Current Practice of Peri- and Postoperative Antibiotic Therapy in Cardiac Surgery in Germany

Abstract

Background: The increasing development of antimicrobial resistance of common bacterial pathogens presents one of the most significant challenges to clinical medicine, particularly intensive care medicine. One factor which has contributed to this development is the (over)use of antibiotic treatment. Therefore the objective of this study was to scrutinize the current practice of empiric antibiotic therapy in cardiac surgery in Germany for 1) perioperative prophylaxis and 2) postoperative therapy prior to the availability of susceptibility patterns for the infecting pathogen. Methods: A questionnaire was sent to all centers performing cardiac surgery in Germany. Questions referred to drugs used as well as dosage, homogeneity and duration of antibiotic prophylaxis, time and/or reason for changing this regimen, drugs used for first-, second-, and third-line empiric postoperative antibiotic treatment, and homogeneity of antibiotic usage. Results: All but 3 institutions (96.3 %) answered. 1. Perioperative prophylaxis: All but 4 centers (94 %) use first- (n = 32 = 43 %) or second-generation cephalosporins (n = 38 = 51 %)' most commonly for 24 hours (n = 60 = 81 %). Prophylaxis never exceeds 3 days. 74 % of all institutions (n = 55) use the same antimicrobial agent for all cardiac procedures performed, while 26 % (n = 19) change their regimen in selected patient groups, most commonly for heart transplantation. The entire prophylaxis is changed mainly according to susceptibility patterns (n = 63 = 85 %), 7 centers (10 %) change according to a fixed time schedule, while 4 institutions (5 %) never change the antimicrobial drug. 2. Empiric postoperative therapy: A total of 29 different antibiotics out of 8 subclasses are used. No major differences between 1st-, 2nd-, and 3rd-line therapy could be detected, with the exception of a decreasing usage of ß-lactams (carbapenems excluded) from 60 % in 1st-line to 23 % in 3rd-line therapy and an increasing usage of glycopeptides from 5 % in 1st-line to 18 % in 3rd-line therapy. 41 institutions (55 %) use the same antibiotic regimen on the intensive care unit and the normal ward, 9 centers (12 %) use the same drug for perioperative prophylaxis and postoperative therapy, and 12 institutions (16 %) prescribe a combination therapy. Conclusions: Perioperative prophylaxis in cardiac surgery in Germany is performed on a relatively uniform basis and at low cost. The heterogeneity of antibiotic regimens for postoperative therapy may indicate the need for recommendations and/or guidelines for this type of treatment. The indications for the usage of reserve antibiotics, e.g. vancomycin, implying the possible risk of creating pathogens with untreatable resistance patterns, as well as strategies aimed at preventing the development of resistance should be the subject of further discussions.

Key words

Perioperative antibiotic therapy - Cardiac surgery