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TECHNICAL REPORTSystematic review and evidence-based guidance on perioperative antibiotic prophylaxisTable 20. Results of the experts’ re-scoring by email of 10 PAP modalities prior to the second expertmeetingPAP modality Author and design of study Quality ofevidenceaccording tothe GRADEapproach*[24,25]Expertgrading onstrength ofevidence;median(range)Expert grading ofimplementability;median (range)1 A multidisciplinary AMteam (includingsurgeons,anaesthesiologists,nurses, pharmacists,infection controlspecialists, and clinicalmicrobiologists) shoulddevelop and implementa protocol ofappropriate PAP.Forbes 2008, non-CBAVan Kasteren 2005, non-CBAWeinberg 2001, ITSHedrick 2007, non-CBALiau 2010, non-CBAPastor 2009, non-CBAPons-Busom et al. 2004, non-CBASun 2009, non-CBAThompson 2011, non-CBATrussell 2001, non-CBAWebb 2006, non-CBAWhite 2007, non-CBAYoung 2011, non-CBAZvonar 2008, non-CBA2 A multidisciplinary AM Gomez 2006, non-CBAteam should regularly Geubels 2004, non-CBAupdate the PAP protocol Pons-Busom et al. 2004, non-CBAaccording to standard,approved guidelines.3 To control the Kritchevsky, RCTappropriate selection of Forbes 2008, non-CBAantibiotics, as well as Van Kasteren 2005, non-CBAtiming and duration of Weinberg 2001, ITS studyprophylaxis, a Hedrick 2007, non-CBAmultidisciplinary AM Liau 2010, non-CBAteam should perform an Pastor 2009, non-CBAaudit of surgeons, Thompson 2011, non-CBAanaesthesiologists and Trussell 2001, non-CBAOR nursing staff and Webb 2006, non-CBAprovide, if necessary, White 2007, non-CBAstructured feedback and Young 2011, non-CBAeducation to healthcarestaff and decisionmakers.4 In order to encourage De Vries 2010, CBAappropriate duration Forbes 2008, non-CBAand dosage of PAP, a Van Kasteren 2005, non-CBAcomputer-assisted Weinberg 2001, ITS studydecision support system Hedrick 2007, non-CBAand automatic reminder Larochelle 2011, non-CBAsystem should be Liau 2010, non-CBAimplemented.Pastor 2009, non-CBAThompson, 2011, non-CBATrussell 2001, non-CBAWebb 2006, non-CBAWhite 2007, non-CBAYoung 2011, non-CBA5 PAP should be theresponsibility of theanaesthesiologist.Kanter 2008, non-CBATrussell 2001, non-CBAWebb 2006, non-CBAZvonar 2008, non-CBA6 PAP should be Mannien 2006, non-CBAadministered within 30– Van Kasteren 2005, non-CBA60 minutes before Weinberg 2001, ITS studyincision (except for Witt 2011, double-blinded RCTvancomycin and Liau 2010, non-CBAfluoroquinolones), Young 2011, non-CBAideally at the time ofanaesthetic induction.3332222222222232243332222222233332222222222222333322(1=stronglydisagree to6=strongly agree)6 (5-6) 6 (4-6)5 (4-6) 6 (4-6)6 (3-6) 6 (3-6)4 (3-6) 4 (3-6)5 (3-6) 5 (3-6)6 (4-6) 6 (4-6)(1=strongly discouragedto 6=implementationstrongly recommend )29
Systematic review and evidence-based guidance on perioperative antibiotic prophylaxisTECHNICAL REPORTPAP modality Author and design of study Quality ofevidenceaccording tothe GRADEapproach*[24,25]Expertgrading onstrength ofevidence;median(range)Expert grading ofimplementability;median (range)7 Although a single doseof PAP is preferred,subsequent dosesshould be givendepending on theduration of theprocedure and the halflifeof the antibiotic,and if significant bloodloss occurs duringsurgery.8 Prolonging prophylaxisafter the end of surgeryis not recommended.9 The PAP protocolshould take intoaccount individualpatient factors like BMI,underlying diseases, orcolonisation withresistant pathogens.Zani 2011, systematic reviewMcDonald 1998, systematic reviewGillespie 2010, Cochrane systematic reviewMeijer 1990, systematic reviewNelson 2009, Cochrane systematic reviewSlobogean 2008, systematic reviewSouthwell-Keely 2004, systematic reviewZannetti 2003, RCTZani 2011, Cochrane systematic reviewGillespie 2010, Cochrane systematic reviewNelson et al. 2009, Cochrane systematic reviewSouthwell-Keely 2004, systematic reviewDhadwal 2007, double blind RCTNúnez-Pererira 2011, non-CBAGarey 2008, ITS studyKato 2007, non-CBAWagner 2011, non-CBALinam 2010, case-control studySchelenz 2005, non-CBASharma 2009, non-CBA10 In surgicalItani et al. 2008, RCTdepartments, patterns Carignan 2008, retrospective cohort studyof MDROs and Kato et al. 2007, non-CBAincidence of Clostridiumdifficile infectionsshould be monitoredproactively so PAP canbe appropriatelyadjusted.43333333433343222211432(1=stronglydisagree to6=strongly agree)6 (4-6) 6 (4-6)6 (2-6) 6 (2-6)5 (2-6) 6 (5-6)4 (3-6) 5 (2-6)(1=strongly discouragedto 6=implementationstrongly recommend )* Quality of evidence according to the GRADE approach [24,25]: 4=high quality, 3=moderate quality, 2=low quality, 1=very lowqualityDefining EU-wide applicability/implementability and addressing barriersIn order to facilitate the discussion and the ranking it was necessary to define terms such as ‘EU-wide applicability’and ‘EU-wide implementability’. The experts were asked to identify key components of these terms so that theycould be easily understood and their ranking and consensus transparent and homogeneous. Components such asfinancial resources, educational aspects, staff resources, cultural issues and hierarchical aspects were some of theidentified topics. While discussing these components, the expert also identified several barriers to EU-wideapplicability and implementability. It was decided to draw a list of potential barriers for each PAP modality, basedon a short literature review and expert input. These barriers were expected to be different in each country,depending on socio-economic and political factors, but the identification of such barriers could be used to fine-tunethe implementation details for the PAP modalities.Final five key modalitiesDuring this second expert meeting, each modality was discussed separately and either rejected, included, orcombined with another modality. The final five key PAP modalities are listed in Table 21.30
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