in the recent years , in response to the medical improvements , the field of infection control has progressed by cooperation of the epidemiology with health sciences to decrease risk factors for health care - associated infections ( hals ) ; therefore , interventions to prevent hals should be implemented .
the primary role of an infection - control program is to reduce the risk of nosocomial infection through protecting patients , employees , health care students , and visitors ( 1 ) .
health care - associated infections are reported in 1.7 million cases annually in the united states with approximately 100,000 deaths ( 2 ) .  
the functions of a hospital epidemiology program vary from institution to institution , but can be generally divided into the following areas : surveillance , outbreak investigation , education , employee health , the monitoring and management of institutional antibiotic use and antibiotic resistance , the development of infection - control policies and procedures , environmental hygiene , and new - product evaluation .
nearly 60% of the admitted patients receive antibiotics , and antibiotic usage varies widely across hospitals ( 3 ) .
the hospital epidemiology program should monitor the current antimicrobial status and susceptibility profiles on a regular basis to observe the trends in the development of antibiotic resistance .
the results should be adjusted with the antimicrobial agents currently used in the hospital .  
the best data are obtained if prophylactic antibiotics are distinguished from antibiotics used for treatment .
efforts should be made to optimize antimicrobial prophylaxis for surgical procedures , optimize selection of the first choice antibiotic and duration of empiric antimicrobial therapy , and improve antimicrobial prescribing practices .
a variety of approaches can be undertaken including educational , administrative , e g formulary restrictions , and direct interventions by a team that manages antimicrobial use in the real time ( 4 ) .
post operation wound infection is a major cause of morbidity , mortality , and health care costs .
a considerable proportion of the millions of operations in the world each year are complicated by a surgical site infection ( ssi ) ( 5 ) .  
when an ssi occurs , hospital readmissions and health care services at home increase ( 6 ) .
the use of antibiotics to prevent postoperative infections plays an important role in reducing the incidence of postoperative infections , duration of stay in hospital , cost of treatment , mortality , and helps the patient go back to the normal life more quickly ( 7 ) .
locally published studies ( in farsi ) indicated that antibacterial agents , ranked second after analgesic drugs in iran and the consumption of these drugs in the country shows positive trend over the years . although it was expected that the new antibiotics reduce the number of deaths and the incidence of infectious diseases , in practice they did not ( 8 , 9 ) . indeed , increasing the incidence of infectious diseases caused by bacterial resistance against antibiotics , emerging and re - emerging of infectious diseases , and mortality of nosocomial infections are mostly due to the incorrect use of antibiotics that is a major health problem in the country ( 8 , 10 , 11 ) .
however , despite the effectiveness of prophylactic antimicrobials to prevent ssis , the use of antibiotic prophylaxis is often inappropriate .  
previous reports indicated that timing of administration , selection of the antibiotic , and duration of prophylaxis were inappropriate in the great majorities of cases ( 5 , 7 , 12 - 16 ) .
while antibiotic prophylaxis is common in surgical procedures , inappropriate use of antibiotics occurs in 25% to 50% of the general elective surgeries ( 17 ) .
unnecessary use of antibiotics and prolonged antibiotic prophylaxis ( more than 48 hours ) are significantly associated with increased risk of antimicrobial resistant microorganisms ( 7 ) .
to establish strategies for rational use of antibiotics to prevent ssi in hospitals , it is necessary to be aware of the current status of antibiotic use patterns . searching the database of ahvaz university of medical sciences ( published dissertations and articles ) shows that official reports or studies in this field in khuzestan province do not exist ; therefore , the current study aimed to determine the prophylactic antibiotic use patterns in a teaching hospital affiliated to jundishapur university of medical sciences .
simple descriptive study . from april 2011 to march 2012 , this study performed in razi hospital affiliated to ahvaz jundishapur university of medical sciences . according to mangram 's guideline ,
post - surgical wounds are categorized as : class 1 : clean wound ; an uninfected operative wound in which no inflammation is encountered and the respiratory , alimentary , genital , or uninfected urinary tract is not entered .
in addition , clean wounds are primarily closed and , if necessary , drained with closed drainage .
operative incisional wounds that follow non penetrating ( blunt ) trauma should be included in this category if they meet the criteria .
class 2 : clean - contaminated wound ; it is an operative wound in which the respiratory , alimentary , genital or urinary tracts are entered under controlled conditions and without unusual contamination .
specifically , operations involving the biliary tract , appendix , vagina , and oropharynx are included in this category , provided that no evidence of infection or major break in technique is encountered .
in addition , operations with major breaks in sterile technique , e.g. open cardiac massage , or gross spillage from the gastrointestinal tract , and incisions in which no acute purulent inflammation is encountered are included in this category .
class 4 : dirty - infected wound ; that is old traumatic wounds with retained devitalized tissue and those that involve the existing clinical infection or perforated viscera .
this definition suggests that the organisms causing postoperative infection were present in the operative field before the operation ( 18 ) . in the current study , based on the extracted data from medical files , the patients possessing the inclusion criteria were reviewed as cases .
procedure was defined as clean if no inflammation was encountered and the respiratory , alimentary , genital , or infected urinary tract was not entered .
procedure was defined as clean - contaminated if genital , alimentary respiratory or infected urinary tract was entered .
operations involving the appendix , biliary tract , vagina and oropharynx are also included in clean - contaminated procedures .
the procedure was dirty - infected if clinical infection existed or devitalized tissue was observed in the old traumatic wounds .
prophylactic antibiotic was necessary for all clean - contaminated procedures and certain clean procedures , that is the ones in which intravascular / joint prosthetic device was inserted or there were risk factors , i.e. diabetes mellitus , malnutrition , obesity , irradiation history , use of immunosuppressant , or smoking . dirty or contaminated procedures under treatment of antibiotics were not considered prophylaxis .
this criterion was as follows : cefazolin is the selected antibiotic for cardiac , orthopedic , vascular , and neurosurgery operations ; where methicillin resistant staphylococcus aureus ( mrsa ) is suspected to cefazolin , the study shifted to vancomycin and in the case of anaerobic pathogens exist , metronidazole was added .
dose and timing of antibiotic is defined as proper if infusion of one to two grams cefazolin , one gram vancomycin or 500 mg metronidazole started 60 minutes before incision and repeated three to five hours cefazolin , six to eight hours metronidazole , or 12 hours vancomycin after the first dose .
duration of prophylaxis was considered sufficient if lasted less than 24 hours , except 48 hours for cardiac surgery .
patients were studied according to the type of surgery , the department they were admitted in , and the regimen of antibiotic prophylaxis .
all variables were analyzed including demographic characteristics , underlying diseases , type of illness , kind of surgery , received antibiotics , the mode and dose of antibiotic , and the length of treatment .
indications for antibiotic use , proper or inappropriate antibiotics , an antibiotic or combination of antibiotics , dosage , and the length of treatment for each patient were administrated , based on the abovementioned definitions in the textbook of infectious diseases ( 7 ) .
from april 2011 to march 2012 , this study performed in razi hospital affiliated to ahvaz jundishapur university of medical sciences .
according to mangram 's guideline , post - surgical wounds are categorized as : class 1 : clean wound ; an uninfected operative wound in which no inflammation is encountered and the respiratory , alimentary , genital , or uninfected urinary tract is not entered . in addition ,
operative incisional wounds that follow non penetrating ( blunt ) trauma should be included in this category if they meet the criteria .
class 2 : clean - contaminated wound ; it is an operative wound in which the respiratory , alimentary , genital or urinary tracts are entered under controlled conditions and without unusual contamination .
specifically , operations involving the biliary tract , appendix , vagina , and oropharynx are included in this category , provided that no evidence of infection or major break in technique is encountered .
in addition , operations with major breaks in sterile technique , e.g. open cardiac massage , or gross spillage from the gastrointestinal tract , and incisions in which no acute purulent inflammation is encountered are included in this category .
class 4 : dirty - infected wound ; that is old traumatic wounds with retained devitalized tissue and those that involve the existing clinical infection or perforated viscera .
this definition suggests that the organisms causing postoperative infection were present in the operative field before the operation ( 18 ) . in the current study , based on the extracted data from medical files , the patients possessing the inclusion criteria were reviewed as cases
procedure was defined as clean if no inflammation was encountered and the respiratory , alimentary , genital , or infected urinary tract was not entered .
procedure was defined as clean - contaminated if genital , alimentary respiratory or infected urinary tract was entered .
operations involving the appendix , biliary tract , vagina and oropharynx are also included in clean - contaminated procedures .
the procedure was dirty - infected if clinical infection existed or devitalized tissue was observed in the old traumatic wounds .
prophylactic antibiotic was necessary for all clean - contaminated procedures and certain clean procedures , that is the ones in which intravascular / joint prosthetic device was inserted or there were risk factors , i.e. diabetes mellitus , malnutrition , obesity , irradiation history , use of immunosuppressant , or smoking . dirty or contaminated procedures under treatment of antibiotics were not considered prophylaxis .
this criterion was as follows : cefazolin is the selected antibiotic for cardiac , orthopedic , vascular , and neurosurgery operations ; where methicillin resistant staphylococcus aureus ( mrsa ) is suspected to cefazolin , the study shifted to vancomycin and in the case of anaerobic pathogens exist , metronidazole was added .
dose and timing of antibiotic is defined as proper if infusion of one to two grams cefazolin , one gram vancomycin or 500 mg metronidazole started 60 minutes before incision and repeated three to five hours cefazolin , six to eight hours metronidazole , or 12 hours vancomycin after the first dose .
duration of prophylaxis was considered sufficient if lasted less than 24 hours , except 48 hours for cardiac surgery .
patients were studied according to the type of surgery , the department they were admitted in , and the regimen of antibiotic prophylaxis .
all variables were analyzed including demographic characteristics , underlying diseases , type of illness , kind of surgery , received antibiotics , the mode and dose of antibiotic , and the length of treatment .
indications for antibiotic use , proper or inappropriate antibiotics , an antibiotic or combination of antibiotics , dosage , and the length of treatment for each patient were administrated , based on the abovementioned definitions in the textbook of infectious diseases ( 7 ) .
of the total 13763 patients 47.5% and 52.5% were male and female respectively , 8945 procedures were clean , 3440 were clean - contaminated , 963 were contaminated and 412 were dirty .
of the total 8586 patients who took antibiotics for preventive purposes , 4815 ( 56% ) required antimicrobial prophylaxis , and 3771 ( 44% ) patients did not .
unnecessary use of prophylactic antibiotics was observed in 3771 ( 44% ) patients . of the total 4815 medical procedures requiring antimicrobial prophylaxis , all received it . of the 4815 patients who received perioperative prophylaxis , 4182 ( 86.9% ) cases
received it appropriately , and 633 ( 13.1% ) received it inappropriately , 397 ( 8.2% ) cases received inappropriate dosage , and 457 ( 9.5% ) cases received antibiotic longer than 24 hours .  
cefazolin , vancomycin , gentamicin , and metronidazole were the most commonly used drugs for prophylactic purposes .
the frequency of patients who received cefazolin in the departments of obstetrics , general surgery , and orthopedics was 4261 , 2457 , and 2322 , respectively .
the frequency of patients who received vancomycin in the departments of obstetrics , general surgery , and orthopedics was 2025,820 , and 705 , respectively .
the number of patients who received gentamicin in the departments of obstetrics , general surgery and orthopedics was 1152 , 2300 , and 1025 respectively , and the number patients who received metronidazole in the departments of obstetrics and general surgery was 512 and 1750 , respectively .   the frequency of patients who received these antibiotics is shown in figure 1 .
antimicrobial selection , cefazolin , vancomycin , and metronidazole , was appropriate in most of the cases except for gentamicin .
comparison of the hospital departments for prophylaxis and unnecessary prophylaxis are shown in tables 2 and 3 .
comparison of the hospital departments for incorrect antibiotic regimen , inappropriate dosage of antibiotic , and the length of treatment are shown in table 4 .
the most unnecessary antibiotic use was observed in general surgery ward and the most inappropriate antibiotic regimen , wrong dosage , and length of antibiotics were observed in obstetrics ward .
of the six infection prevention measures , three core measures contain recommendations regarding the selection of prophylactic antibiotics , timing of administration , and duration of therapy ( 12 ) . in the current study ,
for most of the patients undergoing clean - contaminated surgeries , gastrointestinal , orthopedic , and gynecologic , infection control committee recommended an antibiotic regimen including the first generation cephalosporin such as cefazolin or vancomycin , when mrsa infection is suspected ; with or without metronidazole , if anaerobic pathogens were likely , as the choice antibiotic regimen to prevent post operation infections .
results of the current study revealed that the current patterns of using antibiotics to prevent surgical infections in razi hospital were not favorable . in total , approximately 45% of antibiotics were prescribed without indication and were unnecessary .  
approximately 13% ( 8.2% to 13% ) of the indicated antibiotic prophylaxis was inappropriate at least in antibiotic regimen , dose , or duration of antibiotic administration . in spite of hospital infection control recommendations ,
the application of prophylactic antimicrobials to prevent ssis and use of antibiotic prophylaxis were often inappropriate .
published studies indicate that the antibiotic regimen selection , timing of administration , dose of antibiotic and duration of prophylaxis in majority of the cases is inappropriate ( 5 , 7 , 12 - 16 ) .
for example it is administered when not required , not administered when required , or not administered properly ( 7 , 15 ) .
in contrast to the findings of other studies , however , the prescription of antibiotics in iranian hospitals is irrational , it is not higher than those of the other regions of the world , but it is still unacceptable .  
the infection control committee in razi hospital has not distributed a guideline for surgical prophylaxis based on the standard documents and original researches conducted by microbiology department of the university regarding the most common isolated organisms and susceptibility patterns .
it seems advisable that surgeons consult with infectious diseases specialist before administration of antibiotics for prophylaxis for surgical procedures in special clinical situations ( 19 )   the present study found that approximately 42% of the studied patients received appropriate antimicrobial prophylaxis .
prophylaxis was inappropriately performed in 13% of 4,815 patients requiring prophylaxis . in the current study ,
3771 ( about 44% ) patients received preoperative antibiotic , but they did not need it .
thus , the most common wrong activities of surgical prophylaxis in razi hospital appear to be excessive use of antibiotics .
this finding is consistent with reports from developing countries as well as iran ( 16 , 20 , 21 ) , but in contrast to developed country where the most common error in the surgical prophylaxis practice is omission of antibiotics rather than their excessive use ( 15 ) .
the current study also found that all of the patients under study received antibiotics on time .
as a routine in the hospital , initiation of prophylaxis is at the time of anesthesia induction .
this finding is similar to that of the studies performed in other areas ( 15 , 16 ) .  
however , six different drugs or drug combinations were used ; cefazolin , cefazolin plus gentamicin , vancomycin , vancomycin plus gentamycin , cefazolin plus metronidazole , and vancomycin plus metronidazole .
this problem is similar to that of a study previously performed ( 16 , 22 ) .
surgeons ` unawareness to consult with infectious disease specialists and lack of certain guidelines of antibiotics use for prophylaxis in the hospital may be discussed for these differences . in the current study ,
the rate of longer duration of administration of antibiotics was 9.5% , which ranged from 2.2% in general surgery department to 13.6% in gynecology department .
this finding was inconsistent with that of vaisbrud et al . with 91% ( 15 ) .
after unnecessary use of antibiotics and selection of antibiotics , the most commonly detected error was too long postoperative administration of antibiotics .
majority of iranian surgeons insist on the need for prolonged postoperative use of antibiotic therapy to prevent post - operative infections . it is known well that prolonged use of post - operative antimicrobials not only does not provide additional benefit , but also affects emerging the bacterial resistance ( 7 ) .
the current study had limitations such as retrospective design , restriction to just one hospital , and only three surgery departments . since the condition of all hospitals affiliated to jundishapur university is similar from the study purposes view point ; therefore , restriction to a hospital could not result in significant bias .   in conclusion
however , 44% of those who received prophylaxis did not need it . in patients receiving antibiotics ,
the most common mistakes were antibiotic selection followed by prolonged prophylaxis ( > 24 hours ) , and excess dose of antibiotics . feeding this information back to surgeons and establishing pre - operative prophylaxis guidelines as a routine activity of infection control teams could improve nosocomial infection control program .
 background : despite the effectiveness of prophylactic antimicrobials to prevent surgical site infection the use of antibiotic prophylaxis is often inappropriate.objectives:the current study aimed to determine the pattern of prophylactic antibiotic use in a teaching hospital affiliated to jundishapur university of medical sciences , ahvaz , iran.patients and methods : the current descriptive study included 8586 patients who received prophylactic antibiotics before surgery from april 2011 to march 2012 , in razi hospital affiliated to jundishapur university of medical sciences . 
 indications for antibiotic use , proper or inappropriate antibiotics , an antibiotic or combination of antibiotics , dosage and length of treatment for each patient based on the infectious disease textbook ( mandel 's principle and practice of infectious diseases ) definitions were administrated.results:of the total 8586 patients who took antibiotics for preventive purposes , 4815 ( 56% ) required antimicrobial prophylaxis , and 3771 ( 44% ) patients did not . 
 of the 4815 patients who received prophylaxis , 86.9% received it appropriately , 13.1% received it inappropriately ; 8.2% received inappropriate dosage , and 9.5% received antibiotic longer than 24 hours.conclusions:the current study revealed that 44% of those who received prophylaxis did not need it . 
 in the patients who received antibiotics , the most common mistakes were antibiotic selection followed by prolonged prophylaxis ( > 24 hours ) and excess dose . 
1. Background
2. Objectives
3. Patients and Methods
3.1. Study Design
3.2. Study Time and Place
3.3. Definitions
3.4. Study Population
3.5. Statistics
4. Results
5. Discussion