Antimicrobial Prophylaxis in

Surgery
By Faisel D, 2012
 INTRODUCTION
• Surgical site infections (SSIs) are a significant cause of
morbidity and mortality.

• Approximately 2% to 5% of patients undergoing clean

extra abdominal operations and 20% undergoing intra-
abdominal operations will develop an SSI.

• SSIs have become the second most common cause of

nosocomial infection
 Contd.

• Patients who develop SSIs are

– five times re admission

– Twice mortality

– 60% more likely to be admitted to an ICU.

– lengthen hospital stays

– increase costs
 Class of SSIs
• SSIs
– incisional
• superficial incisional SSI (skin or subcutaneous
tissue)
• deep incisional SSI (deeper soft tissues of the
incision)
– organ/space
• involve any anatomic site other than the incised
areas
–eg, meningitis after brain tumor removal
Contd.
 Contd.

• An infection is considered an SSI if any of the

above criteria is met and the infection occurs
within 30 days of the operation.

• If a prosthetic is implanted during the

operation, the timeline extends out to 1 year.
 Risk factors for SSIs
• Patient and Operation Characteristics That May
Influence the Risk of Surgical Site Infection
Patient Operation
•Age •Duration of surgical scrub
•Nutritional status •Preoperative skin preparation
•Diabetes •Preoperative shaving
•Smoking •Duration of operation
•Obesity •Antimicrobial prophylaxis
•Coexisting infections at •Operating room ventilation
distal body sites •Sterilization of instruments
•Colonization with resistant •Implantation of prosthetic
microorganisms materials
•Altered immune response •Surgical drains
•Length of preoperative stay •Surgical technique
 PATHOPHYSIOLOGY
• during the operation there can be a low-level
inoculums of bacteria introduced into the body

• Prophylactic antibiotic therapy

• presumptive antibiotic therapy

• therapeutic antibiotic therapy

 Surgical wound classification

• classified at the time of operation as

–clean
–clean-contaminated
–contaminated, or dirty
Types of Surgical Operations

High-risk
procedures
Major Pathogens in Surgical Wound Infections
 Choosing an Antibiotic
• Ideal criteria for an antimicrobial in surgical prophylaxis
include the following:
– Spectrum that covers expected pathogens

– Inexpensive

– Parenteral

– Easy to use

– Minimal adverse-event potential

– Longer half-life to minimize need for redosing during procedure

 Extra abdominal operations
• Needs an antimicrobial with strong gram-positive coverage

• Cefazolin
– a benign adverse-event profile

– simple dosing

– low cost

• β-lactam allergy
– clindamycin or

– vancomycin can be used

 Intra abdominal operations
• necessitate broad spectrum coverage of gram negative
organisms and anaerobes
• Antianaerobic cephalosporins
– cefoxitin
– Cefotetan

• β-lactam allergies
– Fluoroquinolones or
– aminoglycosides
+
– clindamycin or
– metronidazole
 Vancomycin
• a cluster of MRSA

• coagulase negative staphylococci

• known MRSA colonization

• high risk for MRSA colonization

 Newer antimicrobials for SSI
prophylaxix
• routinely use is not considered appropriate
– collateral damage

– bacterial resistance

• Ertapenem was superior to standard cefotetan in

elective colorectal surgery
– Greater Clostridium difficile
 β-Lactam Allergy
• A thorough drug allergy history should be taken to discern true
allergy (eg, anaphylaxis) from medication intolerance (eg, upset
stomach)
• β-Lactam allergy testing could spare vancomycine
• Cross-allergenicity between penicillins and cephalosporins is low
– 0.4% for first-generation cephalosporins
– nearly zero for second- and third-generation agents
• severe penicillin allergy (ana-phylaxis)
cephalosporins should be avoided
 Alternative Methods to Decrease SSI

• Supplemental warming - colorectal surgery

• Intensive glucose control - cardiac surgery

• 80% (0.80) inspired oxygen - colorectal surgery

 Other not well studied methods
• Alternative topical routes of antimicrobial
prophylaxis such as
– antimicrobial-impregnated bone cement
– implantable antimicrobial collage sponges
– antimicrobial irrigations
– topical administration of antimicrobial powders

• Irrigation with detergent solutions

 S. aureus decolonization
• Screening for s. aureus, specialy MRSA
– Due to increased CA- MRSA

• Nasal colonization of s. aureus increase risk of an SSI

due to S. aureus
• Decolonization
– mupirocin applied to the anterior nares for 5 days prior to
surgery
– Additionally, skin decolonization with 4% chlorhexidine for 5
days prior to surgery
Principles of Antimicrobial Prophylaxis
• Route of Administration
– IV antimicrobial administration is the most
common

– Per oral erythromycin base and neomycin are

given during the 24 hours prior to surgery
adjunctively to reduce microbial concentrations in
the bowel
Timing of First Dose, contd.

– infuse antimicrobials for surgical prophylaxis within 60

minutes of the first incision

– as close to the first incision as possible

– fluoroquinolones and vancomycin can be infused 120

minutes prior to avoid infusion-related reactions.

– if a proximal tourniquet is used, antimicrobial

administration should be complete prior to inflation
 Contd.
 Dosing and Redosing
– Cefazolin
• 2 g for all patients less than 120 kg
• 3g for patients more than or equal to 120 kg
– Clindamycin should be given as a 900-mg iv
– If an operation exceeds two half-lives of the selected
antimicrobial,
• another dose should be administered.
 Contd.
• Duration

– The duration of antimicrobial prophylaxis should

not exceed 24 hours

– 48 hours for cardiac surgery

PROPHYLAXIS REGIMENS
Contd.
 Gynecologic and Obstetric
• Possible pathogens:
– enteric gram-negative bacilli,
– anaerobes,
– group B streptococci,
– enterococci

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 Contd.
• Prophylaxis for hysterectomy:
– cefazolin
– cefotetan
– cefoxitin
– ampicillin-sulbactam
• Alternatives for β-lactam allergy:
– clindamycin or vancomycin combined with
aminoglycoside, aztreonam, or fluoroquinolone
– metronidazole combined with aminoglycoside or
fluoroquinolone
 Contd.
• Prophylaxis for Cesarean section: most
beneficial
for high-
– cefazolin risk
patients
• Alternatives for β-lactam allergy:
– clindamycin and aminoglycoside

• Antimicrobials should not be administered until

after the first incision and the umbilical cord has
been clamped.
 Orthopedic Surgery
• Possible pathogens:
– gram-positive cocci, mostly staphylococci

• Prophylaxis for total joint arthroplasty (hip or knee):

– cefazolin

• Alternatives for β-lactam allergy:

– clindamycin,
– vancomycin Antimicrobial-impregnated bone
cement ?
 Cardiothoracic and Vascular Surgery
• Possible pathogens:
– gram-positive cocci, mostly staphylococci

• Prophylaxis for cardiac surgeries:

– cefazolin
– Cefuroxime

• Prophylaxis for noncardiac thoracic surgeries:

– cefazolin
– ampicillin-sulbactam
 Contd.
• Prophylaxis for vascular surgeries:
– cefazolin

• For all cardiothoracic and vascular surgeries

alternatives for β-lactam allergy:
– Clindamycin
– vancomycin
 Colorectal Surgery
• Possible pathogens: gram-positive, gram-negative, and
anaerobic organisms
• Parenteral prophylaxis:
– cefazolin and metronidazole
– cefoxitin
– cefotetan
– ampicillin-sulbactam
– ceftriaxone and metronidazole
– ertapenem
 Contd.
• Alternatives for β-lactam allergy:
• clindamycin combined with
– aminoglycoside
– aztreonam or
– fluoroquinolone
• metronidazole combined with
– aminoglycoside or
– Fluoroquinolone administered
• Oral routes for prophylaxis at 19, 18, and
– neomycin with 9 hours prior
• erythromycin or metronidazole to surgery.
 OUTCOME EVALUATION
• The presence of fever or leukocytosis in the
immediate postoperative period does not
constitute SSI and should resolve with proper
patient care.

• Any wound requiring incision and drainage is

considered an SSI regardless of appearance.
 Patient Care Process

• Patient Assessment:

– Conduct thorough medication history.

– Obtain serum creatinine and weight.

– Document allergies and the type of

reaction.
 Contd.
• Therapy Evaluation:
– Consider penicillin allergy testing in patients with
unclear documentation of penicillin allergy.

– Document type of operation patient is to receive.

– Start antimicrobials within 1 hour of surgical

incision (2 hours for vancomycin,fluoroquinolones).
 contd,.
• Care Plan Development:
– Monitor patient for signs of allergic reaction.

– Document any major breaks in surgical technique

and adjust length of antimicrobial therapy if
surgical classification changes.
 Contd.
• Follow-Up Evaluation:
– Monitor for signs and symptoms of postoperative
infection (30 days postoperation, up to 1 year if
prosthesis involved).

– Draw cultures to further guide therapy if SSI

suspected.