ, Delaney CP, Neuhauser DV, Aron DC, Fu P, Koroukian SM. Adherence to surgical care improvement project measures and the association with postoperative infections. J Am Med Assoc. 2010; 303(24):2479-85.
3. Zgonis T, Jolly GP, Garbalosa JC. The efficacy of prophylactic intravenous antibiotics in elective foot and ankle surgery. J Foot Ankle Surg. 2004; 43(2):97-103.