This was quite interesting. I operated on a little girl the other night for a perforated, gangrenous appendicitis. Laparoscopically, I removed the nasty little bugger and washed out her entire peritoneal cavity with liters and liters of irrigant fluid. [On a faintly related tangent, I still can't believe anyone is routinely doing open appendectomies anymore. Only laparoscopy allows you the capability to drain and lavage the peritoneal cavity for complicated appendicitis]. The next day, she looked remarkably better (normal WBC count, afebrile, etc) but I usually keep kids in the hospital for a few days for IV antibiotics, especially for perforated appendicitis. As I reviewed her chart, I noticed that her Zosyn had fallen off the med list. I asked the nurse and she replied that "pharmacy had called earlier notifying that they were terminating the IV antibiotics 24 hours post surgery."
At this point my jugular vein started throbbing in my neck and my face turned a deep shade of Buckeye scarlett. Why was pharmacy unilaterally cancelling my antibiotic orders and making crucial decisions on the care of my patient?
Here's the deal. My hospital has now implemented a policy of limiting unncecessary use of antibiotics by giving the pharmacy the power to cancel antibiotic orders that extend 24 hours past a patient's surgery date. On the surface, it seems like a reasonable policy. Unnecessary courses of antibiotics have certainly contributed to the preponderance of such modern dilemmas as widespread MRSA infections and toxic megacolon from C Diff colitis. And surgeons who lazily/carelessly forget to cancel prophylactic peri-operative antibiotics are certainly much to blame. But there's a difference between antibiotics for prophylaxis versus antibiotics for the treatment of an infectious process. For perforated appendicitis, I'm not giving Zosyn to reduce my rate of superficial surgical site infections, but rather to actually treat an established, complicated infectious disease.
I spoke with the lead ID pharmacist and he was cool and apologetic about the misunderstanding. But the policy remains unchanged. It is now the surgeon's obligation to write in the post op orders "antibiotic to be continued post operatively for X-disease process (appendicitis, diverticulitis, peritonitis, etc)"