The author of this article: Yi Su
In 2015, the National Health Commission issued the “Guidelines for the Clinical Application of Antibacterial Drugs”, which pointed out that the preventive medication time for clean surgery should not exceed 24 hours; excessively extending the medication time cannot further improve the Prophylactic effect, and the prophylactic treatment time exceeds 48 hours, the chance of drug-resistant bacterial infection increases.
Image source: “Guidelines for Clinical Application of Antibacterial Drugs (2015)”
However, according to a survey by the Lilac Garden Forum, only 60 percent of physicians stop antibiotics within 24 hours of surgery for Class I incisions.
Data source: Lilac Garden Forum
In the face of the general consensus at home and abroad and a large amount of evidence-based evidence, some doctors said: I “don’t dare” to stop antibiotics 24 hours after surgery.
From abuse to strict control
Antibiotics are a large class of drugs with a wide range of clinical applications. Since the clinical application of antimicrobial drugs, countless patients’ lives have been cured and saved. However, with the continuous expansion of clinical applications, bacterial resistance caused by the abuse of antibiotics has become a global public health problem.
In 2011, the World Health Organization issued a call to set the theme for World Health Day as “Controlling bacterial resistance, no action today, no medicine tomorrow.”
“There is indeed an abuse of antibiotics in our country, but with the control in recent years, this situation has improved significantly.” said Dr. Ding Liucheng, a urologist at the Second Affiliated Hospital of Nanjing Medical University. , The hospital where he works now has antibiotic management regulations, which are controlled by strict quality control departments. When it comes to medication adjustment, not only the pharmacy department should be asked to provide medication guidance, but also the results of drug sensitivity training.
Dr. Liu Dongsheng from the General Surgery Department of a tertiary hospital also pointed out, “The state stipulates that the proportion of antibiotics used for prevention of Class I incision surgery cannot exceed 30%, so our hospital is also very strict about this. Prolonged antibiotic use is also rare.”
In April 2021, the National Health and Medical Commission issued the “Notice on Further Strengthening the Management of Antimicrobial Drugs to Contain Drug Resistance”, requiring the rational use of antimicrobial drugs to be included in hospital review, public hospital performance Assessment, rational drug use assessment and other work, and appropriately increase the assessment weight. At the same time, it is required that by the end of September 2021, all general hospitals above the second level should join the national antibacterial drug clinical application monitoring network and bacterial resistance monitoring network.
“Except for some implant surgeries and contamination surgeries, which require extended use time. Currently, for clean surgeries, the use of antibiotics is very standardized.” Ding Liucheng said.
In Lilac Garden’s statistics, In addition to the requirements of relevant regulations, “non-use will impose fines and affect performance” is to prompt doctors to stop antibiotics within 24 hours after surgery one of the most important influencing factors.
Ten years after the Ministry of Health issued the document, How is the use of the hospital?
In 2012, the Ministry of Health issued the “National Antibacterial Drug Clinical Application Special Rectification Activity Plan”, which made clear requirements for the use of antibacterial drugs: the intensity of antibacterial drug use in general hospitals should be controlled at 40 DDDs per 100 people-days The following; the proportion of prophylactic use of antibiotics in patients with Class I incision surgery should not exceed 30%, and the prophylactic use of antibiotics should not exceed 24 hours.
“The concept of restricting the use of antibiotics seems to have been mentioned since I first entered clinical work.” Liu Dongsheng recalled that although such a concept has always existed, but earlier Over the years, there seems to be no real impact.
The change of attitude is a gradual process, and to speed up this process, stronger measures are needed. As the country further strengthens the management of clinical application of antibiotics, the use of antibiotics is gradually included in the assessment of medical institutions. Many hospitals have also gradually established an in-hospital assessment mechanism. The most obvious manifestation is that the use of antibiotics will directly affect the performance of doctors.
“I’m definitely still worried about infection,” Liu Dongsheng said. In the early days of the promulgation of the in-hospital system, due to strong regulations, although I was worried, the drug would still be discontinued according to the regulations.
It’s not just doctors who have this idea, some patients may have a more ingrained idea: Why not give me “anti-inflammatory drugs”? What should I do if I get infected? Liu Dongsheng said, “At that time, I didn’t understand the reason. Sometimes when a patient who doesn’t understand it asks me, I can only explain that ‘this is the hospital’s rule’.”
Image source: Figure Worm Creative
According to Liu Dongsheng’s recollection, in the early stage of the implementation of the regulations, after the drug was stopped within 24 hours as required, postoperative infection still existed.
“At first we thought it was a problem of stopping the drug. Later, the hospital continued to hold meetings and lectures for us, and we realized that the operating standard of aseptic surgery is actually more important in infection control. Factors.” Liu Dongsheng said that later, after repeated study and continuous improvement of intraoperative specifications and aseptic operation requirements, the infection rate has indeed decreased, and the discontinuation of postoperative medication has almost no effect.
Visual results are often more convincing than data. Liu Dongsheng introduced that they have been focusing on strict aseptic operations since then, and until now, their patients rarely have postoperative infections. This also completely dispelled their original doubts, and even more confident in the face of patients.
Liu Dongsheng said that now when encountering patients who do not understand, he will explain the reason to them and tell them that stopping the drug will not lead to postoperative infection, instead of just using ” regulations” to prevaricate the patient.
Under a strong system, the rate of antibiotic use in my country has dropped significantly. In 2020, the intensity of antimicrobial use in tertiary public hospitals nationwide was 36.28DDDs, a decrease of 1.5DDDs compared with 2019, and significantly better than the national requirement of 40DDDs[1].
Why are doctors still afraid to stop taking medicines?
A study published in JAMA showed that of 1,931 surgical prescriptions for primary health care institutions in China, 98.0% contained antibiotics, of which 63.8% were for prophylaxis. Not only that, more than 2 antibiotics were used in almost all cases, and the average duration was as high as 5.4 days [2].
Image source: Reference 2
In addition to the lack of concept, some grassroots doctors also bluntly stated that the hospital’s surgical equipment and aseptic operations are indeed not in place, and they can only prolong the use of antibiotics and dare not stop the drugs. And some doctors, although according to regulations to stop antibiotics, but also have their own small methods. Chen Guang (pseudonym), a surgeon at a tertiary hospital in the southwest, revealed: “I will prescribe oral medicine to the patient and let him continue to take it for a few days.”
Doctors “don’t dare” to stop the drug, which still occupies a large base. In the survey of the Lilac Garden Forum, 90% of doctors’ concerns came from – “I stop antibiotics, what should I do if the patient has a dispute after the infection?”
Attorney Zhang Yongquan of Grandall Lawyers (Tianjin) Office said that due to the advancement of aseptic technique and antibiotics in recent years, cases of postoperative infection have been reduced. In the appraisal of dispute resolution, clinical guidelines and handling principles can be presented to the appraiser as a basis, but for such disputes, what is more important is what is the most important factor causing postoperative infection.
And the most common situation is that the preoperative preparation and aseptic operation are not in place. “In a recent case of legal dispute caused by postoperative infection, (the hospital) only wrote the operation record during the operation, and there was no operation record and disinfection record, and no device barcode was pasted, which caused the doctor to be very passive.”
In the “Guidelines for the Clinical Application of Antibacterial Drugs”, it is clearly stated that “The preventive application of antibacterial drugs cannot replace strict disinfection, sterilization technology and fine aseptic operation, Nor is it a substitute for other preventive measures such as intraoperative warming and glycemic control.”
“Although there are more factors to be considered for contaminated wounds, and the timing of drug withdrawal needs to be more cautious. However, in addition to the patient’s basic condition, the factors that affect postoperative infection are more Surgical factors, such as operating room environment, operation time, tools, etc.” In the work communication with other hospital districts, Ding Liucheng also noticed that the aseptic operation is more standardized, and the probability of postoperative infection is often lower. .
Lawyer Zhang Yongquan said that in many similar medical disputes, postoperative antibacterial is not the root problem, but a remedy or preventive measure. “A common phrase used by the patient (my) is ‘the best antibacterial technique is not as good as one ten thousandth aseptic technique’.”
Acknowledgments: This article has been professionally reviewed by Ding Liucheng, Deputy Chief Physician of Urology Department of the Second Affiliated Hospital of Nanjing Medical University, and Zhang Yongquan, Lawyer of Guoco (Tianjin) Law Firm p>
Planning: ame | Producer: gyouza
The source of the title map: Figure Worm Creative
References:
[1] 2020 National Monitoring and Analysis of National Tertiary Public Hospital Performance Assessment
[2] Wang J, Wang P, Wang X, Zheng Y, Xiao Y. Use and Prescription of Antibiotics in Primary Health Care Settings in China. JAMA Intern Med. 2014;174(12 ): 1914–1920. doi: 10.1001/jamainternmed.2014.5214
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