Background

Surgical site infections (SSIs) are a major cause of morbidity and mortality in surgical patients. Antibiotic prophylaxis is recommended when the risk of infection is high and/or the consequences of infection are likely to be severe. In recent years, the prevalence of antibiotic-resistant bacteria has increased markedly, methicillin-resistant Staphylococcus aureus (MRSA) being a cause of particular concern. Glycopeptide antibiotics (vancomycin and teicoplanin) are active against MRSA, but are normally reserved for the treatment of MRSA infections because of the perceived risk of selecting new resistant strains by increasing glycopeptide use. This project considers the implications of switching from non-glycopeptide to glycopeptide antibiotics for surgical prophylaxis.

Objectives

Our overall objective was to determine whether there is a level of MRSA prevalence at which a switch from non-glycopeptide to glycopeptide antibiotics for routine prophylaxis is indicated in surgical environments with a high risk of MRSA infection. We addressed this question by undertaking:

• a systematic review of the effectiveness of glycopeptide compared with non-glycopeptide antibiotic prophylaxis to determine whether there is evidence to guide antibiotic choice for surgical prophylaxis at different levels of MRSA prevalence
• a systematic review of published economic evaluations, to examine the cost-effectiveness of glycopeptide antibiotics compared with appropriate comparators
• a series of supplementary reviews, to support the modelling work and associated research recommendations
• a modelling approach to estimate the cost-effectiveness of glycopeptide antibiotic prophylaxis relative to appropriate comparators, using orthopaedic surgery as an exemplar.

Methods

Results

Conclusions

Publication

• Cranny G, Elliott R, Weatherly H, Chambers D, Hawkins N, Myers L, et al. A systematic review and economic model of switching from non-glycopeptide to glycopeptide antibiotic prophylaxis for surgery. Health Technol Assess 2008;12(1). [PubMed: 18093447]

NIHR Health Technology Assessment Programme

The Health Technology Assessment (HTA) Programme, part of the National Institute for Health Research (NIHR), was set up in 1993. It produces high-quality research information on the effectiveness, costs and broader impact of health technologies for those who use, manage and provide care in the NHS. 'Health technologies' are broadly defined as all interventions used to promote health, prevent and treat disease, and improve rehabilitation and long-term care.

The research findings from the HTA Programme directly influence decision-making bodies such as the National Institute for Health and Clinical Excellence (NICE) and the National Screening Committee (NSC). HTA findings also help to improve the quality of clinical practice in the NHS indirectly in that they form a key component of the 'National Knowledge Service'.

The HTA Programme is needs-led in that it fills gaps in the evidence needed by the NHS. There are three routes to the start of projects.

First is the commissioned route. Suggestions for research are actively sought from people working in the NHS, the public and consumer groups and professional bodies such as royal colleges and NHS trusts. These suggestions are carefully prioritised by panels of independent experts (including NHS service users). The HTA Programme then commissions the research by competitive tender.

Secondly, the HTA Programme provides grants for clinical trials for researchers who identify research questions. These are assessed for importance to patients and the NHS, and scientific rigour.

Thirdly, through its Technology Assessment Report (TAR) call-off contract, the HTA Programme commissions bespoke reports, principally for NICE, but also for other policy-makers. TARs bring together evidence on the value of specific technologies.

Some HTA research projects, including TARs, may take only months, others need several years. They can cost from as little as £40,000 to over £1 million, and may involve synthesising existing evidence, undertaking a trial, or other research collecting new data to answer a research problem.

The final reports from HTA projects are peer-reviewed by a number of independent expert referees before publication in the widely read journal series Health Technology Assessment.

Criteria for inclusion in the HTA journal series

Reports are published in the HTA journal series if (1) they have resulted from work for the HTA Programme, and (2) they are of a sufficiently high scientific quality as assessed by the referees and editors.

Reviews in Health Technology Assessment are termed 'systematic' when the account of the search, appraisal and synthesis methods (to minimise biases and random errors) would, in theory, permit the replication of the review by others.

The research reported in this issue of the journal was commissioned by the HTA Programme as project number 05/36/01. The contractual start date was in September 2005. The draft report began editorial review in May 2006 and was accepted for publication in April 2007. As the funder, by devising a commissioning brief, the HTA Programme specified the research question and study design. The authors have been wholly responsible for all data collection, analysis and interpretation, and for writing up their work. The HTA editors and publisher have tried to ensure the accuracy of the authors' report and would like to thank the referees for their constructive comments on the draft document. However, they do not accept liability for damages or losses arising from material published in this report.

The views expressed in this publication are those of the authors and not necessarily those of the HTA Programme or the Department of Health.

Editor-in-Chief: Professor Tom Walley

Series Editors: Dr Aileen Clarke, Dr Peter Davidson, Dr Chris Hyde, Dr John Powell, Dr Rob Riemsma and Professor Ken Stein

Programme Managers: Sarah Llewellyn Lloyd, Stephen Lemon, Kate Rodger, Stephanie Russell and Pauline Swinburne