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P J S S\ / o l .6 1 ,N o .2 , A p r i l - J u n e2,0 0 6

The Philippine College of Surgeons Evidence-Eased Clinical Practice Guidelines


on Antimicrobial Frophylaxis for Surgical Frocedures

D o r n i n g oS . B o n g a l aJ r . , M . D . , F . P . C . S . ; A l e x A . E r a s m o ,M . D . , F . P . C . S . ;
, .D., F.F.C.S;
, . D . , F . P . S . M . I . D ,F . P . C . P . ;A n t o n i o A . A n : r s t a c i o M
Mario M. PanaliganM
F
.
P
.
C
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S
.a n d
R e n a t oR . M o n t e n e g r o ,M . D . , F . P . C . S ; A n t h o n y R . F e r e z ,M . D . ,
M a i t a T h e r e s aP . R i g o r , M . D . , F . P . C . S .

r o l e i n t h e c o n c e p t i o na r t c ld e s i g no f t h e s t t r c l yt,h e
s n c li n t e r p r e t a t i oonf c l a t aa n c tl l r e
c o l l e c t i o n a, r r a l y s i a
d r a f t i n ga n d r e v i s i o ror f t l r e t n a n u s c r i p t .

Starter Statement

anclhaswide
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SLrrgical
to
andthus,it is necessary
consequellces.
socioeconorlic
r e e x a m i r r tel t e p r a c t i c eo f a n t i m i c r o b i a pl r o p h y l a x i s ExecutiveSurnrnary
e s p e c i a l lrl v' i t ht h e c o n t i n u e c l i v e r s i t iyr ra r r t i r r r i c r o b i a l
prophylaxisnrethodsofferedto patientsby indiviclLral
e yd t l r eg t r i c l e l i n e s
T h e c l i n i c a lq L r e s t i o nasc l c l r e s s b
s u r g e o n sA.l t l r o L r gt hl r et o t a le l i n r i r t a t i oor fr s u r g i c asl i t e z r r e1 ) I s a n t i t t t i c r o b i apl r o p h y l a x i sr e c o t t . t t t t e r t cf ol er c l
infectionis not possible,a reductionin the irrfectionrate
t h e s u l g i c a l p r o c e d u r e ?a n c l 2 ) l i a n t i n r i c r o b i a l
t o a m i n i n r alle v e lw i l l l e s L r li tn c o t t s i d e r a bbl ee l r e f i t isn
e ,l r a ti s /
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telnrs of botlr patientcotnfort and nteclicalresottrces
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t l r o r a c i c a n c l c a r cilo v a s c iltz t r , o t ' t h o p eiccl. t t r o l o g i c .
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A s e a r c ho f p L r b l i c a t i o tur s' a s c a r r i e crl l t t t t t s i t l ga
e f o L r rf r i e n c l sf r o n r t h e
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t e c h n i c ailn c h a r a c t e rt l' t, r o u g ht h e r e t r i e v aol f f i r l l - t e x t o f t h e f o l l o w i r r gc l a t a b a s e s :
l . M e d l i r r e( 1 9 6 6t o p r e s e n t )
l olkirrg
a r t i c l e st l r a tw e r e i d e n t i f i e db y t h e T e c h n i c a W
2
. C o c h r a n eL i b r a r y( 2 0 0 4 )
literaturesearch.They had no
GloLrpaftera systentatic

66

A n t i m i c r o b i a lP r o p h y l a x i sf o r S u r g i c a lP r o c e d u r e s

3. HealthResearchanclDevelopnteltt
Networl<
(HERDIN)
4 . P h i l i p p i n Jeo u n r aol f S u r g i c aSl p e c i a l t i e s
C D - R O M ( 1 9 1 9t o 1 9 9 9 )a n d h a n ds e a r c h e s
flom 2000 to oresent

67

Panali-ean,
MD, FPSMID,FPCP,AntonioA. Arrastasio.
MD, FPCS,RenatoR. Montenegro,
MD, FPCS,Anthony
R. Perez,MD. FPCSand Maita TlreresaP. Rigor,MD.
FPCS.
TbeTeclrnicalWorkingGrouppreparedtheevidencebasedrepoftbasedon the articlesretrievedandappraised.
and validity appraisal,
47 articleswere
Frorr the searchresults.the technicalworkirrggroup After evalr-ration
chosenand usedto answertlreclinicalqllestious.
releruant
articlesfbr firll-text retrievalr"rsing
selectecl
tlre
TheTechuicalWorkingGroup togethelwith theparre
I
N o m i n a lG r o u pt e c h n i q u eT.h e E v i d e n c e - B a s C
e dl i n i c a l
of expertsreviewedthe interim repoft at the Bayauihan
Practice
CLridelines
for AntibioticProphylaxis
in Elective
Hall,UnitedLaboratories,
Inc.(LINILAB)in Mandalr.ryorrg
SurgicalProcedures
rvhich was preparedin 2001 was
CityonNovenber27,2004.ThemodifiedDelphitechnique
reviervedtogetherwith the prirnaryliteraturebetweenthe
was tlren used to deterntinethe degree of colrsensr-rs
clateof thosepreviousgLridelines
Lrpto 2004.Retrieved
regardi ng the recommendations.
studiesrverethenassessed
fbr eligibilityaccordingto the
Thenrenrbers
ofthe expertpanelr.l,ere;
Drs.Dorringo
criteriasetby thegLrideline
developers.
The nrethodologic
B
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.
l
r
.
,
S.
A n t o ni o L . A n a s t a c i oM. a r i oM . P a n a l i g a n ,
qualitiesof the studieswere appraisedby at leasttwo
Alex A. Erasmo,RenatoR. Montenegro,
MaitaTlreresa
P.
inclepenclen
r et v i e w e r su s i r r g a q L r a l i t ya s s e s s r r e r l t
Rigoraud AnthonyR. Perez.The invitedntembelswele
instrurment
developecl
by the PhilippineCardiovascular'Drs.Gr"racla
pe V i I IanLreva
Ir"r
and R i cardoM. Manalastas.lr.
Research
GroLrp,
as usedirrtlre previoLrs
editionof these (POGSrepresentatives)
andDrs. IsaacDavidE. Anrpil ll
guidelirres.'
and RaymundoJoa.qr-rirr
F. Erese(ResearchCourmittee
The clinical evidencewas rateclaccor"ding
to the representatives).
Otherexpeftpanelistscantefi'oll Metro
assessnlent
systemof tlie InfectioLrs
DiseaseSocietyof Manilahospitalsrepreserrted
by Drs. EdgardoR. Cortez.
America:as usedin the flrst eclitionof tlresegLridelines.iJoseAntonioM Salud,Artulo S.DelaPeiia,MaximinoDy
R. Efgar,FranciscoY. Arcellana Jr., Rey MelchorF.
L e v e lI E v i d e n c eo b t a i n e df r o r r a t l e a s t o n e Santos,
l(im Shi C. Tan,ReynaldoSinamban,
Dominador
properlydesigned
randomized
controlled M. ChiongJr'.,LeonardoL. CLraand JesusV. Valencia:
t l i a l o r n r e t a - a n a l y s iosf r a n d o m i z e d Drs.EdwinM. ConzagaandElvisL. Bediafrom Southern
controlledtrials
TagalogChapter;
Dr.JoseC. BLrgayorrgJr.
fromCordillera
Levelll - Evidence
obtainedfrom at leastonewell- ChapterlDr.Vitus S.Hobayanfi'orrCentralLuzon
Chapter;
designecl
controlledstLrcly
withoutproper Dr, Stephen
S.Siguanfi"omCebLr-Eastern
VisayasChapter;
randomizatiorr,
fi'omcolrortor case-contro
I D r s .M a x i m oH , S i m b u l a Jn r .a r r dA l e x E L . C e i l i l l o f l o n r
arralyticstudies (preferablyfrolrr one Northern Mindanao Chapter.Drs. .lasonL. Letranancl
center),fi"ornrl ultip le t i me-series,
or fronr DennisP. Serrano(PUA representatives),
Drs.EnricoP.
d r a n r a t i c r e s u l t s i n u n c o n t r o l l e d R a g a z a a n d H e r r n o g e n e sJ . M o n r o y ( P C R C S
expelirlents
representatives),
Drs.AnclresD. BorrorleoandErlily H.
LevelIII - Evideuce
obtained
fi'ourexpeftconrurittee Tanchuling(POA representatirzes).
Drs. Willy L. Lopez
reports
ol opirrionsof respected
atrtholities andLouieC. Racelis
(AFN representatives),
Drs,Napoleon
o n t h e b a s i so f c l i n i c a l e x o e r i e n c o
e r De Guznran,
Emrrranuel
SanPedroandAntouioB. Rarnos
descriotivestLrcl
i es.
(TCVS representatives),
Drs.AlbertoB. Roxas,Mark R.
Kho,lda MalieT. Lirn,andOrl i no C. B isqLrera
Jr'..( Cancer
TheTechnicalWorkingGroLrpwascomposed
of the Cornnritteerepresentati
ves)
The strengthof recomrrrendations
rurerrbers
of tlre PCS Conrmitteeon Surgicallnfectiorr:
for theguidelines
accordingto the level of agreenrent
of
D o r n i n g oS . B o n g a l aJ r . , M D , F P C S - C l r a i r ,A l e x P . was categorized
ea
, r i o M . t h e p a n e lo f e x p e r t sa f t e ra v o t e b y t h e p a r t i c i p a r r t s :
E r a s r l o , M D , F P C S - R e g e n t - i r r - C l r a r gM
PCSC.onrnrittcconStrrgica|]nf.ections,I999.200'
p r o c e d L r r ePsh. i l i p. l S L r r gS p e c2 0 0 2 : 5 7 ( 4 ) : I 3 5 -1 6 1 .

2006
PJSSVot.61,No.2, APril-June'

68

was approvedby
CategoryA - Recommendation
of at least75 perceritof the mLrlticonsensLts
6.
sectoralexPertPanel
Recommendationwas soruewhat
Category B
controversialand did not meetconsensus
C a t e g o r y C - R e c o r n m e n d a t i o uc a u s e d r e a l
among membersof the expert
disagreernent
panel
Summaryof Guidelines

An alternativeregitneuis cefazolinI gramIV single


d o s e .( l I I - A )
A n t i m i c r o b i apl r o p h y l a x i si s r e c o m m e n d ef do r t h e
f o l l o w i n g o p e n b i l i a r y p r o c e d u r e sC: h o l e c y s t e c t o m y , S p h i n c t e r o t o r r i yC l r o l e c y s t e c t o t r tpyl u s
sphincterotorny, Choledoclroenterostomy
( C h oIe d o c h o d u o c l eons t o t l y , C h oI e d o c l r oudo d e uostonry,plr-rsphi ncterotonry,C hoIedochojej ltrrosC hoIecystojej u nostonry,Cottrmonb i Ie d Lrct
tor-ny),
e x p l o r a t i o n( l - A )
T h e r e c o t n m r e n daendt i r l i c r o b i afl o r p r o p h y l a x i s
in open biliary sllrgeryis cefazolinI gram IV
s i n g l ed o s e .( l - A )
An alternativeregimenis cefuroximeI'5 grarnsIV
s i n g l ed o s e (. l - A )

A n t i n i i c r o b i a lp r o p h y l a x i si s r e c o m m e n d e df o r
oncologicheadandneck
electiveclean-contaminated
surgery.(I-A)
antimicrobialsfor prophylaxis
The recomtnended
t endc o l o g i ch e a da n d
i n e l e c t i v ec l e a r r - c o n t a m i n a o
c
l
i
n
d
a
m
y
c
i
n 3 0 0 n r g I V p r e - 7 . A r r t i m i c r o b i a lp r o p h y l a x i s i s N O T r o L r t i n e l y
a
r
e
neck surgery
my i n
i c choIecystecto
fo r Iaparoscop
recorrnrerrdecl
operativelytherr300 mg IV every 8 hoLrrsfor 24
l o w - r i s kp a t i e n t s(.l - A )
1.7 mg/l<g/
hours in conibinatiorrwith -eentarnicin
IV
dose IV pre-operativelytlien l'7 tt'tglkgldose
8 . A n t i m i c r o b i a l p r o p h y l a x i s i s r e c o r n t n e n c l ef odr
every 8 hoursfor 24 liours.(l-A)
c o l o r e c t aol p e r a t i o n s( .l - A )
may ltoweverbe administered
T'hearninoglycoside
T h e r e c o n r n e n d e dt ' e g i m e nf o r p r o p h y l a x i si n
a s a s i r r g l ed o s e .( l l l - A )
inistered
colorectalsttrgerycottsistsof an orally-adnr
antimicrobial combirred with a parenteral
2. Antimicrobial prophylaxisis NOT roLrtinely
a n t i m i c r o b i a l . T h e r e c o l l l m e n c l e do r a l l y for clean head and neck procedures
recorntrrended
n 0 0m g
a d m i n i s t e r eadn t i m i c r o b i ai ls c i p r o f l o x a c i 5
such as thyroidectomy. parotidectomyand
for 3 dosesire-operatively.(l-A)
s u b m a n d i b u l agrl a n de x c i s i o n (. l I - A )
d n t i m i c r o b i a l sf o r s y s t e m i c
The reconrtnendea
p r o p h y l a x i sa. r e A m o x y c i l l i n - c l a v u l a n iacc i d 1 . 2
3 . A n t i i m i c r o b i a lp r o p h y l a x i si s N O T r o u t i n e l y
g r a r n sl V s i n g l e d o s e A m p i c i l l i n - s u l b a c t a1r .n5
for breastsurgery.(l-A)
reconrurended
g r a n r sI V s i n g l ed o s eC e f o x i t i n2 g r a n r sI V s i n g l e
d o s eC e f a z o l i n2 g r a r n sT V p l L r sM e t r o n i c l a z o5l e0 0
4. Antimicrobial prophylaxisis NOT routirrely
m g I V s i n g l ed o s e( l - A )
for electivegroinherniasurgeryusittg
recourmeuded
l.

p r i r n a r yt i s s u er e p a i r .( l - A )
prophylaxisis likewiseNOT roirtinely
Arrtimicrobial
for electivegroinherniasurgeryusirrg
recotnmetrded
m e s hr e p a i r . ( l - A )
5 . A n t i m i c r o b i a l p r o p h y l a x i s i s r e c o r n r l e n d e df o r
electivegastricarrddtrodenalsurgery.(l-A)
T h e r e c o r r r t n e n daendt i r n i c r o b i af ol r p r o p h y l a x i isn
e l e c t i v eg a s t r o d u o d e nsaul r g e r yi s c e f t t r o x i t n e1 . 5
g r a m sI V s i n g l ed o s e .( l l - A )

9 . A r r t i m i c r o b i a lp r o p h y l a x i si s r e c o m t n e r r d efdo r
( I -A )
iovascltlar procedr-rres.
thoracic uotr-card
ad
n t i r n i c r o b i af ol r p r o p h y l a x i isn
T h er e c o m n t e r r d e
sllrgeryis cefazolinI
thoracicnort-cardiovascular
(
l
A
)
d
o
s
e
.
g r a ml V s i n g { e
1 0 . A n t i n r i c r o b i a lp r o p l r y l a x i si s r e c o t n n r e n d efdo r
v i d e o - a s s i s t etdh o r a c o s c o p i cs t r r g e r y( V A T S ) .

(rr-A)

A n t i m i c r o b i aP
l r o p h y l a x i sf o r S u r g i c a lP r o c e d u r e s

69

Tlrerecommended antirnicrobi
als for vi deo-assisted
ic surgeryareArnpici I Iin-suI bactarnI .5
thoracoscop
g r a r x sI V s i n g l ed o s eA m o x y c i l l i n - c l a v u l a n a
i cc i d
2.4 grans IV singledose (II-A)

l 1 A n t i r r r i c r o b i apl r o p h y l a x i si s r e c o m m e n d e df o r
cardiacsurgery.(l-A)
T h e r e c o m r n e n d eadn t im i c r o b i a sl f o r p r o p h y l a x i s
in cardiacsurgeryare Cefazolin I grarn IV preopelativelythen I grarn IV every 8 hours for 48
h o u r s C e f u r o x i m e1 . 5 g r a m s I V p r e - o p e r a t i v e l y
t h e n 1 . 5 g r a m sI V e v e r y l 2 h o r " r r fso r 4 8 l r o u r s
(I-A)
l r o p h y l a x i si s r e c o m m e n d e df o r
1 2 . A n t i n r i c r o b i ap
peripheralvascular surgery.(l-A)
antirnicrobialfor prophylaxisin
The recommended
peripheralvascularsLrrgeryis cefazolirrI gram IV
pre-operatively
therrI grarnIV every6 hoursfor24
h o L r r s( .l - A )
A n a l t e r n a t i v ree g i m e ni s c e f u r o x i r n e1 . 5g r a r n sI V
pre-operatively
then 1.5 gramsIV everyB hoursfor
2 4 h o L r r s( l. - A )

Alternativeregimensare: Cephalexirr500 mg per


orern TID for 3 doses (l-A) FluoroqLrinolone
(Ciprofloxacin,Ofloxacin, Levofloxacin)400 rng
IV every 12 hoursfor 3 days(lll-A)
1 5 .A n t i r n i c r o b i apl r o p h y l a x i iss r e c o n r m e n d ei nds p i n e
o p e r a t i o u ss r - r c ha s l a m i n e c t o m i e sf,u s i o n s a n d
d i s c e c t o m i e s( l.- A )
The recommended
antinricrobialfor prophylaxisin
spine surgeryis cefazolin I grarrrIV single dose
(I-A)
An alternativeregimenis oxacillin I gram IV preoperativelythen 500 nrg IV every 6 lroursfor' 24
Irours.(l-A)
1 6 . A n t i n r i c r o b i a lp r o p h y l a x i si s r e c o m r n e n d efdo r
c e r e b r o s p i n af llu i d s h u n t i n gp r o c e d u r e s( l.- A )
T h e r e c o m r r e n d e ad n t i r n i c r o b i a lfso r p r o p h y l a x i s
i n C S F s h u n t i n gp r o c e d u r easr eC l o x a c i l l i nI g r a r r r
IV pre-operatively
then I granrIV every6 hoursfor
I
24 hoursOxacillin I gramIV pre-operativelythen
gram IV every 6 hours for 24 lrours (l-A)
If the patienthas a pre-operativestay of at least3
d a y s ,t h e a d d i t i o no f g e n t a m i c i n 2 4 0r n g I V s i n g l e
listed regirnensis
doseto eitlrerof the previor"rsly
(lII-A)
recornmended.

for total
13. Ant i m icrobi al prophyIaxis i s recomrnended
joirrt replacementsurg'rryand electivefixation of
closedlorrgbonefractures.(l-A)
antirlicrobialfor prophylaxisin
The recornrnended
sLrrgery
andelectivefixation 17. Antimicrobial prophylaxis is recommendedfor
totaljoint replacement
of closedlong bonefi'acturesis cefazolinI grarnIV
craniotomy.(l-A)
pre-operatively
therrI gramIV every8 hoursfor24
The recomnlendedantirnicrobialsfor prophylaxis
h o u r s (. l - A )
i n c r a n i o t o r l y a r e C l o x a c i l l i n 1 g r a r r tI V p r e r e g i m e na
s r e :C e f u r o x i t l eI . 5 g r a m sI V
Alternative
operativelytheu I grarn IV every 6 hours for 24
pre-operativelythen
750nrg lV every8 hoursfor24
y en 1
h o u r sO x a c i l l i n 1 g r a m I V p r e - o p e r a t i v e tl h
l r o u r s o r C e f t r i a x o n e2 g r a m s I V s i n g l e d o s e
granrIV every 6 hours for 24 hours (l-A)
(I-A)
If the patienthas a pre-operativestay of at least3
days,the additionof gentamicin240 rng IV single
1 4 . A r r t i r n i c r o b i apl r o p h y l a x i si s r e c o n r n r e n d efdo r
Iistedregirnensis
doseto either of the previor-rsly
transurethralresectionof the prostateto prevent
(llI-A)
recomrrrended.
p o s t o p e r a t i vbea c t e r i u r i aa n d c l i n i c a l s e p t i c e m i a .
(I-A)
antimicrobialfor prophylaxisin
The recomnrended
transnrethralresection of the prostate is
ciprofloxacin500rngtabletper oremBiD for 3 days
(I-A)

for both
18.Antimicrobialprophylaxisis recontntended
electiveand emergeucycesareansections.(l-A)
The recommendedantirnicrobialsfor prophylaxis
i n c e s a r e a ns e c t i o n sa r e A r n p i c i l l i n 2 g r a m s I V

10

P J S SV o l . 6 1 , N o . 2 , A p l i l - J u r r e2, 0 0 6

c n t it r i c r o b i a l s in c et hi s i s
s i n g l ed o s ep r e - o p e r a t i v e ol yr a f l e r c o r d c l a n r p i u g a c l ni rni s t e r i n gp r o p h y l a c t i a
grams
pre-opelatively
concern
for surgeons.
lV singledose
or" the main outconreof
Cefazolin2
atier cord clamping (l-A)
T h e f o l l o w i n gg e n e r a pl r i n c i p l e si n a n t i r t t i c r o b i a l
1 9 . A n t i r r r i c r o b i apl r o p h y l a x i si s r e c o u r r r r e n d ef odr p r o p h y l a x i sw e r e u s e c la s t h e b a s i sf b r c h o o s i n gt l r e
s t h i sa r t i c l e :
a p p r o p r i a taen t i t r i o t i c /i n
a b d o m i n ahl y s t e r e c t o r n(yl .- A )
ad
n t i n r i c r o b i af bl r p r o p h y l a x i isn l . T h ec h o i c eo f t h ea n t i r n i c r o b i sahl o L r lLcrle[ - r a s e c l o n
T h er e c o n i r n e n d e
Iogyo1'ex pectecl
a b d o r r r i n ahl y s t e r e c t o u riys c e f a z o l i n I g r a r r il V
the paranretersof efll cacy,epi dcrni c.l
(
l
A
)
s i n g l ed o s e .
p a t h o g e r r l,o c a l r e s i s t a n c ep a t t e r n s ,s a f e t y a t n c l
l vailability.
a d v e r s er e a c t i o n sc,o s t a n c a
Introduction
2 . T l r ec h o s e na n t i m i c r o b i af lo r p r o p h y l a x issl r o L l lbcel
a d n r i r r i s t e r ewdi t h i r r2 h o u r sb e f o l et l t es t a r to f t h e
S u r g i c a l s i t e i r r l ' e c t i o ni s a p o s t o p e r a t i v e
proceclu
re.
ct-rnrp
I icationwh iclrresults i n signi ficarrtrnorbidity ancl 3 . T h e a c l r n i t r i s t e r edcols e o f t h e a r t t i t n i u ' o b i af lc r r '
. ecause
n t o r t a l i t ay n dm a r k e d l yi n c r e a s ehso s p i t acl o s t sB
p r o p h y l a x i s h o u l cnl o t b e l o w e rl'l t a t tt h e s t a r r c l a r c l
t h i s c o m p l i c a t i o ni s q L r i t ec o m n l o n a n c l h a s w i d e
t l i e r a p e u t iccl o s eo f t h e d r u g .
, a sd e e t t t e nd e c e s s a t ' y4 . I n u r o s t e l e c t i v e p r o c e cul r e s . s i n g l e c o
l se
s o c i o e c o r r o mci oc n s e q u e n c ei st w
t o l e e x a r r r i ut eh e p r a c t i c eo f a r r t i n t i c r o b i aplr o p l r 1 , l 2 n 1 t a n t i n irc r o bi a l p r o p h yal x i s i s r e c o n i n i e n c l e c l .
e s p e c i a l lw
y i t h t h ec o n t i n u e d i v e r s i t yi r ra n t i m i c r o b i a l 5 . 1 1 ' ap r o c e d u r el a s t sl o n g e rt h a r rt h e h a l f ' l i f ' eo l ' t h e
prophylaxisrlethodsofferedto patientsby incliviclual
p l o p l r y l a c t ia
c n t i n t i c r o b i agl i v e n .a s e c o n ccll o s ei s
thereforeuseclttrore
ThesepracticegLridelines
surgeons.
i f ttecessaly
shottlcl
lecorrr
mencled.
Subsequentcloses
a
l
t
i
c
l
e
s
i
n
i
n
c
l
u
s
i
o
n
o
f
s
c
i
e
n
t
i
f
i
c
s t r i n g e nct r i t e r i af c r r
b e g i v e na t i r t t e r v a l ns o t l o r t g e tr l t a t t t , v i c teh e h a l f - t l r e e v a l u a t i o no f a d n r i s s i b l e v i c l e n c ef o r t r e a t u r e n t
l i [ eo f t h e c l r u g .
e f f i c a c y i n o r c l e l t o p r o r r r o t et h e i n t e g r a t i o na r t d 6 . T h e u s e o l ' a n t i n r i c r o b i a ;l r r o p h y l a x i iss t t o t z t
i n t e r p r e t a t i o no f v a l i c l , i n t p o r t a n ta n c l a p p l i c a b l e
I practi ces,pfopel'
for goocli nf'ectioucontt'o
substitLrte
veclevidence.
research-cleri
p a t i e n tp r e p a l a t i o ng, o o d s u r g i c a lt e c h n i q u ea, n
T h e c l i n i c a lq u e s t i o n as d d r e s s e bd y t h e g u i c l e l i n e s
a c l e q u a toep e r a t i n gl o o t n e n v i r o u l n e n ta, n c lg o o c l
a r e l ) i s a n t i m i c r o b i apl r o p h y l a x i sr e c o m r t t e n c l feodr
cl i n ical-juclgnrerr
t.
t h e s u r g i c a l p r o c e d u r e ,a n d 2 ) i f a n t i n r i c r " o b i a l" 7 . T h e f i r r a lc l e c i s i o rn^ e g a irrcrlgt l r eb e r r e l ' i a
t st t dr i s l < s
rvhatis/
fbr the procedr,rre,
prophylaxisis recornrrrended
o f p r o p l r y l a x ifso r a r ri r r d i v i c l u awli l l d ep e r r coll t t l r e
dose/saudduratiou
antirnicrobial/s,
arethe appropriate
p a t i e n t 'rsi s l <o f s u r g i c asl i t ei n f e c t i o nt,h ep o t e n t i a l
o f p r o p l r y l a x i sT? h e g L r i c l e l i n easd d r e s st h e t t e e df o r '
s e v e r i t y o f t h e c o l ' l s e q u e l l c eo sf s u r g i c a ls i t e
p r o p h y l a x ifso r o p e r a t i o nisr r v o l v i n gt h e h e a da n dn e c k ,
i n f e c t i o n t, h e e f f e c t i v e n e sosf p r o p l r y l a x i isr i t h a t
b li ,l i a r y .c o l o r e c t a l .
b r e a s tg, r o i nh e r n i ag, a s t r o d u o d e n a
of ;:rophylaxisl'or
operatiott,anclthc'consecluences
r ,r t h o p e c l i cu, r o l o g i c ,
t h o r a c i ca n d c a r d i o v a s c u l a o
t l r a tp a t i e r r t
n e u r o s u l g i c aaln do b s t e t r i ca n d g y n e c o l o g i sc u r g e r y .
S i g n i f i c a nut p d a t e fsi ' o r nt h ep r e v i o u sv e r s i o no f t h e
regarding
reflectcurrentl<nowleclge
ThesegLriclelines
s r ' a n t i r n i c r o b i aplr o p h y l a x i si t t s L r t ' g e a
g u i d e l i n e si n c l u d et h e d e v e l o p m e not f g L r i d e l i n ef o
l yt t h e t i n r eo f i t s
t eudc o l o g i ch e a da n d n e c k p r e p a r a t i o nG
c l e a na n dc l e a n - c o n t a r n i n a o
. i v e n t l r e c l y n a r n i cn a t u f eo l ' s c i e r r t i f i c
isted
thoracoscopic
surgery,vascular' i n f o r r n a t i oann ctl e c h n ol o g y ,p e r i o ci cl r e vi e w ,u p c l a rt rig ,
video-ass
surgery,
s L r r g e r y s, p i n a l s L l r g e r y ,c e s a r e a r ld e l i v e l y a u d a r r dr e v i s i o na r e t o b e e x p ec t e c l .
. h e g L r i d e l i n el si k e w i s ef o c u s e c l
T h e s eg L r i c l e l i n ne rsa yn o t b e a p p r o p r i a tfeo r u s ei n
- g y r r e c o l o gsiuc r g e r yT
o n t h e p r e v e n t i o no f s u r g i c a l s i t e i n f e c t i o n a s t h e a l l c l i n i c a l s i t u a t i o n s .D e c i s i o r r st o f o l l o w t h e s e
significanteud-pointwhen evaluatiugtlre efficacy of r e c o m r n e n d a t i o n
msu s t b e b a s e do n t h e p r o f e s s i o n a l

Antimicrobial Prophylaxisfor SurgicalProcedures

7l

judgrnentof the surgeonand considerationof individual dateofthosepreviousguideli nesupto and including2004.


patientcircumstances
and availableresoltrces.
Retrievedstudieswere tlren assessedfor eligibility
accordingto the criteriaset by the guidelinedevelopers.
The methodologicqualitiesof the studieswereappraised
Methods
by at least two iridependentreviewersusing a quality
The followingclinicalquestions
wereaddressed
by these assessmentinstrumentdevelopedby the Philippine
guidelines:
CardiovascularResearch
Group,asusedin thefirstedition
l. Is antimicrobialprophylaxisrecomrnendedfor the oftheseguidelines.i ParticLrlar
attentionwasgivento study
surgicalprocedure?
design, with greatestcredencegiven to randomized,
2. If antirnicrobialprophylaxisis recommended
for the controlleddouble-blindstudiesandsystematic
reviewsof
procedure,wltat isI are th e appropriateantim icrobials, properlydonerandomizedcontrolledtrials.
Tlie pertinentresultsof the selectedarticlesbasedon
dose/sanddurationof prophylaxis?
the clinical questionswere sulnlnarizedand compared.
procedures
The followingsLrrgical
were includedirr Whenappropriateandwhererelevantdatawereavailatrle,
t h eg u i d e l i n e s :
tlrerelativeor absoluterisks,risk differences,oddsratios
a. FleadandNeck Surgery
and nunrberneededto treat (NNT) were conlputedarrd
b. BreastSurgery
cornpared.
c. GroinHerniaSurgery
EaclrguideIinewasratedusinga two-partrating system.
d. Gastroduodenal
Surgery
Roman numeralsI through III indicatethe "quality of
e. Biliary Surgery
evidence"while the letters A through C indicate the
f. ColorectalSurgery
"strengthof tlre recommendation.
"
The clinical evidencewas rated accordingto the
g. Thoracicand Cardiovascular
Surgery
assessment
systemof tlre InfectiousDiseaseSocietyof
h. OrthopedicSurgery
America,asusedin thepreviouseditionoftheseguidelines.'
i. UrologicSurgery
j
Neurosurgery
Level IEvidence obtained from at least one
k. Obstetricand GynecologicSurgery
properlydesignedrandomizedcontrolled
trial or meta-analysisof randomized
A searchof publicationswas carried out using a
controlledtrials
sensitivesearclrstrategycombining MESH and free-text
pvidenceobtainedfrom at leastonewellLevel II
searclres.
This strategyinclLrded
an extensivesearchofthe
designedcontrolledstLrdy
withoutproper
followingdatabases:
randorn
ization,fromcohortor case-control
I . Medline(1966to preserrt)
analytic studies(preferablyfrom one
2. Cochrane
Library(2004)
center),frornrnLrltip Ie tinre-series,
or fi"om
3. HealthResearchand DevelopnrentNetwork
dramatic results in uncontrolled
(Herdin)
experiments
4. PhilippineJournalof SurgicalSpecialties
LevelIII - Evidenceobtainedfronrexpertcommittee
CD-ROM (1979to 1999)and handsearches
reportsor opinionsofrespectedauthorities
frorn 2000 to nresent
on the basis of clinical experienceor
descriptive
studies
From tlre searchresults,the teclrnicalworking group
selectedrelevantarticlesfor full-text retrievalusingthe
The TechnicalWorking Croup was conlposedof the
NorninalCroLrp
Teclinique.
The Evidence-Based
Clinical following:
PracticeGLridelines
for AntibioticProphylaxisin Elective
DomingoS. BongalaJr., MD , FPCS- Chair
AlexA.Erasrno,MD,FPCS-Regent-in-Charge
SurgicalProcedures
which was preparedin 2001 was
reviewedtogetherwith the primaryliteraturebetweentlre
Mario M. Panaligan,MD, FPSMID,FPCP
PCSClornmittee
on SurgicalInfeotions,1999-2000.
Evidence-based
clinicalpracticeguidelinestbr antibioticprophylaxisin electivcsurgical
p r o c e d u r ePsh. i l i pJ S L r r S
g p e c2 0 0 2 ;- 5 7 ( 4 )1: 3 5 - l 6 l

2006
PJSSVol. 61,No.2, APril-June'

11

Antonio A. Anastasio,MD, FPCS


RenatoR. Montenegro,MD, FPCS
AnthonyR. Perez,MD. FPCS
Maita TheresaP. Rigor, MD, FPCS

with an intervention.
complicationsand costsassociated
Therefore,an exactcorrelationdoesnot exist betweenthe
"quality of' evidence" and the "strengthof a
recommendation.
"

TheTechnicalWorkingGrouppreparedtheevidence- Operational Definitions


basedreportbasedon the articlesretrievedandappraised. Ant imicr obial Pr ophylaxis
After evaluationand validiiy appraisal,47 articleswere
This was defined as the adrninistrationof a shortchosenand usedto answerthe clinical questions.The courseof an anti-infectivedrr-rgin order to achievethe
TechnicalWorking Group then held severalmeetingsto followinggoals:
discusseach clinical question and the corresponding I Preventthe development
infectionat
of postoperative
)
evidence,formulate the initial recommeudationsand
the surgicalsite,
utilizing the NorninalGroup 2) Prevent postoperativeinfectiorrsmorbidity and
thereafterreacha consensus
wasreachedafterhavingattained
technique.A consensus
mortality,
at least70 percentagreementamongtlre rnembersof tlre 3) Haveno adverseconsequellces
for themicrobialflora
TechnicalWorkingCroup.
of the patientor the hosPital,and
TheTechnicalWorkingGrouptogetherwith thepanel 4) Reducethe dLrration
anclcostof healthcare.
of expertsreviewedthe interim report at the Bayanihan
Inc.(UNILAB) in Mandaluyottg Surgical SiteInJection
Hall,UnitedLaboratories,
r 7 , 2 0 0 4 ' E a c hc l i n i c a l
C i t y . P t r i l i p p i n eosn N o v e m b e 2
adoptedthe standarddefinitionof
Tlieseguidelirres
were wound infectionsas proposedby the Centet'for Disease
question,the evidenceand the recolntnendations
analyzedand the participantsgiven the opportunityto ControfandPreventionin I 992 andusedin thefirst edition
expresstheir opinionsand views. The rnodifiedDelphi of theseguideliries.i
techniquewas then used to determinethe degree of
ing the recommendations'
regard
consensus
l) SuperficialIncisionalSrrrgicalSiteInfection
- rnust occur wttltin 30 days after the operative
forthe gtridelines
The strengthof recommendatioris
accordingto the level of agreementof
mustinvolveorrlytlre skin or sttbctttawas categol'ized
procedure,
neoustissueof the incision,and at leastone of the
the panelofexpertsaftera votationby the participants:
CategoryA - Recommendationwas approved by
followingmust be Present:
ittcision:
multipercent
the
of
least
75
at
of
a. PurulentdrainagefrorntlresLrperticial
corlsensus
aseptically
an
fiorrr
isolated
panel
b. Microorganisms
sectoralexpert
of flLridor tissttefiornthe
obtainedcultLtre
C a t e g o r y B - R e c o m m e n d a t i o nw a s s o m e w l r a t
i
incisiorr;
and did llot lreet consenstls
sttperficial
corrtroversiat
c. At leastoneof the fbllowingsigrrsands)'nrptotlls
C a t e g o r y C - R e c o m m e n d a t i o nc a u s e d r e a l
localizedswelling,
or tenderttess,
of infection-paitt
amongmenrbersof the expertpanel
disagreenrent
r e c l n e s so. r h e a t - a n d s u p e r f i c i a li n c i s i o ni s
culture
ttnless
by thestrrgeott.
openecl
deliberately
The lettersA throLrghC are used to indicatethe
i
s
n
e
g
a
t
i
v
e
.
i
s
i
o
n
i
n
c
o
f
the
use
of
a
against
for
or
"strengthof recomtnendatiou"
irtcisionalSSI by the
d. Diagnosisof sr,rperficial
particularoption. Detertninationof the "strengthof
physiciarr.
attertding
or
sltrgeolt
of several
wasbasedon a consideration
recomntetrdatiott"
criteria,includingthe"qualityof evidence"asdetermined
Site lnfectiorr
SLrrgical
appraisersof the studiesused 2) DeepIrrcisional
by at leasttwo independent
rnust occur within 30 days after the operative
for tlre reconrmendation,potential for lrarm if an
procedureif no implant is left in placeor withirr
interventioudid not take place,as well as the potential
g u i d e l i n efsb r a n t i b i o t i cp r o p h y l a x iisn e l e c t i v se L t r g i c a l
p c s c o m n r i t t eoen s u r g i c a Il n f ' e c t i o n lsg, g g - 2 0 0 0E. v i d e n c e - b a scel idn i c a p
l ractice
6
l
I
3
5
l
2
0
0
2
:
5
7
(
4
)
:
p r o c e d u r ePsh. i l i p. l S u r gS p e c

for SurgicalProcedures
Prophylaxis
Antimicrobial

1 year if irnplant is in place; the infection must


appearto be relatedto the operativeprocedure;the
infectionmustinvolvedeepsofttissues(fascialand
m u s c l el a y e r so) f t h e i n c i s i o na; n da t l e a s to n eo f t h e
f o l l o w i r r gm u s tb e p r e s e n t :
a. Purulentdrainagefrom the deepincisionbut not
componentof the strrgical
from tlreorgan/space
sitel
dehiscesor
b. A deepincisionthat spontaneously
wlren the
a
surgeon
opened
by
is deliberately
t r r eo f t h e f o l l o w i n gs i g n so r
p a t i e nht a sa t l e a s o
s y m p t o m sf:e v e r > 3 8 o Co r l o c a l i z e dp a i n o r
t e u d e r n e s su,nl e s s c u l t u r e o f t h e i n c i s i o r ri s
ruegative;

I3

Results
Head and Neck Surgery
A. Clean-ContaminatedHead and Neck Surgery
l.

I s a n t i r n i c r o b i a lp r o p h y l a x i sr e c o m m e n d e df o r
oncolosicheadandneck
electiveclean-contaminated
surgery?

A n t i r n i c r o b i a lp r o p h y l a x i si s r e c o m m e t r d e fdo r
oncologicheadand neck
electiveclean-contaminated
s u r g e r y(. C A T E G O R YA R E C O M M E N D A T I O N )
Summary of Evidence

trial (Dor, 1973)


A randomizedplacebo-coritrolled
enrolling 102patientswas doneto detenninetheefficacy
(2 gramsof each
of the combinedcloxacillin-arnpicillin
daity) comparedto placebo.There was a statistically
significantdifferericein infectionratesbetweentlretwo
g r o u p sw i t h 1 7 . 3 p e r c e n t( 9 o f 5 2 p a t i e r r t s i)n t h e
d . D i a g r r o s iosf a d e e pi r r c i s i o n aSl S Ib y a s L l r g e o r l
prophylaxisgrolrpand 36 percent( I 8 of 52 patients)in
o r a t t e n d i n gp h y s i c i a n .
t h e p l a c e b og r o u p d e v e l o p i n gi n f e c t i o n s( p < 0 . 0 5 ) .
(LEVEL I EVIDENCE)
I ledtrial
le-blind placebo-contro
A randomizeddoLrb
SurgicalSite Infection
3) Organ/Space
- must occr"rrwitlrin 30 days after the operative (Becker, 1979) enrolling 59 patientswho underwent
procedure
i f n o i m p l a n ti s l e f t i n p l a c eo r w i t h i n h e a d a n d n e c k s u r g e r y f o r c a n c e r o f t h e L l p p e r
tract was done to deternrinethe efTicacy
1 y e a r i f i r n p l a n ti s i n p l a c e ;t h e i n f e c t i o nm u s t aerodigestive
mg IM for 24 hours comparedto
cefazolin
500
appearto be relatedto the operativeprocedure;the of
infectionmustinvolveany partof theanatotnyother placebo.Therewasa statisticallysigrrificantdifference
t l r a nt h e i n c i s i o no, p e n e do r m a n i p u l a t eddu r i n gt h e in infectionratesbetweentlre2 groupswith 3B percent
o p e r a t i v e p r o c e d u r e ;a l t d a t l e a s t o n e o f t h e (12,of 32 patieilts)in the cefazolingroupand87 percent
( 2 0 ' o f 2 3 p a t i e n t s )i n t h e p l a c e b og r o u p d e v e l o p i n g
f o l l o w i n gm u s tb e p r e s e n t :
<
a. Purulentdrainagefrom a drain that is placed i n f e c t i o n sf o r a n R R o f 0 . a 9 ( p 0 . 0 0 1 ) .( L E V E L I
EVIDENCE)
througha stabwound into the organ/space;
rial (Johnson,
A r a n d o m i z e dp l a c e b o - c o n t r o l l et d
b. Microorganisrnsisolated from an aseptically 1 9 8 4 )e n r o l l i n g8 7 p a t i e n t sw a s d o n et o d e t e r r n i nteh e
obtainedcultureof fluid or tissuein the organ/ e f f i c a c y o f t h e t h i r d g e n e r a t i o nc e p h a l o s p o r i r r s
space;
cefoperazoneand cefotaximegiven for 24 hours as
comparedto placeboin preventirrgsurgicalsiteinf'ection.
c . A n a b s c e s so r o t h e r e v i d e n c e o f i n f e c t i o n
a s t a t i s t i c a l l ys i g n i f i c a n t d i f f e r e n c ei n
that is foundon d irect T h e r e w a s
involvingtheorgan/space
infectionratesbetweenthe antimicrobialprophylaxis
examination,during reoperation,or by
and placebogroupswith 10 percentin the cefotaxime
or radiologic examittation;
histopathologic
group, 9.4 percentin the cefoperazonegroup and 78
d . D i a g n o s i os f a d e e pi n c i s i o n aSl S Ib y a s u r g e o n p e r c e n ti n t h e p l a c e b og r o u p d e v e l o p i n gi n f e c t i o n s .
(LEVEL I EVIDENCE)
or attendingphysician.
c . A n a b s c e s so r o t l r e r e v i d e n c e o f i n f e c t i o n
i n v o l v i n gt h e d e e p i n c i s i o nt h a t i s f o u n d o n
direct examination,during reoperation,or by
l r i s t o p a t l r o l o goi cr r a d i o l o g i c e x a m i n a t i o n ;

74

P J S SV o l .6 1 ,N o .2 , A p r i l - J u n e , 2 0 0 6

2. What is/arethe appropriateantimicrobial/s,dose/s prophylaxisand25 percent( I 4 of 56 patients)of those


and duratiorrof propliylaxis?
w h o r e c e i v e d5 d a y s o f a n t i m i c r o b i a lp r o p h y l a x i s
d e v e l o p i nign f e c t i o n(sp > 0 . 0 5 ) (. L E V E L I E V I D E N C E )
T h e r e c o m m e n d eadn t i m i c r o b i a l fso r p r o p h y l a x i s
A r e t r o s p e c t i vset l r d y( R u b i n , 1 9 8 8 )e n r o l l i n g2 3
in electiveclean-contaminated
oucologicheadandneck patientswlro developedbacteriaIsurgicalsiteinfection
surgeryareclindamycin300 mg IV pre-operatively
then following headand neck oncologicsurgeryfoundtlrat
300 nrg IV every 8 hours for 24 hours in combination the most freqLrentlyisolatedorganismswere aerobic
with gentamicin1.7mg/kg/dose
IV pre-operatively
then gram-positive
andgram-negative
whiclrwere
organisms
1 . 7 m g l k g / d o s eI V e v e r y 8 h o u r s f o r 2 4 l r o u r s . isolatedin 91 percentand the anaerobeswhich were
(CATEGORY A RECOMMENDATION)
isolatedin 74 percent.Colorrizationwith Candidawas
seen in 48 percentof casesbut this was observedto
Summary of Evidence
r e s o l v e w i t h o r . r ta n y s y s t e m i c a r r t i f u n g a lt h e r a p y .
(LEVEL
III EVIDENCE)
A r a n d o m i z e dc o n t r o l l e d t r i a l ( J o h n s o n ,1 9 8 4 )
enrolling 107 patients
r.vas
doneto determinetheefficacy
t o c l i n d a m y c i np l u sg e n t a n r i c i n B, Clean Heacl and h'eck Surgerv
o f c e f a z o l i rcro m p a r e d
in preverrting
surgicalsiteinfections.After stratification
p r i o rt o r a n d o rirz a t i o nt o d i s t r i b u t e q u a l l yt l r ev a r i a b l e s 1 . I s a n t i r n i c r o b i aplr o p h y l a x i sr e c o m m e n c l ei nd c l e a n
headand neck surgery?
that might irnpacton the developnrerrt
of postoperative
infectiorrsacrossthe treatmentgroups,a statistically
A n t i m i c r o b i a lp r o p h y l a x i si s N O T r o u t i n e l y
significantreductionin theriskof infectiorrwasobserved
for clearrlreadand neckoperatiorrs
suclr
a t n o n g p a t i e n t sr v h o r e c e i v e d c l i n d a m y c i n p l u s recofflnrencled
y nd submandibular
g e n t a m i c ie
n i t h e ra s s i r r g l ed o s eo r n r u l t i p l ed o s e s( 7 % a s t h y r o i d e c t o m yp, a r o t i d e c t o m a
and 4Yo, respectively)comparedwith patients who g l a n d e x c i s i o n . ( C A T E G O R Y A R E C O M M E N r e c e i v e dc e f a z o l i ne i t l r e ra s s i n g l e d o s e o r m u l t i p l e DATION)
doses(33% and 200/0,respectively).A postoperative
surgical site infection rate of 37 percent was noted Summary of Evidence
a r n o n gt h o s e w h o u n d e r w e n t f l a p r e c o n s t r u c t i o n .
(LEVEL I EVIDENCE)
A r e t r o s p q c t i v se t u d y ( J o h r r s o n 1, 9 8 7 )e n r o l l i n g
A randomized
double-bIind
controlledtrialenrolIing 4 3 8 p a t i e n t s w h o u n d e r w e n t t h y r o i d e c t o n r y .
1l3 patientswas done to determinethe efficacy of p a r o t i d e c t o n ray n, d s u b m a n d i b u l agrl a n de x c i s i o nw a s
t i c a r c i l l i up l u sc l a v u l a n i ac c i dc o m p a r e tdo c l i n d a m y c i n dope. Eighty percentof thesepatientsdicl not receive
plLrs
amikacingivenfor 24 hoLrrs.
Therewasa statistically antib'ioticprophylaxis.Infectionscleveloped
in orrly0.7
significantdifferencein infectionratesbetweenthetwo percent(3 patients)dr-rringthe one month follow-up
groLrpswitlr 36 percent (20 of 55 patients) in tlie periodafter surgerywith one of tliesepatientshaving
t i c a l c iI I i n - c l a v u
l a ni c a c i dg r o L l pa n d I 0 p e r c e n(t6 o f 58 r e c e i v e dp e r i - o p e r a t i v a
e n t i r n i c r o b i apl r o p h y l a x i s .
p a t i e n t si )n t h ec I i n d a m y c i n - a n r i l < agcr ionu pd e v e I o p i n g ( L E V E L I I E V I D E N C E )
i n f e c t i o n s( p < 0 . 0 5 ) .( L E V E [ - I E V I D E N C E )
A r a n d o m i z e dc o n t r o l l e d t r i a l ( J o h n s o n ,1 9 8 6 ) Breast Surgery
e n r o l l i n g1 0 9p a t i e n t su n d e r g o i n g
m a j o rc o n t a m i n a t e d
lread and neck surgery with flap reconstructionwas 1. Is antimicrobial
prophylaxisrecommended
for breast
doneto determinethe efficacy of cefoperazone2grams
surgery?
IV givenfor either1 or 5 days.Tlrerewasno statistically
A n t i m i c r o b i a l p r o p h y l a x i si s N O T r o u t i n e l y
significarrtdifferenceirr postoperativeinfectionrates
r
e
c
o
m m e n d e df o r b r e a s t s u r g e r y . ( C A T E G O R Y A
g
r
o
u
p
s
(
1
0
p
e
r
c
e
n
t
b e t w e e nt h e t w o
with 18
of 53
patients)ofthosewho receivedouedayof antimicrobial RECOMMENDATION)

Antimicrobial Prophylaxisfor SurgicalProcedures

Summary of Evidence

75

likewiseNOT routinelyrecommendedfor electivegroin


lrernia surgery using mesh repair. (CATEGORY A
RECOMMENDATION)

double-blind placebo-control
A randornized,
ledtrial
(Platt, I 990) was doneto determinethe efficacy of preoperativecefonicidcomparedto placeboin preventing Summary of Evidence
surgicalsite infectionsin a mixed group of breastand
herniapatients.A subgroupof 606 patientsunderwent
A meta-analysis
of 5 randomizedcontrolledtrials
t h e f o l l o w i n g e l e c t i v e b r e a s t s u r g i c a l p r o c e d u r e s : on primary tissuerepair and 2 randomizedcontrolled
lumpectomy,local excision,or simple mastectomyin trialson meshrepair(Sanchez-Manuel,
2003)enrolling
percent,
rnodified
percent,
54
radicalmastectomy
in 36
2,660 patientswas done to determinethe efficacy of
in 4 percent,andreduction antimicrobialprophylaxiscomparedto placeboin the
axillarylymphnodedissection
rrrammoplasty
in 6 percent. There was no statistically p r e v e n t i o n o f s u r g i c a l s i t e i n f e c t i o n a f t e r g r o i n
significantd ifferencebetweenthe 2 groups(p = 0.206) herniorrlraphy.There was no statisticallysignificant
with 5.61 percent(17 of 303 patients)in the cefonicid difference in the over-all surgical site infection rate
grolrp and 8.58 percent (26 of 303 patients) in the b e t w e e nt h e 2 g r o u p s( p : 0 . 1 4 )w i t h 3 . 0 8p e r c e n(t 4 0
p l a c e b og r o L r pd e v e l o p i r r gs u r g i c a l s i t e i n f e c t i o n s . of l,297 patients) in tlre prophylaxisgroup and 4.69
(LEVEL I EVIDENCE)
percent(64 of 1,363 patients) in the control grolrp
A p r o s p e c t i v e ,r a n d o r n i z e d ,d o L r b l e - b l i n dt r i a l developingsurgicalsite infectionsfor an oddsratio of
( W a g m a n ,1 9 9 0 )e n r o l l i n g I l 8 p a t i e n t sw a s d o n e t o 0 . 6 1( 9 5 % C l : 0 . 3 2t o I . 1 7 ) .T h e a u t h o r sc o n c l u d e tdh a t
theefficacyof cefazolincomparedto placebo there was no evidencethat the use of prophylactic
determine
in the preventionof surgical site infection in breast antimicrobialsreducedthe surgicalsite infectionrate
in the stLrdywere thosewho after herniarepair.(LEVEL I EVIDENCE)
surgery.PatientsinclLrded
u n d e r w e n tt h e f o l l o w i n g e l e c t i v e b r e a s t s u r g i c a l
analysis of 5 randomizedtrials using
Sr-rbgroup
p r o c e d u r e s :t o t a l m a s t e c t o m yw i t h a x i l l a r y n o d e prirnarytissuerepair(Sanchez-Manuel,
2003)enrolling
percent,
with
in
segmental
mastectomy
dissectiorr 65
1,867patientsshowedthat there was no statistically
axillarynodedissectionin 29 percent,totalmastectomy significantdifference in surgical site infection rates
in 5 percent,and segrnentalmastectomyin I percent. betweenthe two groupswith 3.78 percent(35 of 924
Therewas no statisticallysignificant differencebetween patients)in the prophylaxisgroup and4.87 percent(46
t h e 2 g r o u p s( p : 0 . 7 2 ) w i t h 5 . 0 8 p e r c e n t( 3 o f 5 9 o f 9 4 3 p a t i e n t s ) i n t h e c o n t r o l g r o u p d e v e l o p i n g
and 8.47percent(5 of 59 infectionsfor,an odds ratio of 0.84 (95% Cl: 0.53 to
patients)in thecefazolingroLrp
p a t i e n t si)r rt h e p l a c e b og r o u pd e v e l o p i n gs u r g i c a sl i t e 1 . 3 4 ) "( L E V E L I E V I D E N C E )
i n f e c t i o n s .T h e a u t l r o r sc o n c l u d e dt h a t t h e u s e o f
Subgroupanalysis of 2 randomizedtrials using
prophylacticantibioticsdid not significantlyreducethe meslr repair (Sanchez-Manuel,2003) enrolling 793
i ncidenceof surgical sitei nfectionsafterbreastsurgery. patientsshowedthattherewasno statisticallysignificant
(LEVEL I EVIDENCE)
difference in surgical site infection ratesbetweenthe
two groupswith 1.3 percent(5 of 373 patients)in the
Groin Hernia Surgery
proplrylaxisgroup and4.2 percent(18 of 420 patients)
in the control group developinginfectionsfor an odds
l r o p h y l a x i sr e c o m m e u d e df o r r a t i o o f 0 . 2 8 ( 9 5 % C I : 0 . 0 2 t o 3 . 1 4 ) . ( L E V E L I
l . I s a n t i r n i c r o b i ap
electivegroin herniasurgery?
EVIDENCE)
A r r t i m i c r o b i a lp r o p h y l a x i s i s N O T r o u t i n e l y Gastric and Duodenal Surgery
for electivegroin lrerniasurgeryusing
recornmended
A l . I s a n t i m i c r o b i a lp r o p h y l a x i s r e c o m m e n d e df o r
primary tissue repair. (CATEGORY
RECOMMENDATION) Antimicrobial prophylaxisis
surgery?
electivegastro-duodenal

76

Antimicrobial prophylaxis is recommendedfor


elective gastro-duodenalsurgery. (CATEGORY A
RECOMMENDATION)

PJSSVol. 61,No.2, April-June,2006

An altemativeregimenis cefazolinI grarnIV singlJ


dose(CATEGORY A RECOMMENDATION)
Summary of Evidence

Summary of Evidence
Subgroupanalysisof 96 patientswho underwent
(Stone,
trial
double-blind
randomized
A prospective
gastric surgery in a prospectiverandomizeddor-rble1 9 7 6 )e n r o l l i n g4 0 0 p a t i e n t sw a s d o n et o d e t e r m i n teh e blindtrial (Stone,1976)showedthat patientswho were
efficacy of antimicrobialprophylaxis in preventing given cefazolin i gram IM the eveningbeforesLrrgery,
surgicalsite infectionafter electivegastric,biliary and I gram[M orrcallto the operatingroom and I grarnlM
colonic surgery.Ninety-sixpatientsunderwentgastric on tlreeveningof the operationfor a total of 3 dosesor
operationsfor gastriccancer,gastriculcer or duodenal cefazolin I gram IM on call to the operatingroom, 1
ulcer.Therewasa statisticallysignificantdifferencein gramlM on the eveningof the operatiortand 1 granrIM
surgicalsite infectionratebetweenthe 2 groupswith 4 on the morningaftersurgeryfor a total of 3 doseshada
percentof thosewho were given cefazolin 1 gram IM
significantly lower surgical site infection rate of 4
either I hour or 8 to 12 hoLrrspreoperativelyand 19
percentcomparedto patientswho wereeitlrernot given
p e r c e n to f t l r o s e e i t h e r r r o t g i v e n a n t i m i c r o b i a l
a n t i m i c r o b i a losr i n w h o mt l r ea n t i m i c r o b i a l w asst a r t e d
p r o p h y l a x i so r i n w h o m a n t i b i o t i c s w e r e s t a r t e d
who hada l9 percerrtinfectionrate.Tlre
postoperatively
postoperatively
developinginfectionsfor an ARR of 15
p
e
rcena
t n d t l r e R e l a t i v eR i s k R e d u c t i o n
ARR was l5
p e r c e n (t p : 0 . 0 a 6 ) (. L E V E L I E V I D E N C E )
=
(LEVEL I EVIDENCE)
A p r o s p e c t i v rea n d o m i z e d o u b l e - b l i n dp, l a c e b o - w a s 7 9 p e r c e n (t p 0 . 0 4 6 ) .
A p r o s p e c t i v er a, u d o r n i z eccol n t r o I I e tdr i a l( M o r r i s .
c o n t r o l l e dt r i a l ( N i c h o l s ,1 9 8 2 )e n r o l l i n g3 9 p a t i e n t s
1
9
8
4 )e n r o l l i n g7 8 p a t i e n t su n d e r g o i r regl e c t i v eg a s t r i c
was done to determinethe efficacy of antimicrobial
slrrgery
was doneto comparecefuroximeI .5 gramsIV
2 gramsIV administered
prophylaxisusingcefamandole
2 g r a m sI V s i n g l ed o s e .
then I gram IV 4 hoLrrsand 8 s i n g l ed o s ew i t h r n e z c l o c i l l i n
one hour preoperatively
hoursafter incisioncomparedwith placebofor gastro- T h e r e w a s a s t a t i s t i c a l l ys i g n i f i c a n t d i f f e r e r r c ei n
2.5 percent
performedbecause
ofgastriccancer, infectiouratesbetweenthe two groups.',vith
duodenal
operations
c h r o n i c o r b l e e d i n gg a s t r i c t t l c e r s ,a n d b l e e d i r r go r i n t l r e c e f u r o x i m e g r o r - r pa n d l 8 p e r c e n t i r r t l r e
. l l p a t i e n t si n c l L r d ei dn t h e m e z c l o c i l l i n
o b s t r u c t i ndgu o d e n aul l c e r sA
g r o l r pd e v el o p i n gi r r f e c t i o nfso r a nA R R o f
stLrdyhadclirricalfeaturesthat placedthem at high risk 1 5 . 5p e r c e n t(. L E V E L I I E V I D E N C E )
for the developmentof postoperativesurgical site
Although studieshave shown that cefazolingiven
infection.The surgicalsite infectionrate of 5 percent intramuscu
s for prophyIaxis in gastrolarly is efficacioLt
prophylaxisgroup duodenalsurgery,the expert panel believesthat it is
( I of 19 patients)in the cefamandole
was significantlylower tlran the 35 percentinfection i n d p p r o p r i a tteo a d n r i n i s t etrh e a n t i m i c r o b i at lh r o u g h
rate(7 of 20 patients)in the placebogroupfcrran ARR t h i s r o u t eb e c a u s o
e f t h e p a i n ,r i s l < sa t t di n c o n v eine n c e
. l t h o u g ht h et r i a l
o f 3 0 p e r c e r i ( 9 5 % C I : 2 . 3t o 5 7 . 1 % ) A
dith intranrttsc'ular
t o t h e p a t i e r ritn h e r e n t l ya s s o c i a t ew
w a s I i m i t e d b y t h e s m a l l s a r n p l es i z e , t h e a u t h o r s
i n j e c t i o r r sI t. w a st h e c o n s e t t s uosf t h e e x p e l tp a n e l t h a t
concIudedthat short-termantimicrobialprophylaxisis
c e f a z o l i n l g r a m l V s i n g l e d o s e i s a d e q u a t ef o r
surgicalsiteinfectionsin patients
effectivein preventing
prophylaxis in gastro-duodenalsLrrgeryand thus a
u n d e r g o i r r gg a s t r o d u o d e n asl u r g e r y . ( L E V E L I l
s L r i t a b lael t e r n a t i v ree g i m e t t(.L E V E L I I I E V I D E N C E )
EVIDENCE)
dose/s Biliary Surgery
2. What is/arethe appropriateantirnicrobial/s,
and durationof prophylaxis?
A. Open Biliary Surgery
prophylaxis
in
antirnicrobialfor
The recorrrrlended
surgeryis cefuroximeI .5 grams l . l s a n t i m i c r o b i a lp r o p h y l a x i s r e c o m t n e n d e fdo r
electivegastroduodenal
biliary surgery?
I V singledose(CATEGORY A RECOM MENDATION)

77

Prophylaxis
for SurgicalProcedures
Antimicrobial

A n t i m i c r o b i a lp r o p h y l a x i si s r e c o m m e n d e df o r
p a t i e n t sw h o w i l l u r r d e r g ot l i e f o l l o w i n g b i l i a r y
procedures:
Cholecystectorny
Sphincterotomy
plus sphincterotomy
Cholecystectomy
Choledochoenterostomy
(Choledochoduodenostomy,
plus sphincterotomy,
CIroledochoduodenostomy
Choledochojejunostomy)
C hoIecystoje.iunostomy
C o m m o nb i l e d u c t e x p l o r a t i o n
(CATEGORY A RECOMMENDATION)

c o n c o m i t a n t a l i m e n t a r y p r o c e d u r e s .T h e a u t h o r s
concludedthatantimicrobialprophylaxisin biliarytract
surgeryis effectiveespeciallyin high risk patientsand
that theseresultsindicatethat this is evidenceagainst
tlre further use of no-treatmentcontrols. (LEVEL I
EVIDENCE)
2.

dose/s,
What is/aretheappropriateantimicrobial/s,
prophylaxis?
and durationof

antirnicrobialfor proplrylaxisin
The recommended
biliary surgery is cefazoliri I gratn IV single close.
(CATECORY A RECOMMENDATION)
An alternativeregirnenis cefitroxime1.5gramslV
s i r r g l ed o s e .( C A T E G O R YA R E C O M M E N D A T I O N )

Summary of Evidence
Summary of Evidence
of 60 randomizedcontrolledtrials
A meta-analysis
(Meijer, 1990) for operationson the gallbladderand
s f I I r a n d o m i z etdr i a l se n r o l l i n g
Subgroua
pnalysio
c o m l n o n b i l e d r r c t , i n c l u d i n g c h o l e c y s t e c t o m y , I , 1 2 8 p a t i e n t si n a m e t a - a n a l y s i(sM e i . i e r ,1 9 9 0 )w a s
e x p l o r a t i o n o f t h e c o n l m o n b i l e d u c t a n d done to evaluatethe effectivenessof first generation
was done to determinethe cephalosporins
choledochoenterostomy
comparedwith secondorthirdgeneration
for prophylaxisin biliarysurgery.There
efficacyof antimicrobialprophylaxisfor open biliary ceplialosporins
significantdiffererrcein strrgical
in
the
meta-analysis
no
statistically
42
trials
was
of
A subgroup
sLrrgery.
enrollirig 4,129 patientscomparedthe surgical site site infection rates between the two groups with a
differenceof 0.5 percent(95% Cl:
infection rates amoltg patients given prophylactic cornrnonpercentage
o
/
o
)
1
.
5
a n dp o o l e do d d sr a t i oo f I . l 8 ( 9 5 % C l :
%to2.5
a n t i m i c r o b i a l sw i t h a c o n t r o l g r o u p n o t g i v e n
>
p
0 . 0 5 ) .( L E V E L I E V I D E N C E )
t
o
2
.
0
0
,
0
.
6
9
Tlie resultsshoweda significantlylower
antimicrobials.
S
u
b
g
r
o
u
p
a
n
a
l y s i so f I 5 r a n d o mi z e dt r i a l se n r ol l i r r g
surgicalsite infection rate of 2.1 percent in the
patients
in
a
meta-analysis(Mei.ier,1990)rvas
1,226
prophylaxisgroupcomparedto the 15 percentirrfection
of a singledoseof a
tlre
doneto evaluate effectiveness
rate in the control group for an over-all percentage
prophyIactic
antimicrobialcomparedwith rnultipledose
d iffererrceof 9 percent(.95%CI: 7 %oto 11 %) in favor
regimensfor propliylaxisin biliary surgery.Therewas
o f a n t i b i o t i cp r o p h y l a x i sa, p o o l e do d d s r a t i o o f 0 . 3 0
no statisticallysignificant differencein surgicalsite
( 9 5 % C l : 0 . 2 3 t o 0 . 3 8 )a n d a n N N T o f 1 1 . S u b g r o u p
infectionratesbetweenthe two groupswith a commol.l
analysisfor the two factors that appearedto lrave a percentage
differenceof 0.4 percent(95 % Cl: - I . | %oto
differencesshowed
significanteffecton the percentage
1. 9 % ) a n da p o o l e do d d sr a t i oo f 0 . 8 ( 9 5 % C I : 0 . 4I t o
a significantlystrongerprotectiveeffect of prophylaxis 1 . 5 7 , p> 0 . 0 5 ) ,( L E V E L I E V I D E N C E )
f o r h i g h r i s k p a t i e n t sw l i i l e t h e t i r n i n g o f w o u n d
double-blind multicentertrial (Meijer,
A randornized
inspection rnarkedly influenced the treatment effect 1993) enrolling 1,004 patientswas doneto comparethe
reported.Patientswho were labeledas high risk were efficacy of a single pre-operativedose of cefuroxime
those who had acuteclrolecystitiswithin 4 weeks of a g a i n s tm u l t i p l e d o s e so f t h e s a m e a n t i m i c r o b i a il r r
sLrrgery,emergencycholecystectomy,common dltct p r e v e n t i n gs u r g i c a l s i t e i n f e c t i o n s .T h e r e w a s r t o
stone or ductal exploration,jaundice at the time of statisticallysignificantdifferencein majorsurgicalsite
ageover60years,previousbiliarytractsurgery, infectionratesbetweenthe two groupswith 3.8 percent
sLrrgery,
of the gallbladderon in tlre singledosegroup and4.6 percentin the rnultiple
rnorbidobesity,non-visualization
d
i
a
b
e
t e s m e l l i t u s , a n d dose group developinginfectionsfor an ARR of 0.8
c
h
o
l
e
c
y
s
t
o
g
r
a
p
h
y
,
oral

18

p e r c e n (t 9 5 % C l : - 1 . 7t o 3 . 3 ; p : 0 . 5 2 ) . T h e a u t h o r s
concludedthat there is no significant advantageto
g i v i n gr n u l t i p l ed o s ep r o p h y l a x i cs o m p a r e d
with single
doseprophylaxisin biliary operationsto preventpostoperativeincisionalsurgicalsite irrfections.(LEVEL I
EVIDENCE)

P J S SV o l .6 1 ,N o .2 , A p r i l - J u n e , 2 0 0 6

t l r e r i s k o f d e v e l o p i u gs u r g i c a ls i t e i n f e c t i o n si n l o w risk patients undergoingelective laparoscopic


is modestar,d doesnotj ustifyclinically
cholecystectorny
t h e u s e o f p r o p l r y l a c t i ca n t i m i c r o b i a l s (. L E V E L I
EVTDENCE)
of 6 randonrizedcontrolledtrials
A meta-analysis
(Catarci, 2004) enrolling 974 low-risk patients
wya s
u n d e r g o igne l e c t i v el a p a r o s c oi p
cclrolecystectom
B. LaparoscopicCholecystectomy
whetherantinricrobialprophylaxis
reduces
doneto assess
s nclother
s u r g i c a sl i t ei n f e c t i o n a
l . l s a n t i n i i c r o b i a lp r o p h y l a x i sr e c o r n n t e n d e fdo r t h e r i s k o f d e v e l o p i n g
p
l
a
c
e
b oo r u o
t
o
c
o
r
n
p
l
i
c
a
t
i
o
n
s
c
o
u
r
p
a
r
e
d
s
e
p
t
i
c
cholecystectomy?
laparoscopic
a n t i b i o t i c s .T l r e r e w a s n o s t a t i s t i c a l l y s i g n i f i c a n t
A n t i m i c r o b i a l p r o p l r y l a x i s i s N O T r o u t i n e l y differencein cumulativesurgical site infection rates
for laparoscopic
cholecystectonty
in low- b e t w e e n t h e t w o g r o u p s w i t h 2 . 1 p e r c e n t i r r t h e
recommended
risl<patients.(CATEGORY A RECOMMENDATION) prophylaxisgroLrpand2.9 percentin the controlgroup
d e v e l o p i n gs L r r g i c asli t e i n f e c t i o n sf o r a p o o l e do d d s
; = 0 . 6 3 )T
. h e r ew a s
r a t i oo f 0 . 8( 9 5 % C I : 0 . 3 6t o 1 . 8 6 p
Summaryof Bvidence
l i k e w i s en o s t a t i s t i c a l l ys i g n i f i c a n td i f f e r e n c ei n t h e
A meta-analysis
of 5 randomizedcontrolledtrials cumulatived istantinfectionratesbetweenthetwo groups
( A l - G h n a n i e m2, 0 0 3 ) e n r o l l i n g8 9 9 l o w - r i s kp a t i e n t s with 0.7percentin the prophylaxisgroupand L5 percent
cliolecystectomy
was in the controlgroupdevelopirrginfectionsfor a pooled
undergoing electivelaparoscopic
:
whetherantimicrobialprophylaxisusing o d d sr a t i oo f 0 . 8 2( 9 5 % C l : 0 . 18 t o I . 9 0 ;p 0 . 3 7 ) .T h e
doneto assess
o n et o t h r e ed o s e so f c e p h a l o s p o r i nr se d u c e tsh e r i s ho f authorsconcludedthattlrerewasno needto giveroutine
d e v e l o p i n gs L r r g i c asl i t e i n f e c t i o r r sa n d o t h e r s e p t i c a n t i m i c r o b i a l p r o p h y l a x i s f o r l o w - r i s k p a t i e n t s
a p a r o s c o p icch o l e c y s t e c t o r n(yL.E V E L I
c o m p l i c a t i o n s u c h a s r e s p i r a t o r ya n d u r i n a r y t r a c t L r n d e r g o i nl g
infectiorrcomparedto placeboor no arrtibiotics.Low- EVIDENCE)
It was tlre consensusof the expert panel that
risl<patientswere defined as those who did not have
prophylaxis shoLrldNOT be roLrtirrely
antirnicrobial
a recenthistoryof acutecholecystitis,
acutecholecystitis,
in lowlaparoscopic
cholecystectomy
flor
recommended
j
i, aundice,i mmunesuppress
ion
conlmonbi le d LrctcalcLrl
evidence.
patients
currently
avai
lable
because
ofthe
o r p r o s t h e t i ci m p l a n t s . T h e r e w a s n o s t a t i s t i c a l l y risk
significantd ifferencein incisionalsurgicalsiteinfection The expertsIi kewiseagreed[roweverthat antirnicrobiaIs
d h e n s p e c i f i cc l i n i c a ls i t u a t i o n s
ratesbetweenthe two groupswith 1.5 percentin the m a y b e a d m i n i s t e r ew
proplrylaxisgrolrpand2.2 percentin the controlgroLrp are'presentwhich may increasethe patient'srisk of
d e v e l o p i n gi n c i s i o n a sl u r g i c a ls i t e i n f e c t i o n sf o r a n developinga surgical site infection. Factorssuch as
andotherco-morbid medical
; = 0 . 5 ) . T h e r e patientimmunocompetence
o d d sr a t i oo f 0 . 6 8( 9 5 % C l : 0 . 2 4 t o1 . 9 1 p
wasalsono statisticallysignificantdifferencein organ/ conditions,the surgeon'sexperience,tlre lengthof tlre
space surgical site infection rates between the two operativeprocedure,and the stateof the hospitaland
g r o u p sw i t h 0 . 1 9p e r c e n it n t h e p r o p h y l a x i sg r o u pa n d o p e r a t i n gr o o m e n v i r o n r n e nat n d e q u i p r n e n itn t h e
ld beconsideredin decidingwhetlrer
0.27 percentin the control group developingmajor clinicalsettingshoLr
o
r
t
o
w i t h h o l dg i v i n g a n t i m i c r o b i a lfso r
infectionsfor an odds ratio of 0.93 (95% Cl: 0.06 to t o a d m i n i s t e r
=
l ) . T h e r e w a s n o s t a t i s t i c a l l ys i g n i f i c a n t p r o p h y l a x i s(.L E V E L I I I E V I D E N C E )
1 4 . 9 1 ;p
differerice in distant infection rates between the two
groupswith 0.8 per cent in tlre proplrylaxisgroup and Colorectal Surgery
1 . 6p e r c e n it r rt h e c o n t r o lg r o u pd e v e l o p i n gi n f e c t i o n s
f b r a n o d d sr a t i oo f 0 . 5 ( 9 5 % C I : 0 . 1 4t o I . 7 8 ;p = 0 . 3 ) . L I s a n t i r n i c r o b i a lp r o p h y l a x i sr e c o m m e n d e df o r
colorectalsr-rrgery?
Tlre autlrorsconcludedthat the observedreductionin

Antimicrobial
Prophylaxis
for SurgicalProcedures

A n t i m i c r o b i a l p r o p h y l a x i si s r e c o m m e n d e df o r
e l e c t i v e c o l o r e c t a l p r o c e d u r e s .( C A T E G O R Y A
RECOMMENDATION)

79

f o r a n A R R o f 6 . 7 p e r c e n t( 9 5 % C l : 2 . 3 t o 1 1 . l % ;
p <0.01). In the 9 trialsfrom I 976 onwards,
themortality
rateof 3 .4 percent(15 of 443patients)in theprophylaxis
group was significantly lower comparedto the 8.7
Summary of Evidence
percentmortalityrate(34of 390 patients)in the control
group for an ARR of 5.3 percent(950/o
CI: I .9 to 8.7 o/o:
A meta-analysis
of 26 randomizedcontrolledtrials p < 0.01).The pooledmortality rateof 3.9 percent(36
( B a u n r ,1 9 8 1 )p u b l i s h e df r o m I 9 6 5 t o 1 9 8 0e n r o l l i n g o f 9 12 p a t i e r r t s )i n t h e p r o p h y l a x i s g r o u p w a s
2,052 patientswas done to detennine the efficacy of significantlylowercomparedto the9.7 percentrate(64
v a r i o u s a n t i m i c r o b i a lr e g i m e n sf o r p r o p h y l a x i si n of 657 patients)in the control groupfor an ARR of 5.8
colorectalsurgery conrparedto no antimicrobial in percent.(LEVEL I EVIDENCE)
p r e v e n t i n gs u r g i c a I s i t e i r r f e c t i o n s( 2 6 t r i a l s ) a n d
A meta-analysis
of I 47 randomizedcontrolledtrials
o p e r a t i v em o r t a l i t y( 1 7 t r i a l s ) .O r a l b o w e l - s t e r i l i z i n g( S o n g , i 9 9 8 ) r v a s d o n e t o a s s e s st h e e f f i c a c y o f
r e g i m e n s w e r e u s e d i n f i v e t r i a l s , p a r e n t e r a l antimicrobialprophylaxisin the preventionof sLrrgical
a n t i m i c r o b i a lisn l 3 t r i a l s ,t o p i c a la g e n t si n o n e t r i a l , siteinfectionin patientsr-rndergoing
colorectalsLlrgery.
a n d c o m b i n a t i o nosf t h e s ei n 7 t r i a l s . I n t h e l 2 t r i a l s For,rrtrials
irrclLrded
irr the meta-analysis
whiclr were
through 1975,the sr"rrgical
site iufectiou rate of 21.8
p u b l i s h e ds i n c e 1 9 8 4 t h a t c o m p a r e dp a t i e r r t sg i v e r r
percent(199 of 475 patients)in the prophylaxisgroLrp
antirnicrobialprophylaxiswith a no treatrnentcontrol
was significantlylower conrparedto the 35.7 percent
groupconsistentlyshowedthatthesurgicaI site i nfectiorr
r a t e( 1 3 8 o f 3 8 7 p a t i e n t s )i n t h e c o n t r o lg r o u p f o r a n
A R R o f I 3 . 9 p e r c e n t ( 9 5 %C l : 7 . 9 t o 1 9 . 9% ; p < 0 . 0 1 ) r a t e o f 1 3 p e r c e n t i n t h e p r o p h y l a x i s g r o l r p w a s
andanNNT of 8. In the I 4 trialsfrom 1976onwards,the significantlyIowertlranthe 40 percentinfectionrate in
s L r r g i c asli t e i n f e c t i o nr a t eo f 1 6 . 3p e r c e n t( 9 1 o f 5 5 8 tlrecontrolgroupfor an ARR of 27 percentandan odds
p a t i e n t s )i n t h e p r o p h y l a x i sg r o u p w a s s i g n i f i c a n t l y r a t i o o f 4 . 0 8 ( 9 5 % C l : 2 . 3 3 t o 7 . 1 3 ) . T h e a u t h o r s
lower conrparedto the 4 I .9 percentrate ( 199 of 415 c o n c l u d e tdh a ta n t i m i c r o b i apl r o p h y l a x i iss e f f e c t i v ei n
patients)in thecontroI groLrp
for an ARR of 25.6percent t h e p r e v e n t i o no f s u r g i c a ls i t e i n f e c t i o ni n c o l o r e c t a l
( 9 5 %C I : 1 9 . 6t o 3 1. 6 % ; p < 0 . 0 1 ) T
. h e p o o l e ds u r g i c a l sLrrgery.
(LEVEL I EVIDENCE)
rateof I 9.2 percent (229 of 1, I 90 patients)
siteinf.ection
i n t l r e p r o p h y l a x i sg r o u p w a s s i g n i f i c a n t l y l o w e r 2. {lrat is/arethe appropriateantimicrobial/s,
dose/s,
conrpared
to the 39.1 percerrtrale(337 of 862 patients)
arr"il'd
r-rrati
on of prophylaxi s?
i n t h e c o n t r o lg r o L r pf o l a n A R R o f 1 9 . 9p e rc e n t .T h e
a u t h o r sc o n c l u d e dt h a t a n t i m i c r o b i apl r o p l r y l a x i w
s as
T h e r e c o m m e n d e dr e g i m e n f o r p r o p l r y l a x i si n
preventing
effectivein
sLrrgical
site infectionsand that colorectalslrrgeryconsistsof an orally-adnrinistered
a n y f u r t h e r t r i a l s o n a r r t i u r i c r o b i apl r o p h y l a x i s i n
antiniicrobialcombinedwith a parenteral
antirni crobial.
colorectalsurgeryshoLrldernploya previouslyproven
Therecommended
orally-adrnin
isteredantirnicrobial
standardinsteadof no treatrnerltcolttrols.(LEVEL I
is ciprofloxacin500 mg for 3 doses,startedtheday prior
EVIDENCE)
(CATEGORY A RECOMMENDATION)
to
Seventeen
randonrized
trials in the meta-analysis surgery.
T h e r e c o n t m e n d e da n t i r n i c r o b i a l sf o r s y s t e m i c
(Baum,1981)alsocomparedthe mortalityratesbetweerr
p
r
o
p
h y l a x i sa r e a m o x y c i l l i n - c l a v u l a nai c i d 1 . 2g r a m s
the prophylaxisgroup and the no treatmentcontrol
5g r a m sl V s i n g l e
grolrp.In the B trialsthrouglt1975, tlremortalityrateof I V s i n g l ed o s eA m p i c i l i n - s r , r l b a c t1a.m
4.5 percent(21 of 469patients)i n the prophylaxis group dose Cefoxitin 2 grarnslV single dose Cefazolin 2
was significantlylower comparedto the I 1.2 percent g r a m sI V s i n g l ed o s ep l L r sM e t r o r r i d a z o l5e0 0 m g I V
nrortalityrate(30 of 267 patients)in the controlgroup s i n g l ed o s e( C A T E G O R Y A R E C O M M E N D A T I O N )

80

PJSSVol. 61,No.2, April-June,2006

p < 0 . 0 0 1 )a l l f a v o r e dt h e c o r n b i n e d
o r a l p l r . rssy s t e m i c
group.
The authorconcltrded
antimicrobialprophylaxis
(Song,1998)was doneto compare thattheuseofcombinedoralandsystemicantirnicrobials
A meta-analysis
severaI d iffe rentairtimi crobial regirnensfor prophylaxis f o r p r o p h y l a x i s w a s s u p e r i o r t o u s i n g s y s t e mi c
g amoxiciI lin-clavulanic antirnicrobials
alonein preventing
surgicalsiteinfections
i nclLrdin
in colorectalsLrrgery
(
L
E
VEI- I EVIDENCE)
a c i d . a m p i c i l l i n - s r - r l b a c t acme,f o x i t i n . i n t i p e r t e n r ,i r re l e c t i v ec o l o r e c t asl u r g e r y .
l ss e di n
c e f a z o il n p l Lsr m e t r o n i d a z o l e ,c e f u r o x i m e p l u s
O f t h e o r a l l ya d m i n i s t e r eadn t i m i c r o b i a u
i r rt h e
i s c u r r e n t l ya v a i l a b l e
m e t r o n i d a z o l eg, e n t a r n i c i np l L r sm e t r o n i d a z o l eo r t l r et r i a l s ,o r r l yc i p r o f l o x a c i u
bv the expert
c l i n d a m y c i n ,a n d c i p r o f l o x a c i np l u s m e t r o n i d a z o l e . local market so this was recomrnended
Therewas r1osignificantdifferencein the surgicalsite p a n el .
infectionratesbetweenthe variousproplrylacticagents
alone,doxycycline Thoracic and Cardiovascular Surgery
but regimenssuclrasmetronidazole
a l o n e , p i p e r a c i l l i na l o n e a n d o r a l n e o m y c i np l u s
erytlrromycinalonegiven the day beforethe operatiott A. Thoracic Non-CardiovascularSurgery
(LEVEL I EVIDENCE)
appearedto be inadeqLrate.
S e v e n t e erna n d o m i z e dt r i a l s i n t h e m e t a - a n a l y s i s l . I s a n t i m i c r o b i a pl r o p h y l a x i sr e c o n r m e r r d ef odr
( S o n g ,I 9 9 8 )e n r o Il i n g 2 , 4 5 0p a t i e n t cs o n r p a r eadsi n g l e
larsurgery?
t h o r a c i cn o n - c a r ido v a s c u
d o s e r e g i u r e na d m i r r i s t e r e dp r e o p e r a t i v e l yw i t h a
m u l t i p l e - d o sree g i m e nu s i n gt h e s a m ea n t i m i c r o b i aol r
A r r t i r n i c r o b i apl l o p h y l a x i s i s r e c o m n r e n d e fdo r
. ATEGORY
a c o m b i n a t i o no f a n t i r n i c r o b i a l sN. o n e o f t h e t r i a l s t h o r a ci c r t o n - c a ri do v a s c lua r p r o c e d u r e (sC
found a significantdiffereucein surgicalsite infection A R E C O M M E N D A T I O N )
r a t e sb e t w e e a
n s i n g l ed o s ea n da m u l t i p l e - d o sree g i r n e n
w i t h a p o o l e do d d sl a t i oo f L l 7 ( 9 5 % C l : 0 . 9 t o 1 . 5 3 ) . S u m m a r y o f E v i d e n c e
( t , E V E LI E V I D E N C E )
S i x r a n d o n r i z etdr i a l s i n t h e m e t a - a n a l y s (i sS o n g ,
l ctl r i a l ( A z n a r ,
l d c o r r t r ol e
A r a n d o r inz e dd o u b l e - bi n
p
a
t
i
e
n
t
s
a
f
i
r
s
t
g
e
n
e
r
a
t
i
o
r
r
5
5
1
c
o
m
p
a
r
e
d
I 9 9 B )e n r o l l i n g
s r r r d e r ignogt l r o r a c isct r f g e r y
19 9 I ) e n r o l l i n g1 2 7p a t i e n t L
c e p h a l o s p o r i nw i t h a s e c o n d -o r t h i r d - g e n e r a t i o t t was done to evaluatethe effectivenessof cefazolinI
c e p h a l o s p o r fi o
n r p r o p h y l a x i sN. o n e o f t h e t r i a l sf o r . r n d g r a mI V s i n g l e ' d o sper e o p e r a t i v ecl yo m p a r etdo p l a c e b o
a statisticallysignificant difference in surgical site i n p r e v e r r t i n gs u r g i c a ls i t e i n f e c t i o r r T
. lre irrcisional
infectionratesbetweentlre two groupswith a pooled s u r g i c a ls i t e i n f e c t i o nr a t e o f 1 . 5 p e r c e n t( l o f 7 0
o d d s r a t i o o f 1 . 0 7( 9 5 % C l : 0 . 5 4 t o 2 . 1 2 ) .( L E V E L I p a t i e n t si)n t h e c e f a z o l i ng r o L r p
w a ss i g n i f i c a n t l lyo w e r
EVIDENCE)
t h a nt h e 14 p e r c e nitn f e c t i o nr a t e( 8 o f 5 7 p a t i e n t si )n t h e
A r r e t a - a n a l y soi sf l 3 r a n d o r n i z ecdo n t r o l l e dt r i a l s p l a c e b og r o u pf o r a r e l a t i v er i s l io f 3 . 2 1( 9 5 %C l : I . 5 t o
(Lewis. 2002) enrolling 2,065 patietttswas done to 1 1 . 5 )a n d a n A R R o f 1 2 . 5 .T h e a u t l r o r sc o r r c l u d etcl rl a t
prophylaxiscompared a s i n g l ep r e o p e r a t i vcel o s eo f c e f a z o l i ni s e f f e c t i v ei n
efficacyof systernic
determinethe
to combinedoralandsystemicprophylaxisfor colorectal r e d r - r c i nt hge r a t eo f i n c i s i o n asl u r g i c asl i t ei n f e c t i o n isn
The orally non-card
in preventingsurgicalsiteirrfections.
sLlrgery
(LEV EL I EV I D ENCE)
iacthoracicprocedures.
a d m i r r i s t e r eadn t i m i c r o b i a l Ls r s e di n t h e v a r i o r - rt sr i a l s
i n c l u d e d r l e o l r y c i n - e r y t h r o m y c i u , n e o n t y c i l t - 2 . W h a ti s / a r et h ea p p r o p r i a taen t i m i c r o b i a l /ds o
, se/s,
n r e t r o n i d a z o l er ,r e o m y c i u - t i n i d a z o l ek .a n a m y c i n a n d d u r a t i o no f p r o p h y l a x i s ' ?
de a n
n dc i p r o f l o x a c i nT.h e u r r w e i g h t em
n r e t r o n i d a z oal e
T h e r e c o m n r e u c l eacnl t i n r i c r o b i aflo r p l o p h y l a x i s
r i s k d i f f e r e n c ei n t h e r a t eo f s u r g i c a sl i t e i n f e c t i o n so f
sLrrgeryis cefazolin I
0 . 6 9 ( 9 5 % C I : 0 . 3 9 t o 0 . 9 9 ) ,t l r e w e i g h t e dm e a nr i s k iu thoracicnon-carcliovascrtlar
<
p
(
9
5
%
C
l
:
0
.
2
6
1
o
0.86;
0 . 0 1 )a t t d g r a m l V
single dose. (CATEGORY A
diff-ererro
ce
f 0.56
t h es u n r m a rrye l a t i v er i s ko f 0 .5 1 ( 95 % C L :0 . 2 4t o 0 .7 8 ; RECOMMENDATION)
Summary of Evidence

8l

Antimicrobial Prophylaxisfor SurgicalProcedures

Summary of Evidence
controlledtrial (Aznar,
doLrble-blind
A randornized
thoracicsurgery
199 I ) enroll ing127patientsLrndergoing
was doue to evaluatethe effectivenessof cefazolin 1
comparedto placebo
gramlV singledosepreoperatively
i
n
f
e
c
t i o n .T h e i n c i s i o n a l
s
i
t
e
s
L
r
r
g
i
c
a
l
p
r
e
v
e
n
t
i
l
r
g
iu
percent (1 of 70
1'5
of
rate
site irrfectiorl
sr-rrgical
lower
group
was
sigrrificarrtly
patieuts)in the cefazolin
patients)
in the
(8
of
57
tharithe l4 percetttinfectionr:ate
(95%
.5 to
CI:
1
placebogroupfor a relativerisk of 3 .27
that
I 1.5)and an ARR of 12.5.Tlre authorscoriclLrded
doseof cefazolin is effectivein
a singlepreoperative
site infectiottsin '
therateof incisionalsr-rrgical
reclucing
(LEVEL I EVIDENCE)
thoracicprocedures.
non-carcliac
c o n t r o l l e dt r i a l ( O l a l < ,
A r a n c i o m i z eddo u b l e - b l i n d
the
1 9 9 1 )e n r o l l i n g2 0 8 p a t i e n t sw a s d o n et o c o n r p a r e
efficacy of one doseversussix dosesof cefazolinas
prophylaxisin generalthoracicsurgery' Therewas no
drfferencein the rateof surgical
statisticallysigrrificant
with no infections
two groLlps
the
betweerf
infections
site
g
r
o
u
p and only two
s
i
r
r
g
l
e
d
o
s
e
i
r
r
t
h
e
occurring
group (95% CI:
six-dose
irr
tlre
infectionsoccurring
t h a tg i v i n gs i x
- 0 . 0 0 8t o 0 . 0 4 8 ) .T h e a L r t h o rcso n c l u d e d
doses of cefazolin does not confer any clinically
irnportantbenefit beyondthat obtainedfrorn a single
siteinfectionin elective
dosefor prophylaxisof sLrrgical
(LEVEL
I EVIDENCE)
surgery.
generalthoracic
B. Video-AssistedThoracoscopicSurgery (VATS)
l.

I s a n t i m i c r o b i a lp r o p h y l a x i s r e c o n r t r l e n d efdo r
t hdo r a c o s c o p iscu r g e r y( V A T S ) ?
video-assiste

for
A r r t i u r i c r o b i apl r o p h y l a x i si s r e c o m t n e n d e d
(
V
A
T
S
)'
v i c l e o - a s s i s t e tdh o r a c o s c o p i c s L r r g e r y
(CATEGORY A RECOMMENDATTON)
Summary of Bvidence
(Rovera,2003)enrolling
cohortstLrdy
A prospective
346 patientswas done to determineand cotnparethe
incidencearrdtypes of infectionsoccurringafter two
differentVATS procedures:lung wedgeresectionand
massesand to identify
or rnediastinal
biopsyof pleLrral
risk parameters'The
infection
of
value
predictive
the
was 4.9 percentbut
rate
infection
overallpostoperative

therewasno statisticallysignificarrtd ifferencebetween


tlretwo groupswith 6.47percentof thosewho underwent
wedgeresectionand6.28percentof thosewho ttnderweut
biopsyonly developingirifection.The two groupslrad
o/o;
similar surgical site irrfectionrates (2.8 % vs 1
o / o p; : N S ) , a n d
p : N S ) , p n e u m o n i a( 2 . 8 % v s 3 . 4
:
e m p y e m a( 0 . 7% v s 2 Y o :p N S ) A t n o n gt h ea s s e s s e d
irifectionrisk parameters,all FEVI < 70 percentof
wasobservedmuclturorefrequentlyin infected
expected
oh.
patientstlran in non-infectedpatients(58 % vs 25
p < 0 . 0 5 ) b y m u l t i v a r i a t e a n a l y s i s .( L E V E L I l
EVIDENCE)
2. What is/arethe appropriateantirlicrobial/s'dose/s.
a u dd u r a t i o no f p r o p h y l a x i s ?
i sted
antirl icrobi als fo r v ideo-ass
The recomntended
A
m
p
i
c
i
l
l
i
n
s
L
r
l
b
a
c
t a1r.n5
a
r
e
:
t h o r a c o s c o p iscu r g e r y
A
RECOMMEN(CATEGORY
gramsIV singledose
acid 2.4 grans
DATION) and Amoxycillin-clavr'rlanic
IV singledose(CATEGORYA RECOMMENDATION)
S u m m a r yo f E v i d e n c e
In a cohortstLrdy(Rovera,2003),8 percentdid not
receiveprophylaxisdue to suspectedor established
antibioticallergy.Short-termantibioticprophylaxis was
. 5 g r a m so r
g i v e n u s i n ge i t h e ra m p i c i l l i n - s u l b a c t a lm
isteredasa
m
in
grams
ad
2.2
ic
acid
arrioxic i I I i n-cla'luI an
s i n g l eI V d o s ea t i n d L r c t i oonf a n e s t h e s i aT. h e o v e r - a l l
rateof postoperativeinfectionswas 4'9 percent( I 7 of
3 4 6 p a t i e n t sw) i t h a l l i n f e c t e dp a t i e n t cs o m i n gf r o mt h e
s
groupgivenprophylaxis. Thetotal trumberof i nf-ection
(6.28%)
group
B
in
(6.47%)
and
A
groLrp
occurringin
wasnot significantlyd ifferent.GroupsA andB showed
s f s L r r g i c asli t e i n f e c t i o n( 2 . 8 % v s
s i r n i l a ri n c i d e n c e o
=
p = N S), and
lo/o;p NS), pneumonia(2.8Y0vs 3.4o/o;
:
p
NS). All postoperative
enlpyema(0J% vs 2%o',
with arrtirnicrobial
sr:ccessfirlly
treated
were
infections
therapy and surgical drainage as appropriate'
mortality was nil in both groups. The
Postoperative
postoperativestay was longer for the irrfectedpatierits
patients(8 +
(13 + 7 clays)as comparedto non-itrl'ected
6 clays)bLrtthe differencewas not statisticallysignificant'
(LEVEL II EVIDENCE)

82

C. Cardiac Surgery
l.

I s a n t i m i c r o b i a lp r o p h y l a x i s r e c o m m e n d e df o r
cardiacsurgery?
A n t i n i i c r o b i a lp r o p h y l a x i si s r e c o m m e n d e df o r
cardiac surgery. (CATEGORY A RECOMMENDATION)
Summary of Evidence
Subgroupanalysisof for-rrplacebo-controlled
trials
i n a m e t a - a n a l y s(iK
s r e t e ra n d W o o d s ,1 9 9 2 )e n r o l l i n g
405 patientswas done to determinethe efficacy of
a n t i m i c r o b i a l p r o p h y l a x i s f o r c a r d i a c s L r r g e r ya s
compared
to placebo.
Therewasa statistically
significant
reductionin the sLrrgical
site infectionrate in the group
given antimicrobialprophylaxiswith a summaryodds
ratioof 4.96(95% Cl:2.06to9.72).Tliis corresponds
to
a s i g r r i f i c a nr e
t d L r c t i oi n t h e s u r g i c a l s i t ei n f e c t i o nr a t e
l'ronrabout20 -25 percentin theplacebogroupcompared
t o t h e4 - 5 p e r c e nrta t ei n t h ea n t i t n i c r o b i apl r o p h y l a x i s
g r o u p .( L E V E L I E V I D E N C E )
2. What is/arethe appropriateantimicrobial/s,
dose/s,
and durationof prophylaxis?

P J S SV o l .6 1 ,N o .2 , A p r i l - J u n e2,0 0 6

significantdifferencebetweenthe cefazolilrgroupand
the cefamandole
or cefuroximegroupwhen sternaland
legwound infectionsiteswere analyzedseparately.
The
summaryoddsratio of I .58 (95% Cl: 1.03to 2.45) after
analysisof tlre cornbinedsternaland leg inf-ection
rates
howeversuggests
thatdespitethegenerallylow 5 percent
surgicalsite infectionrate in the cefazoliugroup,there
is a furtherreductionin infectionratesto approximately
3 percentwith the use of tlre secondgeneration
c e p h a l o s p o r i r (r L
s .E V E L I E V I D E N C E )
A r a n d o n r i z e dd o u b l e - b l i n d c o n t r o l l e d t r i a l
( T o w n s e r r d1,9 9 3 )e n r o l l i n gI , 6 4 1p a t i e n t w
s a sd o n et o
comparetlre efficacy of cef'amandole.
cefazolinand
cefuroxinrein preventingsLlrgicalsite irrfectionsafler
cardiacsurgery.There was no statisticallysigrrificant
differerrcein surgical site infectiou rates among the
t l r r e eg r o u p s( p = 0 , 9 2 ) w i t h 8 . 4 p e r c e n t( 4 6 o f 5 4 9
patients)in the cefamarrdole
groLrp,8.4 percent(46 of
547 patients)in the cefazolingroup,and 9 pelcent(49
o f 5 4 5 p a t i e n t s )i r r t h e c e f u r o x i m eg r o L l pd e v e l o p i n g
irrfections.In addition,tlrere was also no significant
differencewith respectto the sitesof irrfectiotrs
andthe
depth of tissue involvementamong the three groups.

(LEVELI EVIDENCE)

A meta-arralysis
of four randomizedcontrolledtrials
(l(riaras,2000) was done to evaluatetlre effect of a
T h e r e c o m m e r r d eadn t i r n i c r o b i a lfso r p r o p h y l a x i s r e d u c t i o ui n t h e d u r a t i o no f p r o p h y l a c t i ac n t i m i c r o b i a l
i n c a r d i a c s u r g e r ya r e C e f a z o l i n l g r a r n I V p r e - r e g i m e n s i n m a j o r c a r d i o v a s c u l a rs u r g e r y o n
operativelythen I gram IV every 8 hours for 48 lrours postoperative
i nfectioLts
colrrp I ications.A randomized
(CATEGORY A RECOMMENDATION)
a n d trial errrolling569 patientswas doneto cot'npare
a long
CefuroximeI .5gramsIV pre-operatively
then I .5 grams d u r a t i o ror f p r o p h y l a x i sL r s i n g
c e f a z o l i n5 0 0 r n gI V p e r
I V e v e r y 8 h o u r s f o r 4 8 h o u r s ( C A T E G O R Y A d a y f o r 4 d a y s w i t h a s h o r t d u r a t i o no f a n t i b i o t i c
RECOMMENDATION)
adririnistration
r-rsing
cefuroxime1.5granrsIV per day
f o r 2 d a y s . T h e r e w a s n o s t a t i s t i c a l l ys i g n i f i c a n t
Surnmary of Evidence
differencebetweentlre two groltpswith a 2.5 percent
surgicalsite infectionrateand 5.7 percent30-daytotal
Subgroupanalysisof six randomizedtrials in a infectionrate in the cefazolingroup and a 1.1percent
meta-ana
lysis (KreterandWoods, 1992) eriroI I ingZ,630 surgicalsite infectionrateand 5.3 percent30-daytotal
patientswas doneto comparethe efficacy of tlre first- infection rate in the cefuroxime group. (LEVEL I
generatiorrcephalosporincefazolin with the second E V I D E N C E )
generationcephalosporins
cefamandoleor cefuroxime
A r a n d o m i z ecdo n t r o l l e d
t r i a le n r o l l i n g8 8 3p a t i e r r t s
for prophylaxisof surgical site infection in cardiac wasdonetocompareceftriaxone2 gramsIV singledose
surgery.The total surgicalsite infectionratesranged with cefazolin500 mg IV every6 hoursfor I day.There
from 2.5 percentto 16.7percentfor tl-recefazolingroup was no statisticallysignificantdifferencebetweenthe
and from 0 percentto 13.5percentin the cefamandole- two groupswith a 0.4percenttotalsLrrgical
siteinfection
or cefuroxime-treated
patients.Tlrerewasno statisticaI ly rate and 5 percent30-day total infection rate in the

Antimicrobial Prophylaxisfor Surgical Procedures

83

ceftriaxonegroupanda I .3 percentsurgicalsiteinfection groin incisionand whetherthe routeof administration


rate and 4.5 percent30-day total infection rate in the was important.The incidenceof groin wound infection
cefazolingroup. (LEVEL I EVIDENCE)
was 24.5 percent (13 of 53 patients) in the no
A r a r r d o m i z e dc o n t r o l l e d t r i a l e n r o l l i n g 1 , 0 0 9 antimicrobialgroup,5.9 percent(3 of 5l patients)in the
patientswas done to conrparecefuroxime 3 grams IV combinedtopical plus intravenouscephradinegroup,
singledosewitlrthecombinationof amoxicillin2 grams while no infectionsoccurredin the topical cephradine
IV every8 hoursfor 4 daysplus netihnycin150 mg IV group of 46 patientsand tlre intravenouscephradine
every l2 hours for 4 days.There was no statistically groupof 55 patients.Comparingsurgicalsite infection
significantdifferencebetweenthetwo groupswith a I .2 ratesby incisionsite betweenthe use of antirnicrobial
percenttotal sLrrgical
siteinfectionrate and5.7 percent prophylaxisand no antimicrobials,the incidenceof
groin and abdominal incision infections were
30-daytotal infectionratein the cefuroximegroupand
s i g n i f i c a n t l yl o w e r i n t h e p r o p h y l a x i sg r o u p a t 1 . 8
a 0.6 percentsurgicalsite irifectionrateand 5.6 percent
percent(3 of I 69 incisions)and 0 percent(0 of 3 I
30-day total infection rate irr the cefazolin groLrp.
incisions)respectively
comparedwith tlrecorresponding
(LEVEL I EVIDENCE)
groin infectionrateof 22.6 percent(14 of 62 incisions)
A randornized
controlledtrial was doneto compare
and abdominalincision infectionrate of 22.2 percent
cefuroximewith ceftriaxoneboth of which were given (2
of 9 incisions)in the no antinricrobialgroLrp.
There
for 48 hours,The total postoperative
infectionratewas wasno statisticallysignificantdifferencein leg incision
5.2 percent(range4.5 % to 5.7 %) but there was no infectionrateswith a I .0 percentrate(3 of286 incisions)
statisticallysignificant difference in infectiorr rates in the prophylaxisgroup comparedwith none(0 of 77
betweentheantimicrobialregirnens.
Despitethevarying i n c i s i o n s )i n t h e n o a n t i m i c r o b i apl r o p h y l a x i sg r o u p .
forms and durationof antimicrobialproplrylaxis,the (LEVEL I EVIDENCE)
total surgicalsite infectionrate in the meta-analysis
of
2,970 patientswas 1.1 percentand there was a trend 2. What is/arethe appropriateantimicrobial/s,
dose/s,
generallyin favor of the shorterregimen.(LEVEL I
and durationof prophylaxis?
EVIDENCE)
glrvariousantim icrobial regimens havebeen
The recommended
antirnicrobialfor prophylaxisin
AlthoLr
periplreral
proplrylaxis
equally
efficacious
for
vascular
sLlrgery
is cefazolinI granrIV preto
be
in
shown
cardiac procedures,cefazolin and cefuroxirnewere operativelytlren'l grarl IV every6 hoursfor 24 hours.
(CATEGORY A RECOMMENDATION)
recornrrrended
by the membersof tlre expertpanel.
,I.5
grarnsIV
An alternativeregimenis cefuroxirle
pre-Qperatively
grams
then 1,5
IV every 8 hoursfor24
D . V a s c u l a rS u r g e r y
hours.(CATEGORY A RECOMMENDATION)
for
l . I s a n t i m i c r o b i a lp r o p h y l a x i sr e c o m r n e n d e d
Summary of Evidence
peripheralvascularsurgery?
A n t i r n i c r o b i a lp r o p h y l a x i si s r e c o m m e n d e df o r
p e r i p h e r a l v a s c n l a r s L r r g e r y .( C A T E G O R Y A
RECOMMENDATION)

A prospectiverandonrizedstudy (Edwards,1992)
enrolling559 patientswas done to determinewhether
the incidenceof vascular sr-rrgical
site infectionsin
p a t i e n t sL r n d e r g o i n a
g b d o r n i n a la o r t i c a n d l o w e r
extremityperipheralvascularsr"rrgical
procedurescan
S u m m a r yo f E v i d e n c e
be redLrcedby administeringa more beta-lactamaseA p r o s p e c t i vbel i n d e dr a n d o m i z e tdr i a l ( P i t t , 1 9 8 0 ) s t a b l ec e p h a l o s p o r i nl i k e c e f u r o x i m e1 . 5 g r a m s I V
Iy, 750 mg IV every3 hours duri ng operation
enrolling217 patientswas done to determinewhether preoperative
p r o p h y l a c t iacn t i m i c r o b i a w
l so u l d r e d u c et h e i n c i d e n c e and750 mg IV every6 hoursfor 24 hourspostoperatively
500
of infection in peripheralvascularprocedureswith a ascomparedto cefazolinI grarnIV preoperatively,

84

2006
PJSSVot.61,No.2, April-June,

a n t i m i c r o b i a l s i n p a t i e n t s u n d e r g o i n gs u r g i c a l
of hip or otlrerlorrgbonefracturesreduces
management
the incidenceof surgicalsiteandotherhospital-acqtrired
infectionsS
. u b g r o u pa n a l y s i so f s e v e t lt r i a l s w l r i c h
compareda siugle pre-operativedose of a parenteral
antibiotic with placeboor tro treatruentslrorvedthat
s i n g l e d o s e a n t i m i c r o b i apl r o p l r y l a x i s i g n i f i c a n t l y
sLrrgicalsite irrfections
reducedthe rate of sLrperficial
(
9
5
%
0
. 5 0 t o 0 . 9 5 )a n d d e e p
C
I
:
0
.
6
9
R
R
o
f
with arr
o f 0 . 4 0( 9 5 % C l : 0 . 2 4
w
i
t
h
a
n
R
R
s u r g i c asl i t ei n f e c t i o n s
t o 0 . 6 7 ) .T e n t r i a l s w h i c h c o n r p a r e cal p r e - o p e r a t i v e
d o s ep l u s2 o r m o r ep o s t o p e r a t i vdeo s e sw i t h p l a c e b o r
n o t r e a t m e n ts h o w e dt h a t t h e u s e o f r n u l t i p l ed o s e
a n t i r n i c r o b i apl r o p h y l a x i sa l s o s i g n i l ' i c a n t l yr e d r r c e d
witlt an RR
surgicalsiteirrl'ectiorrs
the rateof sLrperficial
o f 0 . 4 8( 9 5 % C l : 0 . 2 8t o 0 . 8 1 5 )a r r dd e e ps u r g i c asl i t e
i r i f e c t i o nw
s i t h a r rR R o f 0 . 3 6 ( 9 5 % C l : 0 . 2 1t o 0 . 6 5 ) '
(LEVEL I EVIDENCE)
A m e t a - a n a l y soi sf 15 r a n d o m i z e cdo n t r o l l e dt r i a l s
(SoLrthr,vetl-Keely,
2004) enrolling 2,417 patientswas
d o n e t o e v a l u a t et h e e f f e c t i v e n e s os f a n t i r n i c r o b i a l
s l r o h a c sl t r r g i c ailn t e r v e n t i o n
p r o p h y l a x i fso r p a t i e r l t w
after a proxinialfenloralft'acture.Otttcontesmeasured
ttrinarytt'actittfection,
siteinf-ectiorts,
sLrrgicaI
incILrded
a n dr n o r t a l i t yO. f t h e t e nt r i a l si r r c l L r d ewdh i c hs o u g h t t o
determine whether antinricrobial prophylaxis
s i g n i f i c a n t l yr e d u c e do v e r - a l l s L r r g i c asl i t e i n f e c t i o n
showed
rateswhencomparedwith placebo,threestr'rdies
a s t a t i s t i c a l l y ' s i g n i f i c a nbt e r r e f i tf o r t h e u s e o f
a n t i m i c r o b i a l sf i,v e s t u d i e ss h o w e da t r e n di t t f a v o ro 1 '
a n t i b i o t i c s ,a n d t w o s t u d i e s f a v o r e d p l a c e b o 'T h e
0rthopeclic Surgery
rredresultsshoweda slllnlllaryoddsratioof 0.55
cour.bJ
for total ( 9 5 % C l : 0 . 3 5 t o 0 . 8 5 )f a v o r i r r gt l r eu s eo f p r o p h y l a c t i c
prophylaxisrecolnmended
1. ls antitnicrobial
(LEVEL I EVIDENCE)
-ioint replacetnentarrd elective fixation of closed a r r t i m i c r o b i a l s .
fractures?
long bone
2 . W h a ti s / a r et h ea p p r o p r i a taen t i r n i c r o b i a l /dso. s e / s ,
a n dd L r r a t i oor rf p r o p h y l a x i s ?
for totaI
ArrtirnicrobiaI prophyIaxis is recommended
surgeryandelectivefixatiorrof closed
-iointreplacetnent
T h e r e c o m m e n d eadn t ir l i c r o bi a l f b r p r o p h yl a xi s i n
A
fractures. (CATEGO RY
b on e
l o r rg
joint replacemetrt
surgeryand electivefixationo1'
total
RECOMMENDATION)
is cefazolin I gram IV prefractures
long
bone
closed
'l
every 8 lroursfbr 24 lrours
grarn
lV
operativelytlten
S u m m a r yo f E v i d e n c e
( C A T E G O R YA R E C O M M E N D A T I O N )
trials
controlled
of 22 randomized
A rneta-analysis
( G i l l e s p i e2, 0 0 4 )e n r o l l i n g8 , 3 0 7p a t i e n t sw a s d o n et o Alternativeregimensare:
t h e n7 5 0 m g
determinewhetlrerthe prophylacticadtninistrationof C e f u r o x i m e1 . 5g r a m s[ V p r e - o p e r a t i v e l y
mg every4 hoursduringoperation,and 1 gramevery6
hours postoperativelyfor 24 hottrs.Tlie study showed
that tlrere was lto statisticallysignificant difference
betweenthe two groups with 2.6 percent (7 of 272
patients)in the cefuroximegroup and 1.0percent(3 of
287 patients)in the cefazolirrgroup developingdeep
i n c i s i o n a l s u r g i c a l si irtref e c t i o n( sp = 0 . 2 ) .T h ea u t h o r s
c o n c l u d e dt h a t a l t h o u g h t h e d i f f e r e r r c ew a s n o t
statisticallysignificant,the trend in infection rates
suggeststhat at tlre dosesused in the study, cefazolin
prophylaxisthan
providesmoreeffectiveperi-operative
(LEVEL
I
EVIDENCE)
cefuroxime.
A r a n d o n r i z e dt r i a l ( H a l l , 1 9 9 8 ) e n r o l l i n g 3 0 2
p a t i e n t sw a sd o n et o c o m p a r et h e i n c i d e r r coef s u r g i c a l
s i t e i n f e c t i o n a f t e r v a s c u l a rs l l r g e r y f o l l o w i r r g t h e
a d r n i n i s t r a t i oonf t i c a r c i l l i n3 . 0 g r a r l s / c l a v u l a n a0t e.I
grarrrIV either as a single pre-operativedose or as a
multiple-doseregirnenat 6 hourly intervalsafter the
initial dosefor a maximum of 20 doses'There was a
s t a t i s t i c a l l sy i g n i f i c a n dt i f f e r e n c ei n t h e i n c i d e n c eo f
s e t w e e nt h e t w o g r o l l p sw i t h l 8
s u r g i c asl i t ei n f e c t i o n b
p e r c e n(t2 8o f 15 3 p a t i e n t si)n t h es i n g l ed o s eg r o u pa n d
l 0 p e r c e n (t 1 5 o f 1 4 9 p a t i e n t s i)n t h e n r u l t i p l ed o s e
g r o u p d e v e l o p i n gi n f e c t i o n sf o r a r e l a t i v er i s k o f 2 . 0
( 9 5 Y "C l : - 1 . 0 2t o 3 . 9 2 ) .T h e a u t h o r sc o n c l u d e dt h a t a
le-doseratlrerthana singledoseregimenprovides
mr-rltip
optirnalprophylaxisagainstsurgicalsite infectionfor
p a t i e n t su n d e r g o i n gv a s c u l a r s u r g e r y . ( L E V E L I
EVIDENCE)

Antimicrobial Prophylaxisfor Surgical Procedures

lV every 8 lrours for 24 hours (CATEGORY A


RECOMMEN DATION)
Ceftriaxone2 grams IV single dose (CATEGORY A
R E C O M M E ND A T I O N )

85

analysisof two trials in tlremeta-analysis


SLrbgroLrp
(Gilfespie,2004)wlrichcomparedthe useof prophylaxis
l i m i t e d t o 2 4 h o u r s o r l e s s w i t h l o n g e r p e r i o d so f
a n t i m i c r o b i a l a d r n i n i s t r a t i o nd i d n o t s h o w a n y
statisticallysignificant difference between the two
regimensin termsof superficialsurgicalsite inf-ection
Summary of Evidence
a n R R o f 0 . 5 7( 9 5 % C l : 0 . l 7 t o 1 . 9 3 ) a ndde e p
rateswith
analysisof two trials in a meta-analysis s u r g i c a l s i t ien f e c t i o nr a t e sw i t h a n R R o f L l 0 ( 9 5 %C l :
Sr-rbgroup
(Gillespie2
, 0 0 4 )w h i c l r c o m p a r e da s i n g l ed o s eo f a 0 . 2 2t o 5 . 3 4 ) .( L E V E L I E V I D E N C E )
wli t h m L r l t i p l ed o s e so f t h e
s h o r t a c t i n ga r r t i n r i c r o b i a
s a n l e a g e n t f o r p r o p h y l a x i ss h o w e d a s t a t i s t i c a l l y Urologic Surgery
significantdiff'erencefavorirrgrlLrltipledoses in the
preventionof superficialsLrrgicalsite infection rates A. Transurethral Resectionof the Prostate
r.vitlran RR of 4.82 (95% CI: L08 to 21.61) and deep
surgicalsiteinfectiortrateswith an RR of 7.89(95%CI: l . I s a n t i m i c r o b i a lp r o p l r y l a x i sr e c o n t m e r t d etdb r
1 . 0 1t o 6 1 . 9 8 )(.L E V E L I E V I D E N C E )
resectionof the prostate?
transurethral
S L r b g r o Larnpa l y s i so f t h r e et r i a l si n a m e t a - a n a l y s i s
(Gillespie2
, 0 0 4 )r v h i c hc o n t p a r e da s i n g l ed o s eo f a
A n t i r n i c r o b i a lp r o p h y l a x i si s r e c o m t n e n d e fdo r
l o n g a c t i n ga n t i m i c r o b i awl i t l r r n u l t i p l ed o s e so f o t h e r t r a n s u r e t h r a lr e s e c t i o n o f t h e p r o s t a t et o p r e v e n t
a n t i u r i c r o b i aw
l si t h s h o r t e rh a l f - l i v e sd i d n o t s h o wa n y p o s t o p e r a t i v e
b a c t e r i u r i aa n d c l i n i c a l s e p t i c e m i a .
s t a t i s t i c a l l ys i g n i f i c a n td i f f e r e r r c eb e t w e e nt h e t w o ( C A T E G O R YA R E C O M M E N D A T I O N )
r e g i n r e nisn t e r m so f s u p e r f i c i asl u r g i c a sl i t e i n f e c t i o n
r a t e sw i t h a n R Ro f 1 . 0 1( 9 5 % C l : 0 . 3 5t o 2 . 9 3 )a n dd e e p S u m m a r y o f E v i d e n c e
s il t ei n f e c t i o nr a t e sw i t h a n R R o f 0 . 5 7( 9 5 % C I :
sLrrgica
t h a tt h e e f f e c to f a
0 . 2 0t o 1 . 6 4 )T. h e a u t h o r sc o n c l u d e d
c o n t r o l l e ct rl i a l s
A m e t a - a n a l y soi sf 3 2 r a n d o t r i z e d
s i n g l ed o s ei s s i r n i l a tr o t h a to f m u l t i - d o s e isf t h e a g e r i t (Berry, 2002) enrolling 4.260 patientswas done to
r-rsep
d l o v i d e st i s s u el e v e l s e x c e e d i n gt h e m i n i m t t m determinetlie efficacyof antimicrobialprophylaxisin
i n h i b i t o r yc o r t c e n t r a t i oorvl e r a l 2 - h o u r p e r i o d .I f t h e preventi ng postoperati
i ng
ve bacteri uria i n tnetturtdergo
a n t i b i o t i cc h o s e nh a s a s h o r t - h a l fl i f ' ew h i c h r r a y r l o t
pri
treatment
nrary
transurethral prbstatic resection.The
to beexceeded
concentratiotts
allowmittittrumirrhibitol')/
e n d p o i r r to f b a c t e r i u r i aw a s d e f i n e di n t h e s t u d i e sa s
t h r o L r g l i o tuht e p e r i o dl j ' o mi n c i s i o nt o w o u n dc l o s u r e ,
g r o r , v t hb e t w e . e n1 0 4 a n d 1 0 7 p e r n r l b e t w e e n
d o s er e g i r r r e nnsl a yb ed o n e .( L E V E L
t h eu s eo f r n u l t i p l e
days 2 and 5. Eight trials in tlre metapos{operative
I EVIDENCE)
analysie
s r r r o l l i r r 1g , 9 7 9p a t i e n t lsi k e w i s ee x a r l i n e dt h e
A r a n d o m i z e dd o u b l e - b l i n dn t u l t i c e n t e rt r i a l
efficacy of antirnicrobialprophylaxis in preventing
( M a u e r h a nI,9 9 4 )e n r o l l i n g1 , 35 4 p a t i e n t sw a sd o n et o
septicernia.This secondaryoutcomeof
postoperative
c o m p a r ec e f u r o x i n t e1 . 5 g r a r n s I V p r e - o p e r a t i v e l y
a
p
p
a r e n ts e p s i sw a s d e f i n e d b y o b . i e c t i v e
c
l
i
n
i
c
a
l
l
y
follr:wedby 750 rng every 8 hours for a total of three
parameters
as persistenttemperaturegreaterthan
such
followed
with cefazolinI granrIV preoperatively
closes
C - r e a c t i v pe r o t e i n(.L E V E L
3 B . 5 o Cr,i g o r sa n de l e v a t e d
b y I g r a n rl V e v e r ye i g h th o t t r sf o l ' a t o t a lo f n i n ed o s e s
hip or kneejointarthroplasty. I E V I D E N C E )
Lrndergoirrgtotal
in patierrts
of 32 trials slrowedthat the
The nreta-analysis
weredoneat two to threenronths
assessnleltts
Follow-Lrp
ratewassignificantlylower
event
bacteriuria
combined
and one year afterthe procedure.An intention-to-treat
) i t h t h e u s eo f
(
2
{
3
p
e
r
c
e
n
t
o
f
2
,
3
4
6p a t i e n t s w
a
t
9
.
1
a r r a l y s i sd i d n o t s h o r v a n y s t a t i s t i c a l l ys i g n i f i c a n t
to
the26 percent
as
compared
differencein the strlgicalsite infection ratesbetween prophylacticantirnicrobials
p
p a t i e n t s e) v e n tr a t e i n t l r e l a c e b oo r n o
the two groupswith 3 percentin the cefut'oximegroLrp ( 4 9 7 o f 1 , 9 1 4
risk of bacteriuriairr
a n c l 3 p e r c e n t i r r t h e c e f a z o l i n g r o u p d e v e l o p i n g agentcontrol groLrp.The relative
p
e r c e n t ( 9 5 0C/ Io: - 5 5
R
R
o
f
6
5
w
i
t
h
w
a
s
0
.
3
5
a
l
l
t
r
i
a
l
s
i n f ' e c t i o n (sL. E V E L I E V I D E N C E )

86

to -72).On tlreotlierhand.the subsetof 8 trials slrowed


that the combinedclirricalsepticeuria
episoderatewas
l i k e w i s es i g n i f i c a n t l yl o w e r a t 0 . 7 p e r c e n (t 9 o f 1 . 2 2 9
p a t i e n t sw) i t h t h e u s eo f p r o p h y l a c t i ac n t i r n i c r o b i a al ss
conrparedto the 4.4 percent(33 of 750 patients)event
ratein the placeboor uo agentcoutrolgroupfor a RRR
of 77percent(95%
C I : 5 5 t o - 8 8 ) .T h e r e s u l t ss h o wt l r a t
i f I , 0 0 0 p a t i e n t sw i t h s t e r i l e u r i n e w e r e g i v e n
p r o p h y l a c t i ca n t i m i c r o b i a l sb, a c t e r i u r i aw o L r l db e
a v o i d e di n 1 7 5w h i l e s e p t i c e n r iwa o u l d b e p r e v e n t e idn
9 to 20. Tlreresults of the meta-analysis
thereforeshow
p
r
o
p
h
y
l
a
x
i
s
t h a ta n t i mi c r o b i a l
i s e f f e c t i v ei n d e c r e aisn g
the rate of postoperative
b a c t e r i u r i aa n d c l i n i c a l
s e p t i c e m i a( L
. EVEL I EVIDENCE)

P J S SV o l .6 1 ,N o .2 , A p r i l - J u n e2,0 0 6

p < 0 . 0 1 ) .C e p h a l o s p o r itnr i a l s i r t v o l v e d6 7 p e r c e r rot f


t l r et o t a ls t L r dpy a r t i c i p a n t(s2 , 8 1 4o f 4 , 2 6 0p a t i e n t sa)n d
c o n r b i n etdh e ys h o r v e a
d 6 6 p e r c e r rrte l a t i v ed e c r e a sier r
r i s k ( 9 5 % c l l : - 5 7 t o - 7 3 . p < 0 . 0 1 ) .N i t r o f u r a n r o i n .
p e ni ci l l i n a n dB - p e ni c i l l i nd i d r r o ts i g ni f i c a n t l yc l e c r e a s e
t l r er i s k o f b a c t e r i u r i a l t l r o L r gthl r ep o i r r te s t i n r a t ef so r
e a c h c l a s s w e r e i n t h e d i r e c t i o no f d e c r e a s e d
risk.
(LEVEL I EVIDENCE)
A m e t a - a n a l y soi sf 3 2 r a n d o m i z e cdo n t r o l l e dt r i a l s
( B e r r y , 2 0 0 2e) n r o I I i n g 4 . 2 6p0a t i e r r tasl s oa n a l y z etdh e
duratiorrs
usedin thetrialsby dividing
difTerenttreatrnent
Lrse-cl,
them into 3 groups.Basedon the dose regirtterts
cc'rurse
wereclassifiedaseitlrersingledose
thedLrrations
(predonr
inantlyantibioticadnrin isteredpreoperatively).
(moretlranoneantibioticdoseadministered
slrort-course
or
hoLrrs
of surgeryor until catlteterrerttoval),
within
72
2. What is/arethe appropriateantirnicrobial/s,dose/s,
e x t e n d e dc o l u ' s e( n r u l t i p l ea n t i b i o t i cc l o s e se x t e n d i n g
a n d d u r a t i o no f p r o p l r y l a x i s ?
beyond 72 hours fronr the tirre of tlre procedureor
T h e r e c o n r m e n d eadn t i m i c r o b i af lo r p r o p h y l a x i si n b e y o r r dc a t h e t e rw i t h d r a w a l ) .A n a l y s i s o f a l l t l i a l s
tlte
resectionof the prostateis ciprofloxacin indicatedthat extendedcourseprotocolsdecreased
transurethral
-42
to
500 mg tabletper orernBID for 72 hours(CATEGORY incidenceof bacteriuriaby 72 percent(95% Cl:
-87),
percent
protocols
it
by
68
decreased
short-colrrse
A RECOMMENDATION)
(95% Cl: -56 to -77) andsi ng Ie doseprotocoIs decreased
i t b y 5 7 p e r c e n(t9 5 % C I : - 4 I t o - 6 8 ) .S L r b g r o uapn a l y s i s
r e g i m e n sa r e :
A Iternative
C e p l r a l e x i n5 0 0 m g p e r o r e m T I D f o r 3 d o s e s o f c e p h a l o s p o r i n - b a s e dt l i a l s w i t h s i g n i f i c a n t
h e t e r o g e n e i ti yn c l u d i n -7u s i n g l ec l o s e1. 2 s h o r t - c o u r s e
(CATEGORY A RECOMMENDATTON)
RRR of 82
F l u o r o q u i n o l o n e ( C i p r o f l o x a c i r r , O f l o x a c i n , ancl I extendeclcoursereginrensshor,l'ed
Levofloxacin)400 rng IV every l2 hours for 72 hoLrrs p e r c e n (t 9 5 % Q l : 3 7 t o - 9 5 , p < 0 . 0 1 )f o r t h e e x t e r r d e d
coursereginren, RRR of 71 percent(95% Cl: -63 to
(CATECORY A RECOMMENDATTON)
7 7 , p < 0 . 0 1 )f o r t h es h o r tc o u r s ep r o t o c o l sa n d R R R o f
o l : - 38 t o - 6 2 , p < 0 . 0 1) f o r t h e s i n g l e
5 2 , p e r c e n(t9 5 0 / C
S u m m a r yo f E v i d e n c e
d o s t ' ' p r o t o c o l sT. h e n r e t a - a n a l y s issh o w e d t h a t a
RRRwasaclrievecl
by alltreatrttent
A m e t a - a n a l y soi sf 3 2 r a n d o m i z e cd o n t r o l l e dt r i a l s significantbacteriuria
( Berry. 2002)errro I ling 4,260 patients also analyzedthe d u r a t i o np r o t o c o l s(.L E V E L I E V I D E N C E )
A l t h o L r g ho n l y c 1 r - r i n o l o nseusc h a s c i p r o f l o x a c i r t
a n t i m i c r o b i acll a s s eus s e di n t h et r i a l sb y d i v i d i n gt h e m
and
fleroxacinwere used in tlre trials includedirr the
groups.
into 9
The risk of bacteriuriawas significantly
the expertpanelbelievesthat the Lrseof
with RRR of 55 percent nreta-analysis,
decreased
by aminoglycosides
inthe
(95% CI:0 to -80,p: 0.051). co-trirnoxazole
with RRR o t h e r q L r i n o l o nwe hs i c ha r er l r o r er e a d i l ya v a i l a b l e
if
o f 6 4 p e r c e n t( 9 5 % C l : - 4 t o - 8 7 , p = 0 . 0 4 1 ) .f i r s t local settirrgmay be sLritablealternativeregirnerrs
parenterally
hours
for
a
slrort-colrrse
of
abor,rt
72
used
w
i
t
l
r
g e n e r a t i o nc e p h a l o s p o r i n
RRR of 66 percent
thatthefl uoroquinolonesasa c lassgavethe
(95% Cl: -36 to -82, p < 0.0 | ), second generation considering
c e p h a l o s p o rw
i ni t h R R R o f 6 3 p e r c e n(t 9 5 % C I : - 2 8 t o h i g h e s tr e l a t i v e r i s k r e d u c t i o no f 9 2 p e r c e n tw h e n
-8 I , p < 0.01). tlrird generatiorr
. andomized
c o u t r o l l e dt r i a l st o
cephalosporin
with RRR c o m p a r e dt o p l a c e b o R
5
5
7
6
,
quinolones
<
shoulclbe
p
to
0 . 0 1 ) , a n d evaluatethe efficacyof the other
o f 6 7 p e r c e n t( 9 5 % oC l :
quinolonewith RRR of 92 percent(95ohCI: -75 to -98, donein the future.(LEVEL III EVIDENCE)

Antimicrobial
Prophylaxis
for SurgicalProcedures

81

Neurosurgery

smallertreatmenteffectsfor antimicrobialr"rse
with arr
odds ratio of 0.30, tlrerewas no evidenceof different
A. Spinal Surgery
treatmenteffects witlr tlre inclusion of grarn-rregative
coverageover gram-positive
coveragealone(oddsratio
I . Is antinricrobialprophylaxis
recorlmende
d for spirral o f 0 . 5 4 . p : 0 . 5 ) . T h e a r - r t h o rf sa i l e d t o i d e n t i f ya n y
surgery?
additionalbenefitwhenantimicrobialcoverage
incIuded
Antimicrobialprophylaxisis recommended
in spinal gram-negative
organisnrs.
One trial (Rubinstein,I994)
o p e r a t i o n ss u c l r a s l a m i n e c t o r l i e s ,f u s i o n s , a n d usedcefazolinsingledosewhile anothertrial (Redjian.
d i scectonr
ies.(CATEGORY A RECOMMENDATION) 1990) utilized oxacillin for 24 hours as prophylaxis.
(LEVEL I EVIDENCE)
Summary of Evidence
Four randornized
trials in a meta-analysis
(Barker,
2002)
pre-operative
used
only
and
intra-operative
dosirig
A meta-analysis
of 6 randomizedcontrolledtrials
w
h
i
l
e
t
w
o
t
r
i
a
l
s
u
s
e
d
a
d
d
i
t
i
o
n
a
p
l
o
s
t
o
p
e
r
a
t
i
v
eo s i r r g
d
(Barl<er,2002) enrolling 843 patients was done to
for
12
to
24
hours.
There
was
no
evidence
of different
d e t e r m i n ew h e t h e r a n t i mi c r o b i a l p r o p h y l a x i s w a s
beneficialfor spinaloperationsdespitethe prevailing treatmenteffects witli the different dosing periods
low infectionratewithout pre-operative
antibiotics.In a l t h o u g h t h e t r i a l s L l s i n g p o s t o p e r a t i v ed o s i n g
prophylaxis
group,
the antibiotic
2.2 percent( I 0 of 451 demonstratedslightly smaller treatmenteffects for
( o d d sr a t i oo f 0 . 5 2v e r s u s0 . 3 4 ,p = 0 . 9 6 ) .
patients)developed
sr"rrgical
siteinfectionscomparedto a n t i b i o t i cL r s e
The
authors
failed
to identify any additiorralbenefit
5.9 percent(23 of 392 patients)in the pooledcontrol
regimerrs
wereusedasconrpared
to
armsof thetrials.Tlrerarrdom-effects
pooledodds-ratio whenmr"rltiple-dose
o f 0 . 3 7( 9 5 % C l : 0 . I 7 t o 0 . 7 8 ;p < 0 . 0 1 )d e r n o n s t r a t e ds i n g l e - d o sree g i n r e n s( .L E V E L I E V I D E N C E )
s t a t i s t i c a l l y s i g n i f i c a r r te v i d e n c e o f e f f i c a c y f o r
prophylaxis.
antirnicrobial
It alsodemonstrated
a pooled B. CSF Shunts
risk difference of 2.9 percent favoring the use of
l . I s a n t i m i c r o b i a lp r o p h y l a x i sr e c o m m e n d e df o r
prophylacticantinricrobials.
A meta-analysis
of 6 norrcerebrospiua
f llu i d s h u n t i n gp r o c e d u r e s ?
izedtrialssirnilarlydemonstrated
ranclom
lowerinfection
patientswith an odds
rates among autibiotic-treated
A n t i m i c r o b i a l p r o p h y l a x i s i s r e c o m m e n d e cf ol r
ratioof 0 .22(95% CI: 0 . I 5 to 0.33 , p < 0 .00 I ). (LEV EL
c
e
r
e
b r o s p i n fal lL l i ds h u n t i n gp i o c e d u r e s( C
. ATECORY
I EVIDENCE)
A RECOMMENDATION)
2.

Whatis/arethe appropriate
antimicrobial/s,
dose/s,
Sum:rparyof Eviclence
and clLrration
of proplrylaxis?

T h e r e c o m m e n d eadn t i m i c r o b i af lo r p r o p h y l a x i isn
s p i n a l s u r g e r yi s c e f a z o l i n I g r a m l V s i n g l e d o s e
( C A T E G O R YA R E C O M M E N D A T I O N )
A n a l t e r n a t i v ree g i n r e ni s o x a c i l l i n I g r a ml V p r e operativelythen 500 mg IV every6 hoursfor 24 houls.
( C A T E C O R YA R E C O M M E N D A T T O N )
S u m m a r yo f E v i d e n c e
Threerandomized
(Barker,
trials in a meta-analysis
2002) r-rsedantibioticswith both granr-positiveand
gram-negative
coveragewlrile three randomizedtrials
usedgram-positive
coveragealone.Althoughthe trials
with granr-negativecoveragedemonstratedslightly

A m e t a - a n a l y so
i sf 9 r a n d o m i z e d
c o n t r o l l e dt r i a l s
( H a i n e s ,I 9 9 4 ) e n r o l l i n g 1 , 0 4 4p a t i e r r t w
s a s d o r r et o
d e t e r m i n teh e e f f i c a c yo f a n t i n r i c r o b i aplr o p h y l a x ifsb r
cerebrosp
i ualfl u iclshuntoperations.
OnestLrdy
appearecl
t o s h o w a h i g h e r i n f e c t i o nr a t e i n t h e a n t i r n i c r o b i a l
prophylaxisgroup tlran tlre placebogroup, 3 studies
showedessentiallyno effect for pLophylaxis.
3 studies
s h o w e ds t a t i s t i c a l liyn s i g ni f i c a n t r e n d sf a v o r i r r gl o w e r
infectionratesin the antimicrobial-treated
group,and2
studiesshowedstatistically si gni ficanteffectsfavoling
the antirni crobi aI-treatedgroup. I n the anti b i ot i c-treatecj
g r o u p s ,7 . 2 p e r c e n t( 3 7 o f 5 1 7 p a t i e n t s )d e v e l o p e d
surgicalsite irrfectiollscolxparedto12.9percent(68 of
527 patients)in the pooled control arms of the trials.

PJSSVol. 61,No.2, April-June,2006

88

The estimatedpooledodds-ratioof 0.48 (95% CI:0.31


to 0.73;p = 0.001)demonstrated
statisticallysignificant
evidence of efficacy for antimicrobial prophylaxis.
(LEVEL I EVIDENCE)
A meta-analysis
of 12 randomizedcontrolledtrials
( L a n g l e y , 1 9 9 3 ) e n r o l l i n g 1 , 3 5 9 p a t i e n t sl i k e w i s e
d e m o n s t r a t e dt h a t a n t i m i c r o b i a l p r o p h y l a x i s f o r
c e r e b r o s p i n a fl l u i d s l r u n t o p e r a t i o n ss i g n i f i c a n t l y
reducedthe infectionratewith a Mantel-Haenszel
risk
ratio of 0.52 (95% CI: 0.37 to 0.73,p: 0.0002).
(LEVEL I EVIDENCE)

hoursin one trial and for 36 hours in anothertrial, and


o x a c i l l i r rf o r 2 4 h o u r s .( L E V E L I E V I D E N C E )
C. Craniotomy
1 . I s a n t i m i c r o b i a lp r o p h y l a x i s r e c o m m e n d e df o r
craniotomy?
or
A r r t i r n i c r o b i apl r o p l i y l a x i s i s r e c o n r m e r r d ef d
c r a r r i o t o m y( C
. A T E G O R YA R E C O M M E N D A T I O N )
S u m m a r yo f E v i d e n c e

2. What is/arethe appropriatearrtimicrobial/s,


dose/s,
c o n t r o l l e dt r i a l s
A m e t a - a n a l y s oi sf 8 r a n d o m i z e d
arrddr,rration
of proplrylaxis?
(Barker, 1994) enrolling 2,074 patientswas done to
t h e e f f i c a c yo f a n t i m i c r o b i apl r o p h y l a x i isn
determine
The recommended
antirnicrobialsfor prophylaxis p r e v e n t i n gs u r g i c a sl i t e i n f e c t i o na n d m e n i r r g i t ias f t e r
are: Cloxacillin 1 grarnIV craniotomyand whetherenoughrandomizedstudieson
in CSF shuntingprocedures
pre-operativelytherr I gram IV every 6 hours for 24 a n t i r n i c r o b i a p
l r o p h y l a x i sh a v e b e e n p e r f o r m e dt o
hours (CATEGORY A RECOMMENDATION)
answerthe questioncorrfidently.The cumulativeodds
Oxacillin 1 gram lV pre-operativelythen 1 gram IV r a t i o o f 4 . 2 ( 9 9 . 9 % C l : 1 . 9 t o 9 . 2 ; p < 3 x l 0 - 8 )
e v e r y 6 h o u r s f o r 2 4 h o u r s ( C A T E G O R Y A d e n r o n s t r a t e ds t a t i s t i c a l l y s i g n i f i c a r r te v i d e n c eo f
RECOMMENDATION)
ulative
efficacyfor anti rnicrobi al prophylaxis. The cLrm
treatmenteffect usingdifferences-in-proportion
of 6.2
If thepatierrthasa pre-operative
stayof at least3 days, p e r c e n(t9 9 . 9 % C I :3 t o I 0 ; p < 4 x I 0 - 8 l)i h e w i s ef a v o r e d
theadditionof gentamicin240
mg IV singledoseto either t h e u s eo f p r o p h y l a c t i ac n t i n r i c r o b i a l s .
of the previonsly listed regirrrensis recommended.
T o d e t e r r n i n et l r e m i n i m u m n u m b e r o f s t u d i e s
(CATEGORY A RECOMMENDATION)
r e q u i r e da f t e r w h i c h t h e q u e s t i o no f a n t i m i c r o b i a l
prophylaxis
lravebeenconsidered
fdr craniotomyshoLrld
S u m m a r yo f E v i d e n c e
c l o s e dt,l r ec u n r u l a t i vner e t a - a n a l y suessi r i gp < 0 . 0 0 1a s
the definitionof statisticalsignificanceshowedthatthe
A meta-analysis
of 9 randomizedcontrolledtrials
levelwas aclrievedin 1987afteronly 3 trials
sti,pulated
(Hairres,1994) enrollirig 1,044 patientswas done to
L r s i ntgh eo d d sr a t i on i e t h o do r i n 1 9 8 8a f t e ro n l y 5 t r i a l s
determinethe efficacyof antimicrobialprophylaxisfor
n-proportiorrs
method.Theauthors
usingtlred ifference-i
f l lr - r i d
cerebrospina
s h u n to p e r a t i o n sl n
. t h e a n t i b i o t i c - c o n c l u d e d t l r a t t h e r e i s a n a d v a n t a g et o u s i r r g
treatedgroups,7 .2percent(31of5 17 patients)developed antimicrobialsfor prophylaxisin craniotornyand that
surgicalsite infectionscomparedto12.9percent(68 of f u t u r e s t L r d i e ss l r o u l d c o m p a r e p r o p o s e d n e w
527 patients)in the pooled control arms of tlre trials. a n t i r n i c r o b i a lr e g i m e n sw i t l r o n e o f t h o s e a l r e a d y
The estimatedpooledodds-ratiosof 0.48(95% Cl: 0.31 demonstratedto be effective and not with placebo.
statisticallysignificant (LEVEL I EVIDENCE)
to 0.73;p : 0.001) demonstrated
evidenceof efficacyfor antirnicrobialprophylaxis.The
a r r t i m i c r o b i a l su s e d i n t h e m e t a - a n a l y s i si n c l u d e d 2. What is/aretlreappropriateantirnicrobial/s,
doseis,
g e n t a n r i c ipnl u sc l o x a c i l l i nf o r 6 h o u r s c, e p h a l o t h ifno r
a n d d L r r a t i oor rf p r o p h y l a x i s ?
24 hours in one trial and for 72 hours in anothertrial.
methicillinfor 20 hoursin one trial and for 72 hor"rrs
in
T h e r e c o m m e n d eadn t i r n i c r o b i a lfso r p r o p h y l a x i s
anothertrial, trimethoprim-sulfamethoxazole
for l6 in craniotomyare:CloxacillinI grarnIV pre-operatively

Antimicrobial Prophylaxisfor SurgicalProcedures

89

i ve i nfecti ous comp I i cati ons aftercesarean


of postoperat
at lowestrisk in favor of the
sectionirr the popLrlation
use of prophylactic antibiotics. Antimicrobial
prophylaxiscauseda statistically si gnifi cantreduction
feverwith RR of 0.25(95% C1,0.14to
in postoperative
0.44),endometritiswith RR of 0.05 (95% Cl,0.0l to
0.38)and surgicalsite infectionwith RR of 0.59 (95%
C 1 , 0 . 2 4t o 1 . 4 5 ) .( L E V E L I E V I D E N C E )
A m e t a - a n a l y soi sf 5 1 r a n d o m i z e cdo n t r o l l e dt r i a l s
( S r n a i l la n d H o f m e y r , 1 9 9 9 ) w a s d o n e t o c o m p a r e
antibioticprophylaxiswitlr no treatmentin bothelective
Summary of Evidence
a n d n o n - e l e c t i v ec e s a r e a ns e c t i o n s .T h e u s e o f
sectionreduced
prophylacticantibioticspriorto cesarean
of 8 randomizedcontrolledtrials the incidenceof complicationssecondaryto infection
A rneta-analysis
(Barker, 1994) enrolling 2,074 patientswas done to witli the reductionirr risk for endometritisfound to be
determinethe efficacyof antimicrobialprophylaxisfor sirnilaracrosstlre variouspatierrtgroups.Tlre relative
craniotomyin preventingsr,rrgicalsite irifectionand r i s k f o r e n d o m e t r i t iw
s a s 0 . 38 ( 9 5 % C l : 0 . 2 2- 0 , 6 4 )f o r
o d d sr a t i oo f 4 . 2( 9 9 . 9 % C l : the 9,805 patientswlro underwentelective cesarean
r n e n i n g i t i sT.h ec u m u l a t i v e
significantevidence
1.9 to9.2;p < 3 x I 0-8)demonstrated
s e c t i o nR
, R o f 0 . 3 9( 9 5 % C I : 0 . 3 4- 0 . 4 6 )f o r t h e2 , 1 3 2
prophylaxis.
Thecumulative
of efficacyfor antimicrobial
section,
patientswho underwentemergencycesareatt
of 6.2
treatmenteffectusingdifferences-in-proportion
a n d R R o f 0 . 3 9( 9 5 % C I : 0 . 3I - 0 . 4 3 )f o r a l l t h e | 1 , 9 3 7
percent(99.9%CI: 3 to 10;p < 4 x l0-8)likewisefavored
patientswho underwentcesareansection,The relative
the use of prophylactic antimicrobials. The
risk for surgicalsite infectionwas 0.73(95% Cl:0.53 antimicrobialsused in the trials in the meta-analysis
0.99) for tlte 2,015 patientswho underwentelective
i n c l L r d ecdl i n d a m y c i sni n g l ed o s e c, e f o t i a ms i n g l ed o s e ,
cesareansection,RR of 0.36 (95% CI: 0.26 - 0.51) for
single
singledose,cefazolinplusgentamiciri
vancomycin
the 2,780patientswho underwentemergencycesareall
d o s e , v a n c o m y c i np l u s g e n t a m i c i t t s i n g l e d o s e ,
s
e c t i o na, n dR R o f 0 . 4 1( 9 5 % C l : 0 . 2 9- 0 . 4 3 )f o r a l l t l r e
p i p e r a c i l l i nf o r 3 d o s e s ,c l o x a c i l l i nf o r 4 d o s e s ,a n d
1 1 , 14 2 p a t i e n t s w h o u r r d e r w e n tc e s a r e a ns e c t i o n .
oxacillin for 6 doses.(LEVEL I EVIDENCE)
(LEVEL I EVIDENCE)
tlren1 gramlV every6 hoursfor24 hours(CATEGORY
A RECOMMENDATION)
Oxacillin I grani IV pre-operativelythen I gran-rIV
every 6 hours for 24 lrours (CATEGORY A
RECOMMENDATION)
If the patienthas a pre-operativestay of at least 3
days,the additionof gentamicin240mg IV singledose
to either of tlre previously listed regimens is
r e c o m m e n d e d . ( C A T E G O R YA R E C O M M E N DATTON)

Obstetric and GynecologicSurgery


I.

CesareanSection

dose/s,
2. What is/aretheappropriateantimicrobial/s,
zinddurationof prophylaxis?

The recommendedantimicrobialsfor prophylaxis


in cesarean
deliveryare: Ampicillin 2 gramsIV single
dosepre-operativelyor after cord clampingCefazolin2
for both grams IV single dose pre-operativelyor after cord
Antimi crobial prophylaxis i s recommended
cesarean
sectiotl.(CATEGORY clamping (CATEGORY A RECOMMENDATION)
electiveandemergency
A RECOMMENDATION)
Summary of Evidence
1 . I s a n t i m i c r o b i a lp r o p h y l a x i sr e c o m m e n d e df o r
section?
cesarean

Summary of Evidence

of 51 randomizedcontrolledtrials
A meta-analysis
of 7 randomizedcontrolledtrials (Smaill and Hofmeyr,2002) was done to comparetlre
A meta-analysis
(Chemlow,2001)wasdoneto determinethe efficacyof di fferentantirni crobials givenfor prophyIaxi s i u cesareatr
. he efficacy of ampicillin irr preventing
section' s e c t i o t t s T
antimicrobialprophylaxisfor electivecesarean
significantreductionin tlie risk p o s t o p e r a t i v ei r i f e c t i o n s w a s s i m i l a r t o t h e f i r s t Therewasa statistically

90

PJSSVol. 61,No.2, April-June,2006

g e n e r a t i o cne p h a l o s p o r i nwsi t h O R o f 1 . 2 7( 9 5 % C l : morbidityrates(definedas a tenrperature


above37.9'C
0.84 - 1.93) and to the second- or third-generation on 2 occasionsafterthe first24 hoLrrspost-surgery)
with
c e p h a l o s p o r i nwsi t h O R o f 0 . 8 3( 9 5 % C I : 0 . 5 4- 1 . 2 6 ) . 1 5 . 6p e r c e n itn t h e p r o p h y l a x i sg r o u pa n d 2 5 . l p e r c e n t
The first-generatiorr
cephalosporins
were likewise as of tlrose who did not receive arrtibioticprophylaxis
e f f i c a c i o u s a s t h e s e c o n d - o r t h i r d - g e r - r e r a t i o nd e v e l o p i n gf e b r i l em o r b i d i t yf o r O R o f 0 . 5 5( 9 5 % C l :
c e p h a l o s p o r i nwsi t h O R o f 1 . 2 1( 9 5 % C l 0 . 9 ' l- 1 . 5 l ) . 0 . 4- 0 . 7 ;p < 0 . 0 0 0 1 )(.L E V E L I E V I D E N C E )
(LEVEL I EVIDENCE)
Subgroupanalysisoftrials comparingmLrltipledose 2. What is/arethe appropriateantinricrobial/s,dose/s,
with singledoseregimenshowedthat a multiple dose
and durationof prophylaxis?
regimenfor prophylaxisoffered no additionalbenefit
o v e r a s i n g l ed o s er e g i m e nw i t h O R o f 0 . 9 2( 9 5 % C l :
T h e r e c o m r n e r r da
en
d t i m i c r o b i af lo r p r o p h y l a x iisn
0 . 7 0- r . 2 3 )(.L E V E Lr E V T D E N C E )
a b d o m i n ahl y s t e r e c t o miys c e f a z o l i r Ir g r a mI V s i n g l e
d o s e .( C A T E G O R YA R E C O M M E N D A T I O N )
B. Abdominal Hysterectomy
Summary of Evidence
l . I s a n t i r n i c r o b i a pl r o p h y l a x i sr e c o m m e n d e df o r
abdominalhysterectomy?
A m e t a - a n a l y soi sf 2 5 r a n d o m i z e cdo n t r o l l e d
trials
(Mittendorf,1993) enrolling3,604patientswasdoneto
A n t i r n i c r o b i a lp r o p h y l a x i si s r e c o m m e r r d e fdo r analyzethed i fferent antirnicrobiaIs usedby perforrrri ng
a b d o m i n a l h y s t e r e c t o m y . ( C A T E G O R Y A separate
rneta-analyses
for eaclrantibiotic.Therewasa
RECOMMENDATION)
statisticallysignificantdifferencein tlre postoperative
t f t h o s ew h o d i d n o t
i n f e c t i o nr a t e sw i t h 2 l . l p e r c e u o
Summary of Evidence
receiveantibioticprophylaxiscomparedto I 1.4 percent
( 7 0 o f 6 1 5 p a t i e n t s )f o r t h o s e g i v e n c e f a z o l i n
A m e t a - a n a l y soi sf 2 5 r a n d o m i z e cd o n t r o l l e dt r i a l s ( p = 0 . 0 0 0 21) , 6 . 3p e r c e n(t 1 7 o f 2 6 9 p a t i e n t sf)o r t h o s e
( M i t t e n d o r f1
, 9 9 3 )e n r o l l i n g3 , 6 0 4p a t i e n t w
s a sd o n et o g i v e nm e t r o r r i d a z o(l p
e : 0 . 0 1 5 ) ,a r r d5 . 0 p e r c e n(t 5 o f
d e t e r m i n ew h e t h e rt h e u s eo f p r e o p e r a t i v ae n t i b i o t i c s 10 I p a t i e n t s )f o r t h o s e w h o r e c e i v e dt i n i d a z o l e
preventedseriouspostoperativeinfectionsassociated ( p = 0 . 0 3 4 ) .( L E V E L I E V I D E N C E )
witli total abdominal hysterectomyas comparedto
(Tanos, 1994)evaluatedthe three
A meta-aflalysis
placebo.Therewasa statisticallysignificantdifference generations
of cephalosporins.The infectionratewas
irrpostoperative
infectionratesbetweenthe two groups 10.8percentfor thosewho receiveda first generation
w i t h 9 . 0 p e r c e n (t 1 6 6 o f 1 , 8 3 6p a t i e n t s a
) m o n gt h o s e c e p l r a l o s p o r i n c o n t r a stto 2 3 . 1 p e r c e nat m o n gt h o s e
wlro receivedantibioticproplrylaxisand 21.1 percent w h o d i d n o t r e c e i v ea n t i b i o t i cp r o p h y l a x i fso r a r rO R o f
( 3 7 3o f i , 7 6 8p a t i e n t sa) m o n gt h o s ew h o d i d n o tr e c e i v e 0 . 3 5( 9 5 % C I : 0 . 2t o 0 . 5 ; p < 0 . 0 0 0 1 )T. h e i n f e c t i o nr a t e
antibioticprophylaxisdevelopinginfectionsforan RRR w a s 9 . 7 p e r c e n t f o r t h o s e w h o r e c e i v e da s e c o n d
o f 1 2 . 1 p e r c e n(t p. = 0 . 0 0 0 0 1 )(.L E V E L I E V I D E N C E ) generationcephalosporinin contrastto 26.'7percent
A nreta-analysis
of l7 randomizedcontrolledtrials a m o n g t h o s w
e h o d i d n o t r e c e i v ea n t i b i o t i cp r o p h y l a x i s
(Tanos, 1994) enrolling 2,752 patientswas done to f o r a n O R o f 0 . 2 9( 9 5 % C l : 0 . 2 t o 0 . 6 ; p < 0 . 0 0 0 2 )T. h e
d e t e r m i n e t h e e f f e c t i v e n e s so f c e p h a l o s p o r i n si n infectionratewas 7.4 percentfor thosewho receiveda
p r e v e n t i n gi n f e c t i o L r sc o m p l i c a t i o n sa f t e r e l e c t i v e thirdgeneration
ceplralosporin
in contrastto23.4percent
a b d o m i n a lh y s t e r e c t o m yT. h e r e w a s a s t a t i s t i c a l l y a n r o n gt h o s ew h o d i d n o t r e c e i v ea n t i b i o t i cp r o p h y l a x i s
significantdifferenceirr postoperativeinfection rates f o r O R o f 0 . 2 6 ( 9 5 % C l : 0 . 2 t o 0 . 4 ; p < 0 . 0 0 0 1 ) .
with 9.8 percentin the prophylaxisgrolrp and 23.4 Multivariateanalysisslrowedno advantage
forthenewer
percentin theno prophylaxisgroupdevelopinginfections a n d m o r e e x p e n s i v e s e c o n d a n d t h i r d g e n e r a t i o r r
f o r O R o f 0 . 3 5( 9 5 % C l : 0 . 3 - 0 . 4 ; p = 0 . 0 0 0 1 ) T
. h e r e c e p h a l o s p o r i ns st u d i e dA. s i n g l ed o s ew a ss i g n i f i c a n t l y
was a statistically significant difference in febrile moreefficientconrpared
to mLrltiplecloseprophylaxisin

Antimicrobial Prophylaxisfor Surgical Procedures

9l

. e t a a n a l y s io
s f r a n d o n r i z e dc o n t r o l l e d
preventing
i n f e c t i o nw i t h O R o f 0 . 3 7( p : 0 . 0 0 0 1 ) . T h e 2 . M e i j e r W S , S c h r n i t zP I , . l e e k e.l1 M
c l i n i c a l t r i a l s o f a n t i b i o t i c p r o p h y l a x i s i n b i l i a r y t r a c t s u r g e r y .B r . l
intravenousroute was significantly superior to the
Surg 1990;77:283-290.
intramuscular
routeof administrationwith OR of 0.66
(p < 0.005).(LEVEL I EVIDENCE)
Lrparoscopic Cholecystectorny
l.

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