USA Department of Defense audit of surgical antibiotic prophylaxis prescribing patterns in inguinal hernia repair.

PURPOSE: Antibiotic prophylaxis in inguinal hernia repair (IHR) is contentious in literature and practice. In low-risk patients, for whom evidence suggests antibiotic prophylaxis is unnecessary, many surgeons still advocate for its routine use. This study surveys prescription patterns of Department of Defense (DoD) general surgeons. METHODS: An anonymous survey was sent electronically to approximately 350 DoD general surgeons. The survey asked multiple-choice and free text answers about prescribing patterns and knowledge of current evidence for low-risk patients undergoing elective open inguinal hernia repair without mesh (OIHRWOM), open inguinal hernia repair with mesh (OIHRWM), or laparoscopic inguinal hernia repair (LIHR). RESULTS: 110 DoD general surgeons consented to participate. 58.6, 95 and 84.2% of surgeons always administer antibiotic prophylaxis in OIHRWOM, OIHRWM, and LIHR, respectively. 37.9, 70.9, and 63.2% of surgeons believe that it reduces rates of surgical site infection in OIHRWOM, OIHRWM, and LIHR, respectively. The most common reasons for empirically prescribing antibiotic prophylaxis include "I think the evidence supports it" (27 of 72 responses), "I would rather be conservative and safe" (15 of 72 responses), and "I am following my hospital/department guidelines" (9 of 72 responses). 11.8, 40.8, and 32.9% of surgeons believe current evidence supports antibiotic prophylaxis use in OIHRWM, OIHRWOM, and LIHR, respectively. 50, 18.4, and 22.4% of surgeons believe current evidence refutes antibiotic prophylaxis use in OIHRWM, OIHRWOM, and LIHR, respectively. CONCLUSION: The survey results indicate that the majority of practicing DoD general surgeons still empirically prescribe surgical antibiotic prophylaxis in IHR despite more conflicting opinions that it has no meaningful effect or that current evidence does not supports its use.

Ventral hernia repair outcomes predicted by a 5-item modified frailty index using NSQIP variables.

PURPOSE: Frailty is a decrease in physiologic reserve that is separate from the normal aging process. Previously, an 11-item modified frailty index (mFI) using NSQIP variables predicted outcomes for surgical patients. We aim to validate a condensed 5-item mFI in ventral hernia patients and determine outcomes and the relative impact of each frailty variable. METHODS: The NSQIP database was queried from 2011 to 2016 for patients undergoing VHR. Spearman's rho correlation was used to determine the degree of correlation between 11-item and 5-item mFI raw frailty scores. Chi squared testing was used to determine odds ratios (95% CI) for accumulating frailty variables in both indices with regard to complications vs a baseline of zero variables present on the 11-item scale. Complications were defined by the Clavien-Dindo (CD) classification. Univariate and multivariate analyses were performed on each frailty variable to determine their relative weighted impacts on outcomes. RESULTS: 97,905 patients (99.45%) had all five frailty variables recorded. Only 11,549 patients (11.73%) had all variables from the 11-item mFI. No difference existed between groups for the five mutually shared frailty variables, BMI, emergent vs non-emergent procedures, operative time, or operative approach. For accumulating variables in both indices, the 5-item mFI predicts incidence of any complications, major complications, and discharge not to home similarly to the 11-item mFI. The most significantly weighted variable for complications and discharge not to home is functional status. CONCLUSION: A 5-item mFI accurately predicts outcomes similar to the validated 11-item mFI and captures more patients for analysis.