Impact of individualized feedback letters on adherence to surgical antibiotic prophylaxis guidelines: an interrupted time series study (FEEDBACK-ASAP)


      • Adequate surgical antibiotic prophylaxis (SAP) decreases surgical site infections.
      • Compliance to local SAP guidelines was assessed pre and per-intervention.
      • Intervention consisted of feedback letters sent to surgeons and anesthesiologists.
      • An interrupted time series found a non-significant difference in compliance rates.
      • A longer and multidimensional intervention might improve SAP compliance.


      Surgical antibiotic prophylaxis (SAP) has been proved to decrease the rate of surgical site infections (SSI), but compliance to SAP guidelines remains suboptimal.


      This study evaluated the impact of periodically sending individualized feedback letters to surgeons and anesthesiologists on their compliance rate to SAP guidelines.


      A total of 1491 surgeries were evaluated by retrospective chart review during the pre-intervention period and 668 surgeries were evaluated by prospective chart review during the per-intervention period. Finally, 295 letters were sent to 64 surgeons and 45 anesthesiologists. Compliance rate was assessed as an outcome composed of: indication for SAP, choice of antibiotic agent, antibiotic dose, postoperative duration, timing of the preoperative dose and intraoperative redosing. An interrupted time series design was used to assess a difference on compliance rates before and during the intervention period.


      Sending individualized feedback letters to surgeons and anesthesiologists did not significantly improve the overall compliance to local SAP guidelines.


      Individualized feedback letters could be part of future interventions directed at improving compliance to SAP guidelines, but are likely insufficient by themselves to provide significant results.

      Key Words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to American Journal of Infection Control
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Mitchell R
        • Taylor G
        • Rudnick W
        • et al.
        Trends in health care-associated infections in acute care hospitals in Canada: an analysis of repeated point-prevalence surveys.
        Cmaj. 2019; 191: e981-e988
        • Ozgun H
        • Ertugrul BM
        • Soyder A
        • Ozturk B
        • Aydemir M.
        Peri-operative antibiotic prophylaxis: adherence to guidelines and effects of educational intervention.
        Int J Surg. 2010; 8: 159-163
        • Bratzler DW
        • Houck PM.
        Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project.
        Am J Surg. 2005; 189: 395-404
        • Bratzler DW
        • Dellinger EP
        • Olsen KM
        • et al.
        Clinical practice guidelines for antimicrobial prophylaxis in surgery.
        Am J Health Syst Pharm. 2013; 70: 195-283
        • Sutherland T
        • Beloff J
        • Lightowler M
        • et al.
        Description of a multidisciplinary initiative to improve SCIP measures related to pre-operative antibiotic prophylaxis compliance: a single-center success story.
        Patient Saf Surg. 2014; 8: 37
        • Frenette C
        • Sperlea D
        • Tesolin J
        • Patterson C
        • Thirion DJ.
        Influence of a 5-year serial infection control and antibiotic stewardship intervention on cardiac surgical site infections.
        Am J Infect Control. 2016; 44: 977-982
        • Frenette C
        • Sperlea D
        • Leharova Y
        • Thirion DJ.
        Impact of an infection control and antimicrobial stewardship program on solid organ transplantation and hepatobiliary surgical site infections.
        Infect Control Hosp Epidemiol. 2016; 37: 1468-1474
        • Schmitt C
        • Lacerda RA
        • Turrini RNT
        • Padoveze MC.
        Improving compliance with surgical antibiotic prophylaxis guidelines: a multicenter evaluation.
        Am J Infect Control. 2017; 45: 1111-1115
        • Alerany C
        • Campany D
        • Monterde J
        • Semeraro C
        Impact of local guidelines and an integrated dispensing system on antibiotic prophylaxis quality in a surgical centre.
        J Hosp Infect. 2005; 60: 111-117
        • Onion CW
        • Bartzokas CA.
        Changing attitudes to infection management in primary care: a controlled trial of active versus passive guideline implementation strategies.
        Fam Pract. 1998; 15: 99-104
        • Septimus EJ
        • Owens Jr., RC
        Need and potential of antimicrobial stewardship in community hospitals.
        Clin Infect Dis. 2011; 53: S8-S14
        • Wagner AK
        • Soumerai SB
        • Zhang F
        • Ross-Degnan D.
        Segmented regression analysis of interrupted time series studies in medication use research.
        J Clin Pharm Ther. 2002; 27: 299-309
        • Harrell FE
        • Lee KL
        • Mark DB.
        Multivariable prognostic models: issues in developing models, evaluating assumptions and adequacy, and measuring and reducing errors.
        Stat Med. 1996; 15: 361-387
        • Zhang F
        • Wagner AK
        • Ross-Degnan D.
        Simulation-based power calculation for designing interrupted time series analyses of health policy interventions.
        J Clin Epidemiol. 2011; 64: 1252-1261
        • Ivers N
        • Jamtvedt G
        • Flottorp S.
        Audit and feedback: effects on professional practice and healthcare outcomes.
        Cochrane Database Syst Rev. 2012; 6CD000259
        • Waters JA
        • Francone T
        • Marcello PW
        • et al.
        Quality improvement initiatives in colorectal surgery: value of physician feedback.
        Dis Colon Rectum. 2017; 60: 213-218
        • Tan JA
        • Naik VN
        • Lingard L.
        Exploring obstacles to proper timing of prophylactic antibiotics for surgical site infections.
        Qual Saf Health Care. 2006; 15: 32-38
        • Broom J
        • Broom A
        • Kirby E
        • Post JJ.
        Improvisation versus guideline concordance in surgical antibiotic prophylaxis: a qualitative study.
        Infection. 2018; 46: 541-548