A quality improvement intervention on surgical prophylaxis impact in antibiotic consumption and cost in selected surgical procedures

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"apellidos" => "Felipe Garmendia" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Infection Control Department, The Cuban Hospital, Qatar" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Surgical Department, The Cuban Hospital, Qatar" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Quality and Patient Safety Department, The Cuban Hospital, Qatar" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Impacto de una intervención de mejora de la calidad de la profilaxis quirúrgica en los consumos y costos de antibióticos en procederes quirúrgicos seleccionados" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2826 "Ancho" => 2083 "Tamanyo" => 208494 ] ] "descripcion" => array:1 [ "en" => "Compliance with antibiotic prophylaxis during baseline (January–April) and intervention period (May–December) (per 100 surgical procedures)." ] ] ] "textoCompleto" => "IntroductionAntibiotic prophylaxis (AP) is a key practice for the prevention of surgical site infection (SSI), the most frequent healthcare-associated infection in surgical patients that impacts the quality of care.<a class="elsevierStyleCrossRefs" href="#bib0100">1,2</a>Non-compliance with AP in surgery is frequently reported in the published literature, with compliance fluctuating from 2.5% to 72.3%.<a class="elsevierStyleCrossRefs" href="#bib0110">3–6</a> Similar findings have been reported at the national level in various surgical procedures achieving compliance from 46% to 73%.<a class="elsevierStyleCrossRef" href="#bib0130">7</a> Also, implementing an antimicrobial stewardship program impacts compliance with AP.<a class="elsevierStyleCrossRefs" href="#bib0130">7–10</a> The adverse consequences of an inadequate AP include the increased risk for SSI, overuse of antibiotics, increased antimicrobial resistance, and impairment of healthcare efficiency, among others.<a class="elsevierStyleCrossRefs" href="#bib0100">1,2,7</a>The Cuban Hospital, a public hospital facility member of Hamad Medical Corporation (Doha, Qatar) provided COVID-19 patients with care from 2020 to 2021.<a class="elsevierStyleCrossRef" href="#bib0150">11</a> The facility's Infection Control Program is guided by the Corporate Infection Control Program (ICP). During that period, the number of surgical procedures was limited to some emergency surgeries and cesarean sections, both in COVID-19-confirmed patients, and most required additional antibiotics and antiviral treatment. The AP in surgery was not a priority in the majority of COVID-19 cases over the requirement of intensive antibiotic treatment for the management of severe pneumonia and other complications, most started before surgery. After the resumption of surgical activity during the early post-pandemic period, we observed non-compliance with AP in surgery. Either the moment of administration of the initial dose, the antibiotic selection, the timely discontinuation, and the longer duration of antibiotic use were found during auditing activities.Considering the evidence, a study aiming at evaluating the impact of an intervention in compliance with AP in selected surgical procedures and its effect on antibiotic consumption and cost.MethodsThis prospective interventional study was performed in a community hospital from January to December 2022. The baseline period was considered January–April 2022 and the intervention period May–December 2022. All patients who underwent cesarean section, appendectomies, hernia surgery, open reduction and internal fixation (ORIF), abdominoplasty, and cholecystectomy during the study period were selected.MeasuresThe intervention measures include:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">1.Staff education includes surgeons, nurses, pharmacists and anesthesia staff focused on policy, best evidence review, and monthly data analysis. The frequency of educational sessions was variable among the departments and staff involved and depend on the progress in achieving the project goal, with a minimum of two monthly sessions.</li><li class="elsevierStyleListItem" id="lsti0010">2.Pharmacy interventions. Included the ongoing review of prescriptions and immediate corrective actions, close coordination among clinical pharmacists, anesthesia staff, and surgeons.</li><li class="elsevierStyleListItem" id="lsti0015">3.Monitoring the quality of prescriptions and antimicrobial consumption. The monitoring system, conducted by the infection-control team, was embedded in the SSI surveillance system.</li><li class="elsevierStyleListItem" id="lsti0020">4.Monthly feedback of compliance with antibiotic prophylaxis, consumption and cost. Includes two tiers: (1) addressed to the surgical team (surgeon, anesthesia, and nurses) and clinical pharmacist, (2) addressed to leaders, quality and patient safety (QPS) committees. The feedback report was generated by the infection-control team or clinical pharmacist and involved (1) information about monthly performance, (2) data about selected issues for immediate analysis and actions, and (3) reports for QPS meetings analysis.</li><li class="elsevierStyleListItem" id="lsti0025">5.Improved role of anesthesia staff, assigned the responsibility to administer AP following policy in close coordination with the attending surgeon. Verification of AP administration is done using the WHO checklist during the sign-in.<a class="elsevierStyleCrossRef" href="#bib0155">12</a></li><li class="elsevierStyleListItem" id="lsti0030">6.Department champions. It was identified in each surgical department to support the intervention in monitoring the quality of prescription and immediate analysis of non-compliance and identification of actions for improvement.</li></ul>The compliance with AP was monitored by the infection-control team on an ongoing basis and according to the corporate policy, with monthly data summary. The following key components were identified: timing of the first dose, selection, and dose (including intraoperative booster doses if required), and discontinuation of antibiotics. Timing was considered compliant if the first dose was administered within 60min of the incision in all procedures except for cesarean section which required 15–60min of timing. It was considered compliant for discontinuation if the patient received a single dose before skin incision, and an intraoperative booster dose if required, except for abdominoplasty that required 24h antibiotic, unless there is an indication to prolong the antibiotic order. If the selection of antibiotics and doses (single doses, intraoperative booster if required) was according to the policy it was considered compliant. An intraoperative booster dose is required if the duration of the surgical procedure lasts for over four (4) hours or two half-lives of the prophylactic antibiotic.According to the HMC policy CL 7197 (antimicrobial prescribing) the recommended prophylaxis according to procedures should be:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0035">-Cesarean section, hernia repair with prosthetic material, ORIF, and abdominoplasty: cefazolin or clindamycin.</li><li class="elsevierStyleListItem" id="lsti0040">-Appendectomies: cefuroxime plus metronidazole or clindamycin plus gentamicin. A full therapeutic course is required for gangrenous, perforated appendicitis, abscess, and appendicular mass.</li><li class="elsevierStyleListItem" id="lsti0045">-Cholecystectomy. Cefuroxime or clindamycin plus gentamicin. Prophylaxis given for patients >70 years, obstructive jaundice, recent cholecystitis, and previous biliary surgery.</li></ul>EthicalThe study was conducted as a facility quality improvement (QI) project presented and approved by Hamad Medical Corporation (Doha, Qatar). The project was documented in Login – Life QI (lifeqisystem.com).Statistical analysisAnonymized patient-level data were recorded in an Excel sheet that included compliance with each item of AP and the antibiotics and doses provided. Antibiotics were classified as (1) antibiotics as per policy (see above) and (2) others antibiotics (not included in the corporate policy). The compliance with AP was calculated, for timing, selection and dose, and discontinuation, as a number of surgical procedures compliant with the policy by the number of surgical procedures multiplied by 100.The monitoring of antibiotic consumption was presented as defined as daily dose divided by the number of procedures and expressed by 100, as per the ATC/DDD methodology.<a class="elsevierStyleCrossRef" href="#bib0160">13</a> Data was presented as daily defined dose (DDD) per 100 surgical procedures. Antibiotic cost was calculated as per hospital prices (in Qatari Riyal, QR), and presented as QR per 100 surgical procedures.The X2 tests and the non-parametric Wilcoxon–Mann–Whitney test were used to compare (baseline and intervention data) the compliance with antibiotic prophylaxis, and the antibiotics consumption and cost respectively. For the hypothesis tests that were carried out, a significance level of α=0.05 was set.ResultsThe study involved 192 and 617 surgical procedures in the baseline and intervention periods respectively. The compliance with timing, selection and dose, and discontinuation achieved 100%, 99.2%, and 97.6% from baseline figures of 92.7%, 95.8%, and 81.3% respectively (p<0.001). The antibiotic consumption was reduced by 55.1% during the intervention with a higher contribution of other antibiotics (94.1% reduction) in comparison with antibiotics as per policy (31.2% reduction) (p<0.001). Early during the intervention periods was observed improvement in compliance with timing and selection and doses, while compliance with discontinuation increased from 91.1% in May to 100% in September. Accordingly, the cost was reduced by 47.2% (antibiotic as per policy 31.9%, other antibiotics 94.2%) (p<0.001) (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> and <a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1 and 2</a>).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia>In cesarean sections, the compliance with timing was 88% at baseline and the compliance with discontinuation was 97.8% over the intervention period (3 cases received 2 additional doses). Antibiotic consumption increased by 11.1%, and the cost by 20% concerned improper discontinuation and various cases that required 2g of cefazolin due to obesity. In appendectomies, compliance with AP achieved 100% for timing, selection and dose and 95.4% for discontinuation during the intervention. The timely discontinuation of antibiotics was due to the improper evaluation of the degree of contamination, and the overestimation of the SSI risk in non-complicated appendectomies. Antibiotic consumption was reduced by 32.4%, and cost by 27.7%. In hernia surgery, the addition of 2 doses of cefazolin was observed in a few cases at baseline and during the intervention. During the period July–September has achieved 100% compliance in discontinuation. Antibiotic consumption was reduced by 33.3%, and cost by 66.4%. In ORIF, one case was identified with improper timing at baseline, and the antibiotic consumption increased by 6.3% and the cost by 16.7% due to longer surgical procedures that required an intraoperative booster dose. In abdominoplasty, the administration of additional doses, most received 7-day treatment, constituted the key non-compliance (14.3% at baseline, 95% at intervention). Antibiotic consumption was reduced by 76.7% and cost by 54.9%. In cholecystectomy, the selection of antibiotic non-recommended by the policy explains the compliance at baseline (85.7%), and during the intervention (89.8%). The reduction in antibiotic consumption by 76.3% and the cost by 57.1% was mainly related to the improved prescription of other antibiotics (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).The antibiotics with higher reduction in consumption and cost during the intervention were cefuroxime (consumption −36.1%, cost −55.8%), metronidazole (consumption −50.2%, cost −65.2%), amoxicillin–clavulanic (consumption −90.4%, cost −94.0%), and ceftriaxone (consumption −87.9%, cost −91.2%).DiscussionThe intervention has had a beneficial impact on the quality of AP achieving the quality improvement goal. As a consequence, was observed a significant reduction in antibiotic consumption and costs, mainly related to the timely discontinuation of antibiotics after the surgical procedures. The intervention program has achieved results similar to numerous published research,<a class="elsevierStyleCrossRefs" href="#bib0130">7–10</a> reaching high levels of compliance with corporate policies and significant reduction of costs. The contributions to quality through better adherence to the best evidence, improved efficiency due to the limited use of highly valuable resources, and its impact on the prevention of bacterial resistance are essential values of the experience.It is important to mention that the COVID-19 pandemic brought various consequences for the healthcare systems. The disruption of previously established practices could be considered one adverse consequence. Also, we think that the effects observed are explained by the proactive actions implemented more than a simple recovery in the quality of care because the QI included actions not implemented before the pandemic and achieved higher compliance in comparison with the pre-pandemic period.The study has used improvement actions that have shown their benefits in previous reports.<a class="elsevierStyleCrossRefs" href="#bib0130">7–10</a> It includes staff education, pharmacy interventions, monitoring, and feedback, all of which are critical elements in the quality improvement cycle. A previous intervention performed, but focused on appendectomies, achieved improved compliance and reduction of antibiotic consumption during the initial years (2013–2015) of implementation of antimicrobial stewardship in the same facility as the current study.<a class="elsevierStyleCrossRef" href="#bib0130">7</a> The sustainability of quality improvement is a complex challenge either in the short or long term.<a class="elsevierStyleCrossRef" href="#bib0165">14</a> Some of the quality gaps identified for appendectomies were observed during the current study, which points out a probable sustainability failure. Several factors could be highlighted in the effect of the pandemic on changing antibiotic prescribing patterns and the rapid shift to a predominant non-COVID-19 patient population.<a class="elsevierStyleCrossRef" href="#bib0170">15</a> A recently published systematic review of 14 published studies shows a significant improvement in adherence to AP protocols, with an effect on timing, selection, and discontinuation of AP using audit, feedback, and education among other measures.<a class="elsevierStyleCrossRef" href="#bib0145">10</a>Davey et al.<a class="elsevierStyleCrossRef" href="#bib0165">14</a> in a Cochrane review emphasize the contribution of feedback in increasing the intervention effect on improving antibiotic prescription practices. The comprehensive feedback strategy designed addressed each sensitive element of the system related to AP, providing essential information on a timely basis, to correct and prevent patient safety issues.Two components of the intervention need to be further explored: the inclusion of data to evaluate the adherence to AP in the SSI surveillance system and the role of departmental champions. The first contributes with relevant information to assess infection risk but adds more data to be collected by the infection-control team, increasing the data collection burden and time required. The use of sampling techniques when the number of surgical procedures is significant or the use of data tracked from electronic medical records could facilitate the data collection. Also, the influence of the champions on the quality improvement initiative was crucial. Champions contribute in many ways, but the most important is their influence on their colleagues (surgical team) to change behavior and practices, as well as to maintain open communication with the auditors (infection-control team, clinical pharmacist) and serve as key line of communication between them and the surgical staff.<a class="elsevierStyleCrossRef" href="#bib0175">16</a>We believe that the study had additional benefits related to the change in antibiotic prescribing practices by medical staff. Change in human behavior is an essential and complex area for quality improvement.<a class="elsevierStyleCrossRefs" href="#bib0180">17–19</a> They require multiple actions that include providing theoretical and practical evidence to healthcare professionals about the role of antibiotics in the prevention of SSI, that their prolongation beyond the recommended duration does not provide additional benefits, that the use of drainage or invasive devices does not determine the antibiotics use, among other evidence. Besides, auditing practices and providing feedback on performance could contribute to behavioral change.<a class="elsevierStyleCrossRef" href="#bib0165">14</a> Empirical observations point to a change in the behavior of the professionals involved in the project.The study has various limitations that should be considered. The main limitation of the study is that it is a single-center study with a limited volume of surgical procedures and surgical personnel, which constitutes an advantage for the development of quality interventions. The result presents the effect of the intervention in frequently performed surgical procedures, and no data is available about other procedures for comparison of outcomes. Likewise, due to its limited duration, the study does not provide evidence of the sustainability of the intervention, which will require additional observation time.In conclusion: The implemented strategy was effective in improving the quality of antibiotic prophylaxis with a significant impact in reducing antibiotics consumption and cost. Sustaining the achievement could be a challenge for the improvement team.Ethical approvalThe study was conducted as a facility quality improvement project presented and approved by Hamad Medical Corporation (Doha, Qatar). The project was documented in Life QI (lifeqisystem.com).Authors’ ContributionsStudy design: HGG. Data acquisition: HGG, FJAP, DAMR, NSP, RMDR, ORER, WMM. Data analysis: AVA, SIGP, TMFG, AMFG. Manuscript writing: HGG, FJAP. Critical review and major scientific input: DAMR, NSP, RMDR, ORER, WMM, AVA, SIGP, TMFG, AMFG.FundingNone to declare.Conflict of interestNone to declare for all authors." "textoCompletoSecciones" => array:1 [ "secciones" => array:14 [ 0 => array:3 [ "identificador" => "xres2206437" "titulo" => "Abstract" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Objective" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Methods" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Results" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1851070" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres2206438" "titulo" => "Resumen" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0030" "titulo" => "Antecedentes" ] 1 => array:2 [ "identificador" => "abst0035" "titulo" => "Objetivo" ] 2 => array:2 [ "identificador" => "abst0040" "titulo" => "Métodos" ] 3 => array:2 [ "identificador" => "abst0045" "titulo" => "Resultados" ] 4 => array:2 [ "identificador" => "abst0050" "titulo" => "Conclusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1851071" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Methods" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Measures" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Ethical" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Statistical analysis" ] ] ] 6 => array:2 [ "identificador" => "sec0030" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0035" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0040" "titulo" => "Ethical approval" ] 9 => array:2 [ "identificador" => "sec0045" "titulo" => "Authors’ Contributions" ] 10 => array:2 [ "identificador" => "sec0050" "titulo" => "Funding" ] 11 => array:2 [ "identificador" => "sec0055" "titulo" => "Conflict of interest" ] 12 => array:2 [ "identificador" => "xack760537" "titulo" => "Acknowledgment" ] 13 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2023-05-22" "fechaAceptado" => "2024-03-15" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1851070" "palabras" => array:6 [ 0 => "Antibiotic prophylaxis" 1 => "Surgery" 2 => "Antibiotic consumption" 3 => "Cost" 4 => "Intervention" 5 => "Qatar" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1851071" "palabras" => array:6 [ 0 => "Profilaxis antibiótica" 1 => "Cirugía" 2 => "Consumo de antibióticos" 3 => "Costo" 4 => "Intervención" 5 => "Qatar" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "BackgroundImproper compliance with antibiotic prophylaxis (AP) in surgery is associated with an increased risk of surgical site infection (SSI), and impacts the efficiency of healthcare. ObjectiveEvaluate the impact of an intervention in compliance with AP in selected surgical procedures and its effect on antibiotic consumption and cost. MethodsA prospective interventional study was performed in a community hospital from January to December 2022. The baseline period was considered January–April 2022 and the intervention period May–December 2022. All patients who underwent cesarean section, appendectomies, hernia surgery, open reduction and internal fixation (ORIF), abdominoplasty, and cholecystectomy during the study period were selected. The intervention includes staff education, pharmacy interventions, monitoring the quality of prescriptions and feedback, and improved role of anesthesia staff, and department champions. ResultsThe study involved 192 and 617 surgical procedures in the baseline and intervention periods respectively. The compliance with timing, selection, dose, and discontinuation achieved 100%, 99.2%, and 97.6% from baseline figures of 92.7%, 95.8%, and 81.3%, respectively. The antibiotic consumption was reduced by 55.1% during the intervention with a higher contribution of other antibiotics (94.1% reduction) in comparison with antibiotics as per policy (31.2% reduction). The cost was reduced by 47.2% (antibiotic as per policy 31.9%, other antibiotics 94.2%). ConclusionThe implemented strategy was effective in improving the quality of antibiotic prophylaxis with a significant impact in reducing antibiotic consumption and cost." "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Objective" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Methods" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Results" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "AntecedentesEl cumplimiento inadecuado de la profilaxis antibiótica (PA) en cirugía se asocia con un mayor riesgo de infección del sitio quirúrgico (ISQ) y afecta la eficiencia de la atención médica. ObjetivoEvaluar el impacto de una intervención en la calidad de la profilaxis quirúrgica en procedimientos quirúrgicos seleccionados y su efecto sobre el consumo y costos de antibióticos. MétodosSe realizó un estudio prospectivo de intervención en un hospital comunitario de Qatar desde enero hasta diciembre de 2022. El período de base se consideró de enero a abril de 2022 y el período de intervención de mayo a diciembre de 2022. Todos los pacientes que se sometieron a cesárea, apendicectomías, cirugía de hernia, reducción abierta y fijación interna (ORIF), abdominoplastia y colecistectomía durante el período de estudio. La intervención incluyó educación del personal, intervenciones farmacéuticas, monitorización de la calidad de prescripción y retroalimentación, revisión del rol del personal de anestesia, y de líderes departamentales. ResultadosEl estudio involucró 192 y 617 procedimientos quirúrgicos en los períodos de base e intervención, respectivamente. El cumplimiento con el momento, la selección, la dosis y la interrupción del antibiótico profiláctico alcanzó el 100%, el 99,2% y el 97,6% a partir de las cifras iniciales del 92,7%, el 95,8% y el 81,3%, respectivamente. El consumo de antibióticos se redujo en un 55,1% durante la intervención con una mayor contribución de otros antibióticos (94,1% de reducción) en comparación con los antibióticos de la política (31,2% de reducción). El costo se redujo en un 47,2% (antibiótico según política 31,9%, otros antibióticos 94,2%). ConclusiónLa estrategia implementada fue efectiva en mejorar la calidad de la profilaxis antibiótica con un impacto significativo en la reducción del consumo y costo de antibióticos." "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0030" "titulo" => "Antecedentes" ] 1 => array:2 [ "identificador" => "abst0035" "titulo" => "Objetivo" ] 2 => array:2 [ "identificador" => "abst0040" "titulo" => "Métodos" ] 3 => array:2 [ "identificador" => "abst0045" "titulo" => "Resultados" ] 4 => array:2 [ "identificador" => "abst0050" "titulo" => "Conclusión" ] ] ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2826 "Ancho" => 2083 "Tamanyo" => 208494 ] ] "descripcion" => array:1 [ "en" => "Compliance with antibiotic prophylaxis during baseline (January–April) and intervention period (May–December) (per 100 surgical procedures)." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2387 "Ancho" => 2083 "Tamanyo" => 194349 ] ] "descripcion" => array:1 [ "en" => "Antibiotic consumption (DDD/100 procedures) and cost (QR/100 procedures) during baseline (January–April) and intervention period (May–December)." ] ] 2 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "B: baseline period; I: intervention period; ORIF: open reduction and internal fixation; DDD: daily defined doses; QR: Qatari Riyal." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="\n \t\t\t\t\ttable-head\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col">Variable \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Cesarean section</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Appendectomies</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Hernia surgery</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">ORIF</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Abdominoplasty</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Cholecystectomy</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Total</th></tr><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">B \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">I \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">B \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">I \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">B \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">I \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">B \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">I \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">B \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">I \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">B \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">I \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">B \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">I \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Number of procedures \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">50 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">139 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">71 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">197 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">67 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">128 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">40 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">49 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">192 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">617 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="15" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="15" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Compliance with antibiotic prophylaxis (per 100 procedures)</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Timing \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">88.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">90.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">96.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">92.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100<a class="elsevierStyleCrossRef" href="#tblfn0005">*</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Selection and dose \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">93.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">85.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">89.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">95.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">99.2<a class="elsevierStyleCrossRef" href="#tblfn0005">*</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Discontinuation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">97.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">69.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">95.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">66.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">94 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">95.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">81.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">97.6<a class="elsevierStyleCrossRef" href="#tblfn0005">*</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="15" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="15" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Antibiotics consumption (DDD/100 procedures)</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Antibiotic as per policy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">33.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">37.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">336.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">240.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">44.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">36.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">33.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">35.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">223.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">196.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">85.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">62.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">165.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">113.9<a class="elsevierStyleCrossRef" href="#tblfn0005">*</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Other antibiotics \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">25.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">731.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">25.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">481.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">45.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">115.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6.8<a class="elsevierStyleCrossRef" href="#tblfn0005">*</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Total \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">33.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">37.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">362.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">245.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">44.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">36.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">33.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">35.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">954.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">221.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">455.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">107.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">268.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">120.7<a class="elsevierStyleCrossRef" href="#tblfn0005">*</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="15" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="15" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cost of antibiotics (QR/100 procedures)</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Antibiotic as per policy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">302.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">362.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6260.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4830.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">402.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">135.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">302.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">352.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2027.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1933.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3754.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2726.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3012.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2052.0<a class="elsevierStyleCrossRef" href="#tblfn0005">*</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Other antibiotics \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">542.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">87.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2277.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3447.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">360.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">978.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">56.9<a class="elsevierStyleCrossRef" href="#tblfn0005">*</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Total \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">302.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">362.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6803.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4918.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">402.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">135.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">302.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">352.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4305.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1940.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7201.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3086.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3990.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2108.9<a class="elsevierStyleCrossRef" href="#tblfn0005">*</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3600030.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "*" "nota" => "p<0.001." ] ] ] "descripcion" => array:1 [ "en" => "Compliance with antibiotic prophylaxis, antibiotic consumption and cost according to surgical procedures during baseline and intervention periods." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:19 [ 0 => array:3 [ "identificador" => "bib0100" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:1 [ "titulo" => "Global guidelines for the prevention of surgical site infection" ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:4 [ "edicion" => "2nd ed." 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Quality improvement projects

A quality improvement intervention on surgical prophylaxis impact in antibiotic consumption and cost in selected surgical procedures

Impacto de una intervención de mejora de la calidad de la profilaxis quirúrgica en los consumos y costos de antibióticos en procederes quirúrgicos seleccionados

H. Guanche Garcella,

Corresponding author

humbertoguanchegarcell@yahoo.es
guanche@infomed.sld.cu

Corresponding author.

, F.J. Aragón Palmerob, D.A. Marquez Reynab, N. Seoane Perezb, R.M. Desdin Rodriguezb, O.R. Exposito Reyesb,c, W. Martinez Martinezb, A. Villanueva Ariasb, S.I. Gonzalez Pereza, T.M. Fernandez Hernandezc, A.M. Felipe Garmendiac

a Infection Control Department, The Cuban Hospital, Qatar

b Surgical Department, The Cuban Hospital, Qatar

c Quality and Patient Safety Department, The Cuban Hospital, Qatar

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Antibiotic prophylaxis &#40;AP&#41; is a key practice for the prevention of surgical site infection &#40;SSI&#41;&#44; the most frequent healthcare-associated infection in surgical patients that impacts the quality of care&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Non-compliance with AP in surgery is frequently reported in the published literature&#44; with compliance fluctuating from 2&#46;5&#37; to 72&#46;3&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">3&#8211;6</span></a> Similar findings have been reported at the national level in various surgical procedures achieving compliance from 46&#37; to 73&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">7</span></a> Also&#44; implementing an antimicrobial stewardship program impacts compliance with AP&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">7&#8211;10</span></a> The adverse consequences of an inadequate AP include the increased risk for SSI&#44; overuse of antibiotics&#44; increased antimicrobial resistance&#44; and impairment of healthcare efficiency&#44; among others&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">1&#44;2&#44;7</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The Cuban Hospital&#44; a public hospital facility member of Hamad Medical Corporation &#40;Doha&#44; Qatar&#41; provided COVID-19 patients with care from 2020 to 2021&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">11</span></a> The facility&#39;s Infection Control Program is guided by the Corporate Infection Control Program &#40;ICP&#41;&#46; During that period&#44; the number of surgical procedures was limited to some emergency surgeries and cesarean sections&#44; both in COVID-19-confirmed patients&#44; and most required additional antibiotics and antiviral treatment&#46; The AP in surgery was not a priority in the majority of COVID-19 cases over the requirement of intensive antibiotic treatment for the management of severe pneumonia and other complications&#44; most started before surgery&#46; After the resumption of surgical activity during the early post-pandemic period&#44; we observed non-compliance with AP in surgery&#46; Either the moment of administration of the initial dose&#44; the antibiotic selection&#44; the timely discontinuation&#44; and the longer duration of antibiotic use were found during auditing activities&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Considering the evidence&#44; a study aiming at evaluating the impact of an intervention in compliance with AP in selected surgical procedures and its effect on antibiotic consumption and cost&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">This prospective interventional study was performed in a community hospital from January to December 2022&#46; The baseline period was considered January&#8211;April 2022 and the intervention period May&#8211;December 2022&#46; All patients who underwent cesarean section&#44; appendectomies&#44; hernia surgery&#44; open reduction and internal fixation &#40;ORIF&#41;&#44; abdominoplasty&#44; and cholecystectomy during the study period were selected&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Measures</span><p id="par0030" class="elsevierStylePara elsevierViewall">The intervention measures include&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#46;</span><p id="par0035" class="elsevierStylePara elsevierViewall">Staff education includes surgeons&#44; nurses&#44; pharmacists and anesthesia staff focused on policy&#44; best evidence review&#44; and monthly data analysis&#46; The frequency of educational sessions was variable among the departments and staff involved and depend on the progress in achieving the project goal&#44; with a minimum of two monthly sessions&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#46;</span><p id="par0040" class="elsevierStylePara elsevierViewall">Pharmacy interventions&#46; Included the ongoing review of prescriptions and immediate corrective actions&#44; close coordination among clinical pharmacists&#44; anesthesia staff&#44; and surgeons&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#46;</span><p id="par0045" class="elsevierStylePara elsevierViewall">Monitoring the quality of prescriptions and antimicrobial consumption&#46; The monitoring system&#44; conducted by the infection-control team&#44; was embedded in the SSI surveillance system&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4&#46;</span><p id="par0050" class="elsevierStylePara elsevierViewall">Monthly feedback of compliance with antibiotic prophylaxis&#44; consumption and cost&#46; Includes two tiers&#58; &#40;1&#41; addressed to the surgical team &#40;surgeon&#44; anesthesia&#44; and nurses&#41; and clinical pharmacist&#44; &#40;2&#41; addressed to leaders&#44; quality and patient safety &#40;QPS&#41; committees&#46; The feedback report was generated by the infection-control team or clinical pharmacist and involved &#40;1&#41; information about monthly performance&#44; &#40;2&#41; data about selected issues for immediate analysis and actions&#44; and &#40;3&#41; reports for QPS meetings analysis&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">5&#46;</span><p id="par0055" class="elsevierStylePara elsevierViewall">Improved role of anesthesia staff&#44; assigned the responsibility to administer AP following policy in close coordination with the attending surgeon&#46; Verification of AP administration is done using the WHO checklist during the sign-in&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">12</span></a></p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">6&#46;</span><p id="par0060" class="elsevierStylePara elsevierViewall">Department champions&#46; It was identified in each surgical department to support the intervention in monitoring the quality of prescription and immediate analysis of non-compliance and identification of actions for improvement&#46;</p></li></ul></p><p id="par0065" class="elsevierStylePara elsevierViewall">The compliance with AP was monitored by the infection-control team on an ongoing basis and according to the corporate policy&#44; with monthly data summary&#46; The following key components were identified&#58; timing of the first dose&#44; selection&#44; and dose &#40;including intraoperative booster doses if required&#41;&#44; and discontinuation of antibiotics&#46; Timing was considered compliant if the first dose was administered within 60<span class="elsevierStyleHsp" style=""></span>min of the incision in all procedures except for cesarean section which required 15&#8211;60<span class="elsevierStyleHsp" style=""></span>min of timing&#46; It was considered compliant for discontinuation if the patient received a single dose before skin incision&#44; and an intraoperative booster dose if required&#44; except for abdominoplasty that required 24<span class="elsevierStyleHsp" style=""></span>h antibiotic&#44; unless there is an indication to prolong the antibiotic order&#46; If the selection of antibiotics and doses &#40;single doses&#44; intraoperative booster if required&#41; was according to the policy it was considered compliant&#46; An intraoperative booster dose is required if the duration of the surgical procedure lasts for over four &#40;4&#41; hours or two half-lives of the prophylactic antibiotic&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">According to the HMC policy CL 7197 &#40;antimicrobial prescribing&#41; the recommended prophylaxis according to procedures should be&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">-</span><p id="par0075" class="elsevierStylePara elsevierViewall">Cesarean section&#44; hernia repair with prosthetic material&#44; ORIF&#44; and abdominoplasty&#58; cefazolin or clindamycin&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">-</span><p id="par0080" class="elsevierStylePara elsevierViewall">Appendectomies&#58; cefuroxime plus metronidazole or clindamycin plus gentamicin&#46; A full therapeutic course is required for gangrenous&#44; perforated appendicitis&#44; abscess&#44; and appendicular mass&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">-</span><p id="par0085" class="elsevierStylePara elsevierViewall">Cholecystectomy&#46; Cefuroxime or clindamycin plus gentamicin&#46; Prophylaxis given for patients &#62;70 years&#44; obstructive jaundice&#44; recent cholecystitis&#44; and previous biliary surgery&#46;</p></li></ul></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Ethical</span><p id="par0090" class="elsevierStylePara elsevierViewall">The study was conducted as a facility quality improvement &#40;QI&#41; project presented and approved by Hamad Medical Corporation &#40;Doha&#44; Qatar&#41;&#46; The project was documented in Login &#8211; Life QI &#40;lifeqisystem&#46;com&#41;&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Statistical analysis</span><p id="par0095" class="elsevierStylePara elsevierViewall">Anonymized patient-level data were recorded in an Excel sheet that included compliance with each item of AP and the antibiotics and doses provided&#46; Antibiotics were classified as &#40;1&#41; antibiotics as per policy &#40;see above&#41; and &#40;2&#41; others antibiotics &#40;not included in the corporate policy&#41;&#46; The compliance with AP was calculated&#44; for timing&#44; selection and dose&#44; and discontinuation&#44; as a number of surgical procedures compliant with the policy by the number of surgical procedures multiplied by 100&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">The monitoring of antibiotic consumption was presented as defined as daily dose divided by the number of procedures and expressed by 100&#44; as per the ATC&#47;DDD methodology&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">13</span></a> Data was presented as daily defined dose &#40;DDD&#41; per 100 surgical procedures&#46; Antibiotic cost was calculated as per hospital prices &#40;in Qatari Riyal&#44; QR&#41;&#44; and presented as QR per 100 surgical procedures&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">The <span class="elsevierStyleItalic">X</span><span class="elsevierStyleSup">2</span> tests and the non-parametric Wilcoxon&#8211;Mann&#8211;Whitney test were used to compare &#40;baseline and intervention data&#41; the compliance with antibiotic prophylaxis&#44; and the antibiotics consumption and cost respectively&#46; For the hypothesis tests that were carried out&#44; a significance level of <span class="elsevierStyleItalic">&#945;</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;05 was set&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Results</span><p id="par0110" class="elsevierStylePara elsevierViewall">The study involved 192 and 617 surgical procedures in the baseline and intervention periods respectively&#46; The compliance with timing&#44; selection and dose&#44; and discontinuation achieved 100&#37;&#44; 99&#46;2&#37;&#44; and 97&#46;6&#37; from baseline figures of 92&#46;7&#37;&#44; 95&#46;8&#37;&#44; and 81&#46;3&#37; respectively &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; The antibiotic consumption was reduced by 55&#46;1&#37; during the intervention with a higher contribution of other antibiotics &#40;94&#46;1&#37; reduction&#41; in comparison with antibiotics as per policy &#40;31&#46;2&#37; reduction&#41; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; Early during the intervention periods was observed improvement in compliance with timing and selection and doses&#44; while compliance with discontinuation increased from 91&#46;1&#37; in May to 100&#37; in September&#46; Accordingly&#44; the cost was reduced by 47&#46;2&#37; &#40;antibiotic as per policy 31&#46;9&#37;&#44; other antibiotics 94&#46;2&#37;&#41; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> and <a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1 and 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall">In cesarean sections&#44; the compliance with timing was 88&#37; at baseline and the compliance with discontinuation was 97&#46;8&#37; over the intervention period &#40;3 cases received 2 additional doses&#41;&#46; Antibiotic consumption increased by 11&#46;1&#37;&#44; and the cost by 20&#37; concerned improper discontinuation and various cases that required 2<span class="elsevierStyleHsp" style=""></span>g of cefazolin due to obesity&#46; In appendectomies&#44; compliance with AP achieved 100&#37; for timing&#44; selection and dose and 95&#46;4&#37; for discontinuation during the intervention&#46; The timely discontinuation of antibiotics was due to the improper evaluation of the degree of contamination&#44; and the overestimation of the SSI risk in non-complicated appendectomies&#46; Antibiotic consumption was reduced by 32&#46;4&#37;&#44; and cost by 27&#46;7&#37;&#46; In hernia surgery&#44; the addition of 2 doses of cefazolin was observed in a few cases at baseline and during the intervention&#46; During the period July&#8211;September has achieved 100&#37; compliance in discontinuation&#46; Antibiotic consumption was reduced by 33&#46;3&#37;&#44; and cost by 66&#46;4&#37;&#46; In ORIF&#44; one case was identified with improper timing at baseline&#44; and the antibiotic consumption increased by 6&#46;3&#37; and the cost by 16&#46;7&#37; due to longer surgical procedures that required an intraoperative booster dose&#46; In abdominoplasty&#44; the administration of additional doses&#44; most received 7-day treatment&#44; constituted the key non-compliance &#40;14&#46;3&#37; at baseline&#44; 95&#37; at intervention&#41;&#46; Antibiotic consumption was reduced by 76&#46;7&#37; and cost by 54&#46;9&#37;&#46; In cholecystectomy&#44; the selection of antibiotic non-recommended by the policy explains the compliance at baseline &#40;85&#46;7&#37;&#41;&#44; and during the intervention &#40;89&#46;8&#37;&#41;&#46; The reduction in antibiotic consumption by 76&#46;3&#37; and the cost by 57&#46;1&#37; was mainly related to the improved prescription of other antibiotics &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">The antibiotics with higher reduction in consumption and cost during the intervention were cefuroxime &#40;consumption &#8722;36&#46;1&#37;&#44; cost &#8722;55&#46;8&#37;&#41;&#44; metronidazole &#40;consumption &#8722;50&#46;2&#37;&#44; cost &#8722;65&#46;2&#37;&#41;&#44; amoxicillin&#8211;clavulanic &#40;consumption &#8722;90&#46;4&#37;&#44; cost &#8722;94&#46;0&#37;&#41;&#44; and ceftriaxone &#40;consumption &#8722;87&#46;9&#37;&#44; cost &#8722;91&#46;2&#37;&#41;&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Discussion</span><p id="par0125" class="elsevierStylePara elsevierViewall">The intervention has had a beneficial impact on the quality of AP achieving the quality improvement goal&#46; As a consequence&#44; was observed a significant reduction in antibiotic consumption and costs&#44; mainly related to the timely discontinuation of antibiotics after the surgical procedures&#46; The intervention program has achieved results similar to numerous published research&#44;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">7&#8211;10</span></a> reaching high levels of compliance with corporate policies and significant reduction of costs&#46; The contributions to quality through better adherence to the best evidence&#44; improved efficiency due to the limited use of highly valuable resources&#44; and its impact on the prevention of bacterial resistance are essential values of the experience&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">It is important to mention that the COVID-19 pandemic brought various consequences for the healthcare systems&#46; The disruption of previously established practices could be considered one adverse consequence&#46; Also&#44; we think that the effects observed are explained by the proactive actions implemented more than a simple recovery in the quality of care because the QI included actions not implemented before the pandemic and achieved higher compliance in comparison with the pre-pandemic period&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">The study has used improvement actions that have shown their benefits in previous reports&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">7&#8211;10</span></a> It includes staff education&#44; pharmacy interventions&#44; monitoring&#44; and feedback&#44; all of which are critical elements in the quality improvement cycle&#46; A previous intervention performed&#44; but focused on appendectomies&#44; achieved improved compliance and reduction of antibiotic consumption during the initial years &#40;2013&#8211;2015&#41; of implementation of antimicrobial stewardship in the same facility as the current study&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">7</span></a> The sustainability of quality improvement is a complex challenge either in the short or long term&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">14</span></a> Some of the quality gaps identified for appendectomies were observed during the current study&#44; which points out a probable sustainability failure&#46; Several factors could be highlighted in the effect of the pandemic on changing antibiotic prescribing patterns and the rapid shift to a predominant non-COVID-19 patient population&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">15</span></a> A recently published systematic review of 14 published studies shows a significant improvement in adherence to AP protocols&#44; with an effect on timing&#44; selection&#44; and discontinuation of AP using audit&#44; feedback&#44; and education among other measures&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">10</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">Davey et al&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">14</span></a> in a Cochrane review emphasize the contribution of feedback in increasing the intervention effect on improving antibiotic prescription practices&#46; The comprehensive feedback strategy designed addressed each sensitive element of the system related to AP&#44; providing essential information on a timely basis&#44; to correct and prevent patient safety issues&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Two components of the intervention need to be further explored&#58; the inclusion of data to evaluate the adherence to AP in the SSI surveillance system and the role of departmental champions&#46; The first contributes with relevant information to assess infection risk but adds more data to be collected by the infection-control team&#44; increasing the data collection burden and time required&#46; The use of sampling techniques when the number of surgical procedures is significant or the use of data tracked from electronic medical records could facilitate the data collection&#46; Also&#44; the influence of the champions on the quality improvement initiative was crucial&#46; Champions contribute in many ways&#44; but the most important is their influence on their colleagues &#40;surgical team&#41; to change behavior and practices&#44; as well as to maintain open communication with the auditors &#40;infection-control team&#44; clinical pharmacist&#41; and serve as key line of communication between them and the surgical staff&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">16</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">We believe that the study had additional benefits related to the change in antibiotic prescribing practices by medical staff&#46; Change in human behavior is an essential and complex area for quality improvement&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">17&#8211;19</span></a> They require multiple actions that include providing theoretical and practical evidence to healthcare professionals about the role of antibiotics in the prevention of SSI&#44; that their prolongation beyond the recommended duration does not provide additional benefits&#44; that the use of drainage or invasive devices does not determine the antibiotics use&#44; among other evidence&#46; Besides&#44; auditing practices and providing feedback on performance could contribute to behavioral change&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">14</span></a> Empirical observations point to a change in the behavior of the professionals involved in the project&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">The study has various limitations that should be considered&#46; The main limitation of the study is that it is a single-center study with a limited volume of surgical procedures and surgical personnel&#44; which constitutes an advantage for the development of quality interventions&#46; The result presents the effect of the intervention in frequently performed surgical procedures&#44; and no data is available about other procedures for comparison of outcomes&#46; Likewise&#44; due to its limited duration&#44; the study does not provide evidence of the sustainability of the intervention&#44; which will require additional observation time&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">In conclusion</span>&#58; The implemented strategy was effective in improving the quality of antibiotic prophylaxis with a significant impact in reducing antibiotics consumption and cost&#46; Sustaining the achievement could be a challenge for the improvement team&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Ethical approval</span><p id="par0165" class="elsevierStylePara elsevierViewall">The study was conducted as a facility quality improvement project presented and approved by Hamad Medical Corporation &#40;Doha&#44; Qatar&#41;&#46; The project was documented in Life QI &#40;lifeqisystem&#46;com&#41;&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Authors&#8217; Contributions</span><p id="par0170" class="elsevierStylePara elsevierViewall">Study design&#58; HGG&#46; Data acquisition&#58; HGG&#44; FJAP&#44; DAMR&#44; NSP&#44; RMDR&#44; ORER&#44; WMM&#46; Data analysis&#58; AVA&#44; SIGP&#44; TMFG&#44; AMFG&#46; Manuscript writing&#58; HGG&#44; FJAP&#46; Critical review and major scientific input&#58; DAMR&#44; NSP&#44; RMDR&#44; ORER&#44; WMM&#44; AVA&#44; SIGP&#44; TMFG&#44; AMFG&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Funding</span><p id="par0175" class="elsevierStylePara elsevierViewall">None to declare&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conflict of interest</span><p id="par0180" class="elsevierStylePara elsevierViewall">None to declare for all authors&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Improper compliance with antibiotic prophylaxis &#40;AP&#41; in surgery is associated with an increased risk of surgical site infection &#40;SSI&#41;&#44; and impacts the efficiency of healthcare&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objective</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Evaluate the impact of an intervention in compliance with AP in selected surgical procedures and its effect on antibiotic consumption and cost&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Methods</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A prospective interventional study was performed in a community hospital from January to December 2022&#46; The baseline period was considered January&#8211;April 2022 and the intervention period May&#8211;December 2022&#46; All patients who underwent cesarean section&#44; appendectomies&#44; hernia surgery&#44; open reduction and internal fixation &#40;ORIF&#41;&#44; abdominoplasty&#44; and cholecystectomy during the study period were selected&#46; The intervention includes staff education&#44; pharmacy interventions&#44; monitoring the quality of prescriptions and feedback&#44; and improved role of anesthesia staff&#44; and department champions&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The study involved 192 and 617 surgical procedures in the baseline and intervention periods respectively&#46; The compliance with timing&#44; selection&#44; dose&#44; and discontinuation achieved 100&#37;&#44; 99&#46;2&#37;&#44; and 97&#46;6&#37; from baseline figures of 92&#46;7&#37;&#44; 95&#46;8&#37;&#44; and 81&#46;3&#37;&#44; respectively&#46; The antibiotic consumption was reduced by 55&#46;1&#37; during the intervention with a higher contribution of other antibiotics &#40;94&#46;1&#37; reduction&#41; in comparison with antibiotics as per policy &#40;31&#46;2&#37; reduction&#41;&#46; The cost was reduced by 47&#46;2&#37; &#40;antibiotic as per policy 31&#46;9&#37;&#44; other antibiotics 94&#46;2&#37;&#41;&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusion</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">The implemented strategy was effective in improving the quality of antibiotic prophylaxis with a significant impact in reducing antibiotic consumption and cost&#46;</p></span>"
        "secciones" => array:5 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Background"
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          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Objective"
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          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Methods"
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          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Results"
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          4 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Conclusion"
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      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Antecedentes</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">El cumplimiento inadecuado de la profilaxis antibi&#243;tica &#40;PA&#41; en cirug&#237;a se asocia con un mayor riesgo de infecci&#243;n del sitio quir&#250;rgico &#40;ISQ&#41; y afecta la eficiencia de la atenci&#243;n m&#233;dica&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Objetivo</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Evaluar el impacto de una intervenci&#243;n en la calidad de la profilaxis quir&#250;rgica en procedimientos quir&#250;rgicos seleccionados y su efecto sobre el consumo y costos de antibi&#243;ticos&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">M&#233;todos</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Se realiz&#243; un estudio prospectivo de intervenci&#243;n en un hospital comunitario de Qatar desde enero hasta diciembre de 2022&#46; El per&#237;odo de base se consider&#243; de enero a abril de 2022 y el per&#237;odo de intervenci&#243;n de mayo a diciembre de 2022&#46; Todos los pacientes que se sometieron a ces&#225;rea&#44; apendicectom&#237;as&#44; cirug&#237;a de hernia&#44; reducci&#243;n abierta y fijaci&#243;n interna &#40;ORIF&#41;&#44; abdominoplastia y colecistectom&#237;a durante el per&#237;odo de estudio&#46; La intervenci&#243;n incluy&#243; educaci&#243;n del personal&#44; intervenciones farmac&#233;uticas&#44; monitorizaci&#243;n de la calidad de prescripci&#243;n y retroalimentaci&#243;n&#44; revisi&#243;n del rol del personal de anestesia&#44; y de l&#237;deres departamentales&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Resultados</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">El estudio involucr&#243; 192 y 617 procedimientos quir&#250;rgicos en los per&#237;odos de base e intervenci&#243;n&#44; respectivamente&#46; El cumplimiento con el momento&#44; la selecci&#243;n&#44; la dosis y la interrupci&#243;n del antibi&#243;tico profil&#225;ctico alcanz&#243; el 100&#37;&#44; el 99&#44;2&#37; y el 97&#44;6&#37; a partir de las cifras iniciales del 92&#44;7&#37;&#44; el 95&#44;8&#37; y el 81&#44;3&#37;&#44; respectivamente&#46; El consumo de antibi&#243;ticos se redujo en un 55&#44;1&#37; durante la intervenci&#243;n con una mayor contribuci&#243;n de otros antibi&#243;ticos &#40;94&#44;1&#37; de reducci&#243;n&#41; en comparaci&#243;n con los antibi&#243;ticos de la pol&#237;tica &#40;31&#44;2&#37; de reducci&#243;n&#41;&#46; El costo se redujo en un 47&#44;2&#37; &#40;antibi&#243;tico seg&#250;n pol&#237;tica 31&#44;9&#37;&#44; otros antibi&#243;ticos 94&#44;2&#37;&#41;&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conclusi&#243;n</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">La estrategia implementada fue efectiva en mejorar la calidad de la profilaxis antibi&#243;tica con un impacto significativo en la reducci&#243;n del consumo y costo de antibi&#243;ticos&#46;</p></span>"
        "secciones" => array:5 [
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            "identificador" => "abst0030"
            "titulo" => "Antecedentes"
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            "identificador" => "abst0035"
            "titulo" => "Objetivo"
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          2 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "M&#233;todos"
          ]
          3 => array:2 [
            "identificador" => "abst0045"
            "titulo" => "Resultados"
          ]
          4 => array:2 [
            "identificador" => "abst0050"
            "titulo" => "Conclusi&#243;n"
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        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
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            "imagen" => "gr1.jpeg"
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Compliance with antibiotic prophylaxis during baseline &#40;January&#8211;April&#41; and intervention period &#40;May&#8211;December&#41; &#40;per 100 surgical procedures&#41;&#46;</p>"
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      1 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
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        "figura" => array:1 [
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Antibiotic consumption &#40;DDD&#47;100 procedures&#41; and cost &#40;QR&#47;100 procedures&#41; during baseline &#40;January&#8211;April&#41; and intervention period &#40;May&#8211;December&#41;&#46;</p>"
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      2 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
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        "mostrarDisplay" => false
        "detalles" => array:1 [
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            "identificador" => "at1"
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          "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">B&#58; baseline period&#59; I&#58; intervention period&#59; ORIF&#58; open reduction and internal fixation&#59; DDD&#58; daily defined doses&#59; QR&#58; Qatari Riyal&#46;</p>"
          "tablatextoimagen" => array:1 [
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Variable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
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                  \t\t\t\t  " colspan="2" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Cesarean section</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="2" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Appendectomies</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="2" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Hernia surgery</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="2" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">ORIF</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="2" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Abdominoplasty</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="2" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Cholecystectomy</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="2" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Total</th></tr><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">I&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">I&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">I&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">I&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">I&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">I&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">I&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Number of procedures</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">139&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">71&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">197&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">67&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">128&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">49&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">192&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">617&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="15" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="15" align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Timing&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">88&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Antibiotics consumption &#40;DDD&#47;100 procedures&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Other antibiotics&nbsp;\t\t\t\t\t\t\n
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