56
Abstract
Purpose: The aim of the present study 
was to evaluate the impact of an educatio-
nal intervention package on perioperative 
antimicrobial prophylaxis (PAP) prescrip-
tion practice in three elective procedures—
total hip arthroplasty (THA), caesarean 
section (CS), and radical prostatectomy 
(RP)—in a single tertiary care hospital in 
Slovenia.
Methods: An interventional study was 
performed to evaluate the impact of an 
Izvleček
Namen: Namen raziskave je bil preu-
čiti vlogo edukacije v izboljšanju pred-
pisovanja perioperativne antibiotične 
zaščite (PAZ) na treh kirurških oddel-
kih Univerzitetnega kliničnega centra 
Maribor pri treh vrstah načrtovanih ki-
rurških posegov (vstavitev totalne kolč-
ne endoproteze-TKE, radikalna odprta 
prostatektomija-RP in carski rez- CR).
Metode: V intervencijski raziskavi 
smo opazovali vpliv edukacijskega 
Ključne besede: 
perioperativna antibiotična zaščita, 
priporočila, skladnost, kirurgija, 
izobraževalna intervencija.
Key words: 
perioperative antibiotic prophylaxis, 
recommendations, compliance, 
surgery, educational intervention.
Predpisovanje perioperativne antibiotične zaščite v 
terciarni bolnišnici v Sloveniji - vloga edukacije pri 
izboljšanju predpisovanja 
Preoperative antibiotic prophylaxis in a single 
tertiary hospital in Slovenia—the role of education 
in recommendation compliance
Avtor / Author Matej Žnidarič1, Matjaž Vogrin2,3, Andrej Moličnik2, Faris Mujezinović4, 
Niko Kavčič5, Nina Gorišek Miksić6,7 
Ustanova / Institute 1Univerza v Mariboru, Medicinska fakulteta, Maribor, Slovenia; 2Univerzitetni klinični center 
Maribor, Klinika za kirurgijo, Oddelek za ortopedijo, Maribor, Slovenija; 3Univerza v Mariboru, 
Medicinska fakulteta, Katedra za ortopedijo, Maribor, Slovenija; 4Univerzitetni klinični center 
Maribor, Klinika za ginekologijo in perinatologijo, Maribor, Slovenija; 5Univerzitetni klinični 
center Maribor, Klinika za kirurgijo, Oddelek za urologijo, Maribor, Slovenija; 6Univerzitetni 
klinični center Maribor, Oddelek za infekcijske bolezni in vročinska stanja, Maribor, Slovenija; 
7Univerza v Mariboru, Medicinska fakulteta, Katedra za infektologijo, Maribor, Slovenija;
1University Maribor, Faculty of Medicine, Maribor, Slovenia; 2University Medical Centre 
Maribor, Clinic for Surgery, Department for orthopaedic surgery, Maribor, Slovenia; 
3University Maribor, Faculty of Medicine, Department for orthopaedic, Maribor, Slovenia;4 
University Medical Centre Maribor, Clinic for gynaecology and perinatology, Maribor, 
Slovenia; 5University Medical Centre Maribor, Clinic for Surgery, Department for urology, 
Maribor, Slovenia; 6University Medical Centre Maribor, Department for infectious diseases, 
Maribor, Slovenia; 7University Maribor, Faculty of Medicine, Department of Infectious 
diseases and febrile conditions, Maribor, Slovenia;
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paketa na izboljšanje predpisovanja 
PAZ v skladu z lokalnimi priporočili. 
V predintervencijskem obdobju smo 
pregledali po 30 popisov treh izbranih 
vrst elektivnih kirurških posegov. Pri 
vseh posegih smo pridobili podatke o 
ustreznosti PAZ (indikacija, izbira, 
odmerek, in število odmerkov ter čas 
aplikacije PAZ). Paket izobraževal-
nih intervencij je vključeval razgovor s 
predstojniki, izobraževanje zdravnikov 
na izbranih oddelkih z diskusijo ter pri-
loženimi žepnimi kartončki s priporoči-
li. V postintervencijskem obdobju (3-6 
mesecev po intervenciji) smo ponovno 
pregledali medicinsko dokumentacijo 
po 30 primerov posegov vseh treh vrst 
in vnovič analizirali skladnost predpi-
sovanja.
Rezultati: Pri izbranih elektivnih 
posegih (TKE, CR, RP) so v predinter-
vencijskem obdobju predpisovali PAZ 
povsem skladno s priporočili v 67 %, 
70 % in 3.3% pregledanih posegov. 
Ugotavljali smo odstopanje na podro-
čju ustreznega časa aplikacije pred ki-
rurškim posegom in trajanja PAZ. Ve-
čje odstopanje od priporočil pri posegu 
RP je posledica dejstva, da gre za velik 
poseg v trebušni votlini, kjer se kirurg 
glede na poseg včasih odloči za podalj-
šanje PAZ. Po izobraževalni interven-
ciji se je izboljšala skladnost predpiso-
vanja PAZ s priporočili na vseh treh 
oddelkih, skladno so predpisovali pri 
80%, 90% in 50% primerov pri TKE, 
CR in RP.
Zaklju~ek: Z enostavnim izobraže-
valnim ukrepom lahko tudi v našem 
okolju izboljšamo predpisovanje PAZ, 
kar pomembno vpliva na zmanjšanje 
porabe protimikrobnih zdravil, posle-
dično se zmanjša vpliv na razvoj pro-
timikrobne odpornosti, znižajo se tudi 
stroški. 
educational intervention package on PAP 
compliance. PAP prescription practices for 
three elective types of surgery (THA, CS, 
and RP) were observed. Thirty operative 
reports for each type of surgical procedure 
were evaluated according to indication, 
timing of preoperative prophylaxis admi-
nistration, antibiotic selection and dosage, 
and total prophylaxis duration. This was 
followed by an educational intervention 
package that included a discussion with de-
partment leaders led by an infectious dise-
ase specialist and an educational seminar 
and discussion for surgeons, supplemented 
by PAP recommendations provided as poc-
ket reminders. Then, the compliance with 
PAP recommendations for the same types 
of procedures performed in the post-inter-
ventional period (3–6 months after the 
intervention) was evaluated again.
Results: Complete pre-interventional 
compliance with local guidelines was ob-
served in 67%, 70%, and 3.3% of THA, 
CS, and RP cases, respectively. A major 
deviation from PAP recommendations 
was observed in the timing of preoperative 
PAP administration before surgery and in 
the total PAP duration A deviation from 
recommendations for RP, which is a major 
surgical procedure, was observed as a lon-
ger postoperative PAP duration compared 
to the intraoperative course. In the post-
-interventional period, an improvement in 
total compliance with PAP recommenda-
tions was observed in 80.0%, 90.0%, and 
50.0% of THR, CS, and RP procedures, 
respectively. 
Conclusion: Our study revealed an 
improvement in adherence to PAP recom-
mendations after an educational interven-
tion package for selected procedures at the 
University Medical Centre Maribor. This 
simple intervention can have an important 
impact on patient care quality by reducing 
antimicrobial medication use, resistance 
development, and treatment cost.
Naslov za dopisovanje /  
Correspondence
Doc. dr. Nina Gorišek Miksić, dr. med., 
Univerzitetni klinični center Maribor, 
Oddelek za infekcijske bolezni in 
vročinska stanja, Ljubljanska 5, 2000 
Maribor, Slovenija
Telefon +386 23212657
Fax +386 23312391
E–mail: ninamiksic@gmail.com
Članek prispel / Received
20. 1. 2021
Članek sprejet / Accepted
18. 7. 2021
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INTRODUCTION
Throughout history, the incidence of infections has 
been an important driver of improvements in medical 
care. Surgical site infections (SSIs) remain one of the 
major causes of hospital morbidity and mortality (1). 
They are one of the most common complications 
after surgery, which account for approximately 17% 
of all infections acquired in a hospital setting (HAI). 
According to Cassini et al., an estimated 3.5 million 
Europeans are affected by HAIs each year, of which 
2.5 million die or suffer from serious complications 
(2). HAIs affect 501/100,000 patients daily and SSIs 
are the third most common cause of HAI (2). SSIs 
have been associated with a longer postoperative 
recovery time and additional surgery to treat infection 
complications (2, 3). A British study found that SSIs 
prolong hospitalization time from 3.3 to 21 days and 
significantly increase medical treatment cost (4). 
Among the important measures for reducing SSIs, 
appropriate perioperative antibiotic prophylaxis (PAP) 
can prevent up to 80% of SSIs (5). SSIs most commonly 
develop due to the introduction of bacteria from the 
patient's flora or surroundings into the wound area 
during a surgical procedure (6). In a large-scale study 
that included 21 meta-analyses of randomized control 
studies with a total of 48,909 patients, Bowater et 
al. concluded that regardless of the type of surgery 
(clean, clean-contaminated, and contaminated), PAP 
significantly reduced the proportion of all SSIs in a 
hospital setting (7). Therefore, PAP is recommended 
only for procedures with a higher risk of postoperative 
SSI and in procedures with a low risk of infection where 
infection consequences are likely to be devastating 
(8). PAP contributes considerably to the total amount 
of antibiotics used in the hospitals worldwide. It is 
estimated that 15% of all antibiotics are used for 
surgical prophylaxis (5,9). Unfortunately, many studies 
have shown noncompliance with the recommended 
PAP guidelines in up to 88% of cases, most commonly 
PAP that was administered for too long (5). A recent 
study in 14 German hospitals found that PAP was 
prescribed according to the recommendations in 
5–85% of all cases (10). In a large-scale study including 
3,253 neurosurgical procedures, Schmitt et al. found 
that an adequate PAP regimen was prescribed in only 
10% of all cases (11). A French hospital reported in 
2008 that PAP was adequate in 58% of all observed 
surgical procedures. Surgeons largely opted for PAP 
with a correct indication in 85% of cases, chose the 
correct antibiotic in 82.8% of cases, and administered 
the antibiotic at the appropriate time prior to surgery 
in only 40% of cases (12).
Zupan et al. performed an extensive study on 
compliance with PAP guidelines in Slovenia at the 
University Clinical Centre Ljubljana. They found total 
compliance with the recommended PAP in 26% of all 
cases and the lowest recommendation compliance in 
the number of PAP doses (46%), which is comparable 
to other studies across Europe (13). 
Optimizing PAP is an important intervention in the 
antimicrobial stewardship program in hospital settings. 
The European Centre for Disease Prevention and 
Control (ECDC) has published key PAP modalities 
to be implemented to improve PAP compliance (5). 
Education was found to be an important intervention 
in improving PAP compliance in different studies 
(14). Ozgun et al. found that educational intervention 
improved some aspects of PAP, though it failed 
to improve the total compliance rate in a Turkish 
hospital (15). Hulscher et al. discussed the important 
role of many determinants in hospital antimicrobial 
agent use in different countries in Europe and North 
America, as well as the associated cultural, conceptual, 
and behavioural dimensions (16).
Social, cultural, and organizational factors have a 
significant impact on the effectiveness of interventions 
for optimizing antimicrobial use. Consequently, 
intervention efficacy is not the same across different 
societies and should be examined in a local 
environment as well (17).
METHODS 
An interventional study was performed at the tertiary 
care hospital at the University Medical Centre Maribor. 
The impact of an educational intervention package 
on compliance with local PAP recommendations was 
studied in three different types of elective surgical 
procedures.
Three surgical departments were included in the study: 
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Department of Orthopedic Surgery, Department 
of Urology, and Department of Perinatology. In 
the pre-interventional period, compliance with the 
recommended local PAP guidelines was observed 
in three different types of elective surgery: total hip 
arthroplasty (THA), radical prostatectomy (RP), and 
caesarean section (CS). A total of 30 consecutive 
elective surgical procedures of each type performed 
before December 31st, 2018 were included in the pre-
interventional study. Medical records from patients 
with preoperative infectious disease, those who 
received nonprophylactic antibiotics 48 h before the 
operation, and records from non-elective procedures 
were excluded. 
Medical records for each procedure were reviewed 
and the following data were obtained: indication, 
antibiotic selection, antibiotic dosage, preoperative 
timing of PAP administration, and PAP duration 
(number of doses). The preoperative PAP timing 
and dosage information was collected from 
handwritten anesthesia documentation for every 
surgical procedure. Prescribed PAP compliance with 
local recommendations is presented in Table 1. 
INTERVENTION
In March 2019, an educational intervention package 
was presented to each of the three departments 
separately. The educational package included first a 
personal meeting between an infectious disease (ID) 
specialist and the department leaders (surgeons) to 
discuss local PAP guidelines, their PAP administration 
habits, doubts about PAP recommendations, and 
possible reasons for noncompliance with PAP 
guidelines. This was followed by an educational 
meeting with surgeons at all three departments, which 
involved an educational program on antimicrobial 
prophylaxis conducted by the ID specialist, focusing 
on different aspects of importance of appropriate 
PAP, continued by a conversation with surgeons 
about specific problems and possible solutions at 
their surgical departments. The educational meeting 
was reinforced by the distribution of pocket PAP 
recommendations prepared for each department. 
The post-interventional period was defined as 3–6 
months after the intervention. The medical records 
of 30 consecutive procedures performed during 
the post-interventional period were reviewed. The 
surgeons (except the department leader) were not 
aware of the post-interventional observations. The 
same set of PAP data was obtained. 
The collected data were analyzed using the statistical 
software package SPSS version 24 IBM. A descriptive 
statistical analysis was carried out using chi-square test 
and Fisher’s exact test when appropriate. Differences 
between groups were significant for variables yielding 
a p-value of < 0.05.  
The study was approved by the Medical Ethics 
Commission (KME) of University Medical Centre 
Maribor on March 8, 2019 (letter number: UKC-
MB-KME-19/19).
Table 1. Local recommendations for perioperative antibiotic prophylaxis at the University Medical Centre Maribor for 
selected surgery types.
Surgical procedure First-choice antibiotic Time of application Alternative antibiotic Time of application Duration
Total hip 
arthroplasty
cefazolin –
 2 g iv
3 g iv – for weight > 
120 kg
0–60 min before 
incision
vancomycin –
 1 g iv
60–90 min before 
incision
up to 24 h (1–3 
doses), preferred 
single-dose 
regimen
Radical 
prostatectomy
cefuroxime 
1.5 g iv
0–60 min before 
incision
gentamicin
120 mg iv
0–60 min before 
incision single dose
Caesarean section cefazolin 2 g iv
0–60 min before 
incision
clindamycin 900 
mg iv + gentamicin 
120 mg iv
0–60 min before 
incision single dose
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Table 2.  Comparison of PAP1 prescription compliance among all three studied departments before and after the 
intervention. 
Surgical procedure First-choice antibiotic Time of application
CRITERIA
BEFORE 
N (%)
(N=30)
AFTERN 
(%)
(N=30)
P*
BEFORE N 
(%)
(N=30)
AFTER 
N (%)
(N=30)
P*
BEFORE
N (%)
(N=30)
AFTER
N (%)
(N=8)
P**
Indication 29 (96.7) 29 (96.7) 0.895 29 (96.7) 29 (96.7) 1.00 28 (93.3) 8 (100.0) 1.00
Antibiotic choice 29 (96.7) 26 (86.7) 0.895 26 (86.7) 29 (96.7) 0.785 21 (70.0) 6 (75.0) 1.00
Dosage 29 (96.7) 26 (86.7) 0.327 26 (86.7) 29 (96.7) 0.686 22 (73.3) 6 (75.0) 0.164
Time of 
preoperative 
administration
20 (67.0) 24 (80.0) 0.378 24 (80.0) 29 (96.7) 0.579 9 (30.0) 6 (75.0) .0291
Number
of doses (total 
duration)
3 
doses***
27 (90.0)
3 
doses***
4 (13.3) 0.00001 29 (96.7) 29 (96.7) 0.579 3 (10.0) 7 (87.5) .0001
1 dose***
3 (10.0)
1 dose***
26 (86.7)
Total compliance 20 (67.0) 24 (80.0) 0.373 21 (70.0) 27 (90.0) 1 (3.3) 4 (50.0) 0.004
1 PAP - perioperative antibiotic prophylaxis
* p-value for chi-square test
** p-value for Fisher’s exact test
*** both single- and three-dose PAP was considered correct in evaluation of compliance with PAP for this type of procedure
RESULTS 
The results of pre- and post-interventional 
compliance rates were expressed as percentage 
values and presented in Table 2. 
In the pre-interventional period, the last 30 
elective surgeries of each type performed before 
31th December 2019 were included. The post-
interventional period was defined as 3–6 months 
after the intervention. The analysis evaluated 30 
consecutive cases of each procedure type performed 
in the defined time period, although due to their 
low frequency, only eight RP procedures were 
included in the post-interventional analysis.
Total pre-interventional compliance rate with 
local PAP guidelines for THA and CS procedures 
was observed in 67.0% and 70.0% of cases, 
respectively, whereas total compliance rate in RP 
surgery was 3.3%. A major deviation from PAP 
recommendations was observed in the timing 
of preoperative PAP administration for THA 
and RP procedures and in the number of PAP 
doses (duration) for the RP procedure, whereas 
compliance with indication, antibiotic choice, 
and dosage was satisfactory for all three types of 
surgeries. RP is a major intraabdominal procedure 
and prolonged PAP after the procedure is usually 
associated with the intraoperative course and 
possible intraoperative complications. 
For the THA procedure, all of the patients 
received PAP within 24 h (as recommended) 
pre-interventionally and no prolonged PAP was 
observed. There is still debate about a single-dose 
PAP vs. PAP administered within 24 h (three doses) 
for this type of surgery, although recent studies 
have confirmed that a single dose of PAP prior 
to the procedure is sufficient for SSI prevention 
(18, 19). A recommendation for a single dose 
of PAP was proposed in the department of the 
educational intervention package. A significant 
switch to a single-dose PAP was observed in the 
post-interventional study period, although PAP 
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administration within 24 h after the procedure 
was considered appropriate for the study purposes 
as well.
A trend towards improvement in total post-
interventional compliance was observed for 
the THA and CS procedures and a significant 
improvement in the RP procedure was present: 
67.0%, 70.0%, and 3.3% to 80.0%, 90.0%, and 
50.0% for the THA, CS, and RP procedures, 
respectively. The most significant improvement 
rate was also observed in the number of PAP 
doses (single-dose switch) in the THA group post-
interventionally.
DISCUSSIONS
We studied the impact of an educational 
intervention package on compliance with PAP 
recommendations in three surgical procedures. 
Non-compliance with PAP recommendations is 
a major problem in many countries around the 
world, including Slovenia (5,13).
Different interventions for optimizing PAP 
were studied (20-22). Among different factors, 
cultural norms have an important influence on 
antimicrobial medication use and PAP compliance 
(23-25). Ukawa et al. studied the influence of 
cultural and social norms defined using the 
Hofstede cultural dimensions on PAP adherence 
in European countries and found that prolonged 
PAP positively correlated with power distance 
and uncertainty avoidance index (23). Borg et al. 
observed a correlation between prolonged PAP 
(longer than 24 h) and cultural dimension index 
in different EU countries (24).
A high-power distance index indicates that people 
accept a hierarchical order. This may contribute 
to the antibiotic prescription decisions made 
by the senior medical staff, which tend to be 
unchanged by emerging research evidence (25). 
The present study is the first to investigate the 
effect of an educational intervention package on 
prescription of PAP in a tertiary care hospital 
in Slovenia. According to the Hofstede cultural 
dimension model, Slovenia is a country with 
a high power distance index (score of 71), high 
uncertainty avoidance index (score of 88), and low 
individualism index (score of 27) (26). Due to the 
cultural differences among EU countries, it was 
assumed that an educational intervention package 
might not have the same effectiveness as described 
in some northern EU countries. In a Dutch study 
by van Kasteren et al., the effect of an educational 
consultation on compliance with recommended 
PAP was studied in 13 Dutch hospitals, where 
PAP compliance increased from 5.4% before the 
intervention to 63.5% after the intervention (27).
Our study revealed some deviations in PAP 
prescription from the recommended guidelines 
in all three evaluated procedures, with an overall 
compliance rate of 67.0%, 70.0%, and 3.3% for 
THA, CS, and RP procedures, respectively. An 
overall adherence to the recommendations for 
PAP was observed (> 93% compliance rate), an 
appropriate antibiotic was chosen in 70–96% of 
cases, and the antibiotic dose was appropriate in 
73–96.7% of cases. A major deviation from PAP 
recommendations was observed in the preoperative 
timing of PAP for all three procedures (appropriate 
timing was achieved in 67.0%, 80.0%, and 30.0% 
of procedures, respectively). Results were similar 
to those from other studies, whereas the study 
from the University Clinical Center Ljubljana 
showed a far better compliance (86%) with the 
recommended timing of PAP administration. As 
stated by Zupan et al., work organization is the 
most probable cause of inappropriate PAP timing, 
which is similar to what was discovered during 
conversations with surgeons in the present study 
(13).
A particularly good pre-interventional compliance 
with the recommended PAP duration was observed 
in the THA and CS procedures, whereas PAP was 
prolonged in the RP procedure. However, RP is a 
major abdominal surgical procedure (with a higher 
postoperative complication rate) and the three 
selected procedures cannot be compared directly. 
The majority of THA patients (90%) received three 
pre-interventional PAP doses (within 24 h). The 
international guidelines for this type of procedure 
are inconsistent for the number of PAP doses 
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(one vs. three), although new research supports a 
single-dose PAP for this procedure. A single-dose 
recommendation was implemented for the THA 
procedure during the educational seminar in the 
present study. In the post-interventional period, 
the proportion of patients receiving a single dose 
of PAP during the THA procedure increased 
significantly from 10.0% to 86.7%. The switch to 
a single dose has a significant impact on reducing 
antibiotic consumption, consequently reducing 
side effects and treatment costs. We consider 
significant progress in switching the number of 
PAP doses from three to one preoperative dose 
after an educational intervention as an important 
indicator of successful intervention.
A significant improvement was also observed in 
the duration of PAP in the RP procedure, though 
the sample size was far too small for further 
conclusions. 
The present study revealed an improvement 
after an educational intervention package in the 
overall compliance with PAP recommendations 
for all three types of procedures. According to 
the ECDC review, it should be the responsibility 
of an anaesthesiologist to ensure appropriate 
preoperative timing for PAP (5). Although the 
present intervention did not include members 
of the anaesthesiology team, an improvement 
in appropriate PAP timing was observed in all 
three procedures, suggesting organizational issues 
among important factors in PAP improvement. 
We assume that gaining support for improvement 
from the department leaders during personal 
discussions before the intervention was also an 
important factor for successful intervention.
Pocket cards with PAP guidelines were distributed 
to surgeons during the educational session as well, 
which might have had an additional influence 
on PAP improvement. In a study conducted by 
Ritchie et al. at two Dutch hospitals, adherence to 
appropriate PAP procedures improved from 29% 
before the introduction of the information pocket 
cards to 74% after the introduction (p < 0.001) 
(28).
STUDY LIMITATIONS
The present study has several limitations, including 
small sample size and inclusion of only three 
surgical departments/procedures in a tertiary 
care hospital. The educational intervention 
package was a combination of three separate 
educational interventions (personal conversation, 
seminar, and distribution of pocket cards with 
PAP recommendations), so it is not possible to 
assess their separate influence on PAP compliance 
improvement. The effect of education was observed 
over the course of a relatively short time interval 
of 3–6 months post-interventionally. Repeated 
observations over a longer period will provide a 
more accurate idea of the intervention success. 
The effect of education might diminish over time 
and the impact of educational intervention should 
be reassessed after a longer time period to better 
plan successful and lasting interventions for the 
future. 
CONCLUSIONS
We studied the impact of an educational 
intervention package on compliance with local 
PAP recommendations in a Slovenian tertiary 
care hospital. While there are many reasons for 
noncompliance to PAP guidelines, we found that 
surgeon education is a reasonable and cost-effective 
intervention that can lead to improvement in 
compliance with PAP recommendations and 
should be implemented as a routine practice.
ACKNOWLEDGEMENTS
We thank all of our colleagues for providing 
critiques of the manuscript.
63 ACTA MEDICO-BIOTECHNICA
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