Introduction. - Les infections liées au geste chirurgical, (un quart des infections nosocomiales), sont une cause importante de morbidité, et augmentent la mortalité postopératoire. Intégrée dans le respect des mesures élémentaires d'hygiène et les bonnes pratiques chirurgicales, l'antibioprophylaxie est un des outils essentiels de la réduction de ce risque infectieux. L'antibioprophylaxie chirurgicale représente environ un tiers des prescriptions d'antibiotiques à l'hôpital. Ses modalités (choix des molécules, administration...) font l'objet de recommandations validées, mais sa réalisation reste imparfaite.

Matériel et méthode. - Étude 1 : évaluation (3 audits de pratiques) de l'application de l'antibioprophylaxie chirurgicale, et de l'impact des recommandations sur ces dernières. Étude 2 : évaluation des kits d'antibioprophylaxie par une étude prospective, comparative, monocentrique de deux groupes : patients exposés vs patients non exposés.

Résultats. - Étude 1 : il a été montré une augmentation significative du nombre de prescriptions d'antibioprophylaxie entre 1994 et 2002 (+23 %). Après une augmentation transitoire de 1994 à 1998, la conformité avec les recommandations dans l'indication de prescription de l'antibioprophylaxie a diminué de 7 % entre 1998 et 2002. On a noté cependant une amélioration globale de l'application des recommandations. Étude 2 : les kits d'antibioprophylaxie ont permis une meilleure conformité des pratiques par rapport aux recommandations. Les modalités de réalisation de l'antibioprophylaxie se sont avérées conformes en tous points par rapport au référentiel pour 82 % des patients exposés, vs 41 % des non exposés.

Conclusion. - La diffusion des référentiels s'est avérée dans notre étude indispensable pour l'amélioration de la prescription, mais insuffisante. La délivrance nominative journalière des antibioprophylaxies chirurgicales sous la forme de kits d'antibioprophylaxie a permis d'optimiser le respect des recommandations, en corrigeant de manière importante les limites persistantes identifiées par les audits de pratiques.

Introduction. - Surgical wounds infections represent a major cause of morbidity and are at the origin of an increase in the postoperative mortality rate. Those infections represent in France one-fourth of the nosocomial infections. Combine with the elementary hygiene rules and the surgical “good practices”, antimicrobial prophylaxis with antibiotics is an essential tool for the reduction of the surgical wound infections rate. In the French hospitals, antimicrobial prophylaxis represents one-third of the antibiotic prescriptions. The rules for the application of surgical prophylaxis are based on current guidelines for antibiotic prophylaxis, however, guidelines are not totally respected.

Material and methods. - Study 1: assessment of the guidelines application (practical audit) of the antibiotic antimicrobial prophylaxis in surgery, and of their impact on the established prescriptions: three audits were realized with four years interval (1994, 1998 and 2002), in order to estimate the evolution in the application of the current guidelines, which indirectly estimate the evolution of the guidelines impact. Study 2: assessment of the use of an antibiotic kit through a prospective comparative study of two groups: exposed patients vs non-exposed patients. Nominatives kits contained the recommended antibiotics with recommended posology and the instructions for each surgical procedure.

Results. - Study 1: this study showed a significant increase in the antibiotics prescription volume since 1994 (+23%). After a temporary increase from 1994 to 1998, the conformity of the effective prescriptions with the current guidelines for the indication to realize or not to realize an antibiotic surgical prophylaxis decreases of 7% between 1998 and 2002. Nevertheless, we noticed an overall improvement in the guidelines application for the modalities of the antimicrobial prophylaxis when it was prescribed in a valid indication. Persistent weak points were in 2002 the antibiotic molecule choice (error rate of 25%), the duration of prescription (rate of abnormal prolonged antibiotic prophylaxis of 19%), and the timing of administration (error rate of 31%). Study 2: antibiotic kits have permitted to increase the accordance of the antimicrobial prophylaxis prescriptions with the guidelines. Antibiotic prophylaxis was in total agreement with guidelines for 82% of exposed patients vs 41 for non-exposed patients. Choice of the antibiotic molecule, timing of administration and duration of prescription were the parameters particularly well rectified by this new antibiotic prophylaxis technical.

Conclusion. - In this study, guidelines diffusion seems to be an essential but also an insufficient point for the improvement of the quality prescriptions in surgical antimicrobial prophylaxis. The “day by day” nominative antibiotic prophylaxis deliverance in the shape of a « ready to use » antibiotic kit went with an increase in the respect of the recommendations, by correcting in a significant way the persistent weak points identified during the first part of our study. The antibiotic prescriptions control is an imperative goal in individual health (the patient himself), but also in public health (the community). This radical change in habits is listed in a policy of antimicrobial agent prescription improvement (best efficacy with less cost).