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Surgical Prophylaxis
Ripal Joshi
37
Pharmacology
Professional
09/05/2013

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Term
Antibiotic Prophylaxis
Definition
¡ Administration of antibiotic with in patients
with no signs of infection to reduce the
risk of post-operative wound infection
¡ Should be given PRIOR to procedures
where the risk
¡ Cover the predominant flora of operative
site
Term
Sugical site infection
Definition
 Occur within 30 days of surgery
¡ Definition
§ Incisional (i.e cellulitis)
▪ Superficial
▪ Deep § Organ/space
▪ Can involve any anatomic area other than the incision site
▪ Patient who develops bacterial peritonitis after bowel surgery
¡ If prosthetic implant involved, a deep incisional or organ space SSI can be reported up to a year (Staph a. or staph coag -)
Term
Antibiotic Prophylaxis issues
Definition
¡ Effectives of antibiotics most dependent upon having tissue levels of the antibiotic at time of initial skin incision
¡ Prolonged surgery – antibiotics may need to be re-dosed
¡ No convincing data to document efficacy for post operative administration
Term
Ideal Antibiotic
Definition
¡ Includes activity against suspected
pathogens
¡ Does not induce bacterial resistance
¡ Effective tissue penetration
¡ Minimal toxicity
¡ Minimal side effects
¡ Long half life
¡ Cost effective
Term
Prophylaxis Definition
Definition
§ Antibiotics administered before contamination of previously sterile tissues or fluids
§ Goal: prevent a surgical site infection (SSI) from developing
Term
Wound Classification
Definition
¡ Clean (SSI risk < 2%)
¡ Clean-contaminated (SSI risk 2 - 10%)
¡ Contaminated (SSI risk 10-20%)
¡ Dirty (SSI risk > 30%)
¡ Wound classification can be influenced by surgical findings (i.e. gangrenous gallbladder)
Term
Clean Procedures
Definition
¡ Antimicrobial prophylaxis NOT routinely
recommended
¡ Exceptions include operations that can
have a negative outcome
§ i.e. Craniotomy, cardiac surgery, or prosthetic
device implantation
¡ Elective, not emergency, nontraumatic
¡ Primary closed
¡ No acute inflammation
¡ Not involving respiratory, GI, biliary, and
GU tracts
¡ i.e. Most plastic and dermatologic surgery
Term
Clean Contaminated Procedures
Definition
¡ Urgent or emergency case that is
otherwise clean
¡ Elective opening of respiratory, GI, biliary
or GU tract with MINIMAL spillage
¡ i.e. Invasive head and neck surgery,
hysterectomy
Term
Contaminated
Definition
¡ Nonpurulent inflammation
¡ Gross spillage of GI tract
¡ Entry into biliary or GU tract in the presence of infected bile or urine
¡ Major break in technique
¡ Penetrating trauma < 4 hours old
¡ Chronic open wounds to be grafted or
covered
¡ i.e. Colorectal surgery
Term
Dirty
Definition
¡ Purulent inflammation (i.e. abscess)
¡ Preoperative perforation of respiratory, GI, biliary, or GU tract
¡ Penetrating trauma > 4 hours old
¡ i.e. Perforated appendicitis with abscess formation
Antibiotics are utilized for treatment and not prophylaxis
Term
Increased risk of infection
Definition
¡ Age
¡ Nutritional status
¡ Diabetes
¡ Smoking
¡ Obesity
¡ Coexisting infection at distal body sites
¡ Colonization with resistant
microorganisms
¡ Altered immune response
¡ Length of pre-operative stay
¡ Duration of surgical scrub
¡ Preoperative skin preparation
¡ Preoperative shaving
¡ Duration of operation
¡ Antimicrobial prophylaxis
¡ Operating room ventilation
¡ Sterilization of instruments
¡ Implantation of prosthetic materials
¡ Surgical drains
¡ Surgical technique
Term
Prevention of SSI
Definition
¡ Appropriate timing
§ Relation to incision time
§ Repeated dosing based upon on length of
procedure and antibiotic half life
¡ Appropriate selection
¡ Appropriate duration
Term
Predict Pathogen
Definition
¡ Nose
§ S. aureus, pneumococcus, meningococcus
¡ Skin
§ S. aureus, S. epidermidis
¡ Mouth/pharynx
§ Streptococci, pneumococcus, e. coli,
bacteroides, fusobacterium,
peptostreptococcus
¡ Urinary tract
§ E. coli, proteus, klebsiella, enterobacter
¡ Colon
§ E. coli, klebsiella, enterobacter, bacteroides
spp, clostridia,
¡ Biliary tract
§ E. coli, klebsiella, proteus, clostridia, enterobacter
¡ Vagina
§ Streptococci, staphylococci, E. coli,
peptostreptococci, bacteroides species
¡ Upper respiratory tract
§ Pneumococcus, H. influenzae
Term
Antibiotic Selection
Definition
¡ Cefazolin is the most common agent
utilized when skin flora is the source of contamination
§ 1 gram in patients who are < 80 kg
§ 2 grams in patients who are ≥ 80 kg
¡ Clean procedures
Term
Administration of antibiotic
Definition
¡ Pre-operative antibiotic
§ Given within 60 minutes before initial surgical incision
§ Exception: Vancomycin and the
fluoroquinolones should be given within 60 – 120 minutes
▪ Prolonged infusion time with these antibiotics
¡ Cefazolin, other cephalosporins, and
ampicillin-sulbactam can be given IV or IV push over 3-5 minutes
Term
Dosing
Definition
¡ Dose Optimize
§ Preoperative dose is IMPORTANT
¡ Adjust antimicrobial prophylaxis dose for obese patients (body mass index >30)
¡ Obesity linked to increased risk for SSI
Term
Duration
Definition
¡ Duration should be less than 24 hours for most procedures
¡ Exception: Cardiac
§ 48 hours
Term
Antimicrobial Prophylaxis
Definition
¡ Should be directed against the most likely infecting organisms but it does not need to eradicate every potential pathogen to be effective
Term
Principle of antimicrobial prophylaxis
Definition
Preop administration, serum levels adequate throughout procedure with a drug active against expected microorganisms

High Serum Levels
Preop timing
IV route
Highest dose of drug

During Procedure
Long half-life
Long procedure–redose
Large blood loss–redose

Duration
None after wound closed
24 hours maximum
Term
Nasal screening and decolonization
Definition
¡ Colonization of nares with S. aureus =
risk factor
¡ Intranasal application of mupirocin
ointment may reduce the rate of nasal
carriage of S. aureus
¡ Chlorhexidine (CHG) may also benefit
Term
Peri-operative Antibiotic re-dosing
Definition
¡ Re-dose with 2 half lives in normal renal function
¡ Underlying disease states may affect
antibiotic metabolism
§ Thermal burn and spinal cord injuries -> Increased clearance
§ Cardiac à Increased Vd and decrease
clearance
Term
SCIP
Definition
¡ Surgical Care Improvement
¡ Formerly known as Surgical Improvement
Project (SIP)
¡ Began in 2002
¡ CMS and Joint Commission
§ Financial reimbursement
§ Value based purchasing
Term
SCIP (Inpatient)
Definition
¡ Cardiac/CABG
¡ Colorectal
¡ Hip/Knee Arthroplasty
¡ Hysterectomy
¡ Vascular
Term
SCIP Measures - Appropriate antibiotic
choice
Definition
Number of patients who received the appropriate prophylactic antibiotic

over

All patients for whom prophylactic antibiotics are indicated
Term
SCIP Measures - Appropriate timing of
prophylactic antibiotics
Definition
Number of patients who received the prophylactic antibiotic within 1hr prior to incision (2hr: Vancomycin or Fluoroquinolones)

over

All patients for whom prophylactic antibiotics are indicated
Term
SCIP Measures - Appropriate discontinuation of antibiotics
Definition
Number of patients who received prophylactic antibiotics and had them discontinued in 24 h (48h cardiac)

over

All patients who received prophylactic antibiotics
Term
Other SCIP measures
Definition
¡ Temperature
¡ Glucose
¡ Hair removal
¡ Catheter
¡ VTE prophylaxis
Term
Healthcare associated infections
Definition
¡ No reimbursement for hospital acquired
infections
§ CLABSI
§ CAUTI
Term
Cardiac Surgery
Definition
¡ Common pathogens:
§ S. aureus, S.epidermidis
¡ Recommended Antimicrobial
§ Cefazolin1-2 g, Cefuroxime 1.5 g
§ Vancomycin 10-15 mg/kg
Term
Gastroduodenal Surgery
Definition
¡ Esophageal, gastroduodenal surgery
¡ Common pathogens
§ Enteric gram negative bacilli, gram positive
cocci
¡ Recommended Antimicrobial
§ Cefazolin
Term
Colorectal Surgery
Definition
¡ Common pathogens
§ Enteric gram negative bacilli, enterococci, anaerobes
¡ Recommended Antimicrobial
§ Cefazolin + Metronidazole
§ Cefoxitin
§ Ciprofloxacin + Metronidazole
Term
Neurosurgery
Definition
¡ Common pathogens
§ S. aureus, S. epidermidis
¡ Recommended Antimicrobial
§ Cefazolin
§ Vancomycin
§ Clindamycin
Term
Gynecological Surgery
Definition
¡ Vaginal, abdominal, or laparoscopic
hysterectomy
¡ Common pathogens
§ Enteric gram negative bacilli, anaerobes,
Group B Strep, Enterococci
¡ Antimicrobial agent
§ Cefazolin, Cefoxitin
Term
Vancomycin
Definition
¡ Consider use in high suspicion of MRSA
¡ Life threatening allergy to penicillins and cephalosporins
¡ Justification needed for SCIP
Term
Antimicrobial Resistance
Definition
¡ Colonization with antibiotic resistant hospital flora during surgery may lead to an SSI
Term
Drains and Intravascular Devices
Definition
¡ NO evidence to support need for
continuing antibiotic prophylaxis while
drains and devices are in place
Term
Pharm role
Definition
¡ Correct antibiotic
§ Allergy clarification
§ Minimize antimicrobial resistance
¡ Dose optimization
¡ Duration
§ Automatic stop
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