Supplements
Supplementary Methods.Monitoring the appropriateness of surgical prophylactic antibiotics.
Supplementary Figure 1. Number of isolates tested for in vitro susceptibility.
Supplementary Figure2. Trends of antibiotic use in departments not targeted by surgical prophylaxis monitoring.
Supplementary Figure 3. Trends of in-hospital mortality.
Supplementary Table 1.Performance indicators of surgical prophylactic antibiotics per type of surgery.
Supplementary Table 2.Changing trends of antibiotic use in departments not targeted by surgical prophylaxis monitoring compared to the preintervention period.
Supplementary Table 3. Changing trends of antimicrobial resistance rates in microorganisms isolated in the hospital.
Supplementary Table 4. Changing trends of antibiotic costin USD.
Supplementary Methods
Monitoring the appropriateness of surgical prophylactic antibiotics.
The surgical procedures included in the program were coronary artery bypass, valvuloplasty, artificial heart valve replacement, artificial hip and knee replacement, gastrectomy, colectomy, rectosigmoidectomy, laparoscopic cholecystectomy, cesarean section, and hysterectomy. Measured performance indicators included timing of antibiotic administration, selection of appropriate regimen, and duration of antibiotic prophylaxis.Electronic medical records of the patients who underwent targeted surgeries in designated months of the year (usually 3 months) were reviewed for the evaluation of the performance indicators. Administration of prophylactic antibiotics within 1 hr prior to skin incision was considered appropriate. In knee arthroplasty, antibiotics were required to be administered before the inflation of tourniquet. Use of aminoglycosides, 3rd/4th generation cephalosporins, and use of more than one antimicrobial agent were considered inappropriate. Co-administration of 1st-generation cephalosporin and metronidazole was allowed in colorectal surgeries. Proportion of the patients with antibiotics in discharge medication and total duration (days) of prophylactic antibiotics were also measured. Exclusion criteria included pediatric patients, transferred patients, emergency operation, surgery due to trauma, concomitant surgeries in different fields, presence of fever within 24 hr before and 3 days after surgery, and presence of infection during admission.
Supplementary Figure 1. Number of isolates tested for in vitro susceptibility.
Supplementary Figure 2. Trends of antibiotic use in departments not targeted by surgical prophylaxis monitoring. (A) Total antimicrobial agents. (B) 3rd generation cephalosporins. (C) Aminoglycoside. (D) Vancomycin. Dashed line, actual administration; solid line, fitted regression line. Shade denotes surgical prophylactic antibiotics monitoring (SPA) period. p values, compared to preintervention slope.
Supplementary Figure 3. Trends of in-house mortality.
Supplementary Table 1. Performance indicators of surgical prophylactic antibiotics per type of surgery (%).
Type of surgery / Overall / Inappropriate selection of SPA / Prescription of antibiotics as discharge medication2007 / 2008 / 2009 / 2010 / 2007 / 2008 / 2009 / 2010 / 2007 / 2008 / 2009 / 2010
Gastric / 100 / 99.6 / 98.9 / 99.6 / 0 / 0 / 0 / 0 / 0 / 1.8 / 0 / 0
Colorectal / 100 / 100 / 99.3 / 100 / 0 / 0 / 1.9 / 0 / 0 / 0 / 1.9 / 0
Gallbladder / 100 / 100 / 100 / 100 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0
Cardiac / 100 / 99.4 / 99.7 / 99.7 / 0 / 0 / 0 / 0 / 0 / 2.4 / 0 / 0
Obstetric / 100 / 99.8 / 100 / 100 / 0 / 1.9 / 0 / 0 / 0 / 0 / 0 / 0
Gynecologic / 100 / 99.1 / 100 / 99.8 / 0 / 0 / 0 / 0 / 0 / 3.4 / 0 / 0
Knee / 77.4 / 99.1 / 100 / 100 / 0 / 3.4 / 0 / 0 / 89.8 / 1.8 / 0 / 0
Hip / 77.4 / 99.1 / 100 / 100 / 0 / 1.9 / 0 / 0 / 95.3 / 2.0 / 0 / 0
Supplementary Table 2. Changing trends of antibiotic use in departments not targeted by surgical prophylaxis monitoring compared to the preintervention period.
Antibiotic class / SPA Period / CDSS PeriodImmediate change / Change in slope / Change in slope
Mean / LCI / UCI / P / Mean / LCI / UCI / P / Mean / LCI / UCI / P
Total / 12.56 / -17.10 / 42.21 / 0.69 / -6.10 / -9.73 / -2.47 / <0.01 / -1.50 / -3.10 / 0.10 / 0.08
3rd generation cephalosporin / -4.36 / -15.09 / 6.36 / 0.73 / -1.36 / -2.68 / -0.05 / 0.05 / -0.45 / -0.97 / 0.08 / 0.12
4th generation cephalosporin / -15.22 / -31.40 / 0.97 / 0.08 / -0.95 / -3.06 / 1.16 / 0.63 / -0.54 / -1.63 / 0.54 / 0.53
Aminoglycoside / 3.36 / 0.38 / 6.35 / 0.03 / -0.28 / -0.65 / 0.09 / 0.19 / 0.19 / 0.04 / 0.33 / 0.01
Antipseudomonal penicillin / 8.25 / 3.45 / 13.05 / <0.01 / 0.28 / -0.31 / 0.87 / 0.58 / -0.18 / -0.44 / 0.07 / 0.23
Quinolone / 0.36 / -9.64 / 10.37 / >0.99 / 1.17 / -0.16 / 2.49 / 0.11 / 0.03 / -0.64 / 0.70 / >0.99
Carbapenem / 5.98 / -3.02 / 14.97 / 0.28 / -2.04 / -3.19 / -0.89 / <0.01 / -0.05 / -0.61 / 0.52 / >0.99
Vancomycin / 7.15 / 2.55 / 11.74 / <0.01 / -1.23 / -1.78 / -0.67 / <0.01 / 0.10 / -0.11 / 0.31 / 0.60
SPA, surgical prophylactic antibiotics monitoring. CDSS, computerized decision support system. LCI, lower confidence interval. UCI, upper confidence interval.
Supplementary Table 3. Changing trends of antimicrobial resistance rates in microorganisms isolated in the hospital
Resistant Pathogens / SPA Period / CDSS Period*Slope (95% CI) / P / Slope (95% CI) / P
ESBL-producing E. coli / -0.07 (-0.84 - 0.70) / 0.86 / -0.49 (-0.83 - -0.16) / 0.01
Cefepime-resistant P. aeruginosa / 2.24 (1.26 – 3.21) / < 0.01 / 0.23 (-0.20 – 0.67) / 0.29
Meropenem-resistant P. aeruginosa / 0.77 (0.19 – 1.35) / 0.01 / -0.63 (-0.90 - -0.37) / < 0.01
Amikacin-resistant K. pneumoniae / -1.77 (-3.75 – 0.21) / 0.09 / -0.89 (-1.80 – 0.03) / 0.06
Quinolone-resistant E. coli and
K. pneumoniae / -1.07 (-2.96 – 0.82) / 0.27 / -0.49 (-1.36 – 0.38) / 0.28
MRSA / 0.03 (-0.77 – 0.82) / 0.95 / -0.42 (-0.78 - -0.06) / 0.03
VRE / 0.33 (-1.11 – 1.77) / 0.66 / 0.18 (-0.34 – 0.71) / 0.49
SPA, surgical prophylactic antibiotics monitoring. CDSS, computerized decision support system. ESBL, extended-spectrum beta-lactamase. MRSA, methicillin-resistant S. aureus. VRE, vancomycin-resistant enterococci.
*Compared with trends during the preintervention period
Supplementary Table 4. Changing trends of antibiotic costin USD
Antibiotic class / SPA Period / CDSS Period*Slope (95% CI) / P / Slope (95% CI) / P
Total / -171.37 (-311.83 - -30.90) / 0.01 / -7.32 (-59.72 – 45.08) / > 0.99
Cephalosporins / -79.54 (-156.52 - -2.55) / 0.05 / -26.25 (-60.93 – 8.44) / 0.31
Carbapenems / -78.98 (-145.21 - -12.75) / 0.02 / 2.07 (-27.60 – 31.75) / > 0.99
Penicillins / 11.03 (-14.98 – 37.04) / > 0.99 / -7.75 (-18.80 – 3.30) / 0.42
Quinolones / -7.63 (-39.17 – 23.91) / > 0.99 / 0.23 (-15.65 – 16.11) / > 0.99
Vancomycin / -12.85 (-37.46 – 11.76) / > 0.99 / 15.64 (5.38 – 25.90) / <0.01
SPA, surgical prophylactic antibiotics monitoring. CDSS, computerized decision support system.
*Compared with trend in preintervention period