Antibiotic prophylaxis in surgery CSu2 Policy Antimicrobial prophylaxis is used to reduce the incidence of post operative wound infection; patients undergoing procedures associated with high infection rate, those involving implantation of prosthetic material, and those in which the consequences of infection are serious should receive perioperative antibiotic. This is the use of antibiotics before, during and after a diagnostic, therapeutic or surgical procedure to prevent infectious complications. The goals of prophylactic administration of antibiotics to surgical patient are to: 1. Reduce the incidence of surgical site infection (SSI) 2. Use antibiotics in a manner that is supported by evidence of effectiveness 3. Minimize the effect of antibiotics on the patient's normal bacterial flora 4. Minimize adverse effects 5. Cause minimal change to the patient's host defences Notes Following factors associate with increase risk for surgical site infection. Antibiotic prophylaxis in surgery is not enough to prevent surgical site infection. Be cautious about the following factors: Patient Factors: Extremes of age
Diabetes/Perioperative hyperglycemia Concurrent tobacco use (heavy smokers) Remote infection at the time of surgery Obesity Malnutrition Low preoperative serum Albumin Concurrent steroid use Prolonged preoperative stay Prior site irradiation Colonization with S. Aureus Procedural Factors: Lack of preoperative antiseptic showering Shaving of the site night prior to procedure Use of razor for hair removal Improper preoperative skin preparation Failure to redoes antibiotics Inadequate operation room ventilation Increased operation room traffic Break in sterile technique and asepsis Perioperative hypothermia, hypoxia Poor surgical technique (poor hemostasis, tissue trauma)
Procedure 1. patients with a history of anaphylaxis, laryngeal edema, bronchospasm, hypertension, local swelling, urticaria or pruritic rash occurring immediately after a penicillin therapy are potentially at increased risk of immediate hypersensitivity to beta lactamas and should not receive prophylaxis with a beta lactam antibiotic 2. Ask patients or his/her guardian about other conditions for contraindication of specific an bio cs like G6PD. 3. Recording indication of antibiotic prophylaxis 4. Recording and order kind of antibiotic or antibiotics 5. The antibiotics selected for prophylaxis must cover expected pathogens for that operative site 6. Prophylactic antibiotic for surgical procedures should often be administered intravenously 7. Intravenous prophylactic antibiotics should be given in operation room and 30 minutes before the skin is incised 8. A single dose of antibiotic with a long enough half life to achieve activity throughout the operation is recommended 9. Prophylactic antibiotic therapy should be given as single dose except in special circumstances (for example, prolonged surgery more than three hours, major blood loss more than 20%) 10. Prophylac c an bio c must be discon nued within 24 hours from the end of surgery 11. During prolonged procedures, antibiotic prophylaxis should be repeated with proper intervals. 12. The guideline does not cover specific condition like: 12.1. Coverage for Prevention of endocarditis in susceptible patients 12.2. Coverage for Instrumentation or prophylaxis in patient with prosthetic implants, undergoing dental surgery or other surgery that may cause bacteremia
12.3. Treatment of anticipated infection in patients undergoing emergency surgery for contaminated or dirty operations 12.4. Administration of oral antibiotics for bowel preparation or to achieve selective decontamination of the gut 12.5. Use of antibiotics for transplant surgery
Abdominal Gastroduodenal surgery in patients with hemorrhage, cancer, obstruction, or other high risk features Cefazolin 1 2 g IV preoperatively, or : Clindamycin 600 mg + Gentamicin 120 mg IV preoperatively. Gastric by pass Percutaneous gastrostomy Cefazolin, or Ceftriaxone, or Ce izoxime: 1 2 gr IV preoperatively. Biliary tract in patients who have acute symptoms, jaundice, or other high risk features or who have had previous surgery Cefazolin or Ce izoxime: 1 2 g IV preoperatively. : Gentamicin 80 mg IV preopera vely and q 8 h for 3 doses ERCP (with obstruction) Ciprofloxacin 500 750 mg PO, 2 hrs prior to procedure continue... or Ce izoxime 1.5 gr, or Pipracillin/Tazobactam 4.5 gr IV, 1 hr prior to procedure.
... continue Abdominal continue Appendectomy (without perforation) Cefotaxime, Cefotetan, or Cefmetazole 1 2 g IV preopera vely and q 6 h for 3 doses; : Metronidazole 500 mg + Gentamicine 1.5 mg/kg preoperatively Colorectal surgery, elective Neomycin 1 g + Erythromycin base 1 g PO at 1, 2 and 11 PM on the day before surgery ± parenteral drugs listed below for emergency surgery Colorectal surgery, emergency Cefotixin, cefotetan, cefmetazole 2 g IV preopera vely and q 4 h for 3 doses. OR: Cefazolin 1 2 gr + Metronidazole 500 mg IV, OR: Metronizadole 500 mg IV + Gentamicine 1.7 mg/kg IV preopera vely and q 8 h for 3 doses
Cardiac Median sternotomy, coronary artery by pass graft surgery, valve surgery, or pacemaker insertion Cefazolin 2 g preopera vely and q 4 6 h intraopera vely or Cefuroxime 1.5 g IV preopera vely and q 4 6 intraoperatively or Vancomycin 1 g preoperatively Non cardiac thoracic Pneumonectomy, lobectomy, other resections, or esophageal surgery Cefazolin 1 2 g IV preopera vely and q 6 h for 24 h or Vancomycin 1 g IV preoperatively
Neurosurgery Craniotomy: High risk (eg. Re explorations, microsurgery, entry into sinuses or naso/oropharynx) Vancomycin 1 g IV + Gentamicine 1.5 mg/kg IV preoperatively : Clindamycin 900 mg IV, once. Craniotomy: clean (non important) Cefazolin 1 2 gr, or Vancomycin 1 gr IV, once. CSF shunt placement (High Risk), in hospitals with high infec on rates (15 20%) Trimethoprim 160 mg IV + Sulfa methoxazole 800 mg IV preopera vely and q 12 h for 3 doses OR: Vancomycin 10 mg + Gentamicine 3 mg injected into a cerebral ventricle CSF shunt surgery Cefazolin 1 2 gr, or Vancomycin 1gr IV, once.
Obstetricsgynecology Cesarean section for premature rupture of membranes, or active labor, Elective C/S Cefazolin 1 g IV, as soon as clamping cord, and q 6 h for 2 doses Ampicillin 2 g IV prior to C/S and after that in PROM case 2 doses (every 6 hrs) Abor on, 2 nd trimester instillation Cefazolin 1 g IV preopera vely and q 6 h for 2 doses Abor on, 1 st trimester in patients with a history of pelvic inflammatory disease, gonorrhea, or multiple partners Penicillin G 1 2 million units IV preopera vely and 3 h later or Doxyciline 100 mg PO, 1hr before the procedure, and 200 mg a er procedure. continue... Ampicillin 2 g IV + Clindamycin 900 mg IV + Gentamicin 80 mg IM preopera vely, and 2 doses after that
... Continue Hysterectomy, vaginal or abdominal Cefazolin 1 g IV preoperatively and q 6 h for 2 doses Obstetricsgynecology Cefoxi n or Cefotetan 1 2 gr, or Cefuroxime 1.5 gr, IV, 30 min. before surgery Ophthalmic Extraction of lens, with or without insertion of prosthesis Gentamicin, tobramycin, or neomycin gramicidinpolymyxin B drops over 2 24 h + Cefazolin 100 mg subconjunctivally at the end of procedure Otolaryngologic Major head and neck surgery involving mucosa of the oral cavity or pharynx Cefazolin 1 2 g IV preopera vely and q 8 h for 2 doses OR:Clindamycin 600 900 mg IV + Gentamicin 1.5 mg/kg IV preopera vely and q 8 h for 2 doses
Urologic Prostatectomy if bacteriuria is present Cefazolin 1 g IV preopera vely & q 8 hrs, 3 doses, followed by Nitrofurantoin or TM/SX PO until removal of catheter, or for 10 days Ce riaxone 1 g IV preopera vely & Q12 hrs 2 doses, followed by Ciprofloaxacine 500 mg BD, PO until removal of catheter or for 10 days. Transrectal prostate biopsy Ciprofloxacin 500 mg PO 12 hrs prior to biopsy, and repeated preoperatively. Penile prosthesis insertion Cefazolin 1 g IV preoperatively continue... Urethral Catheterization or removal Cystoscopy (Urodynamics) (only in high risk patients) 500 mg Ciprofloxacin or 2 tablet of Co-trimoxazole, single dose, oral, 30-120 minutes preoperatively
... continue TUR-P (Prostate ) Ciprofloxacin 500 mg Co-trimoxazole 2 tablets preoperatively and every 12 hrs for 2 days or until removal of catheter TUR-BT (Bladder tumor) Ciprofloxacin 500 mg Co-trimoxazole 2 tablets preoperatively single dose, or stop before 24 hrs Ureteroscopy Single dose, preoperatively: Ampicillin 2 gr IV + Gentamicin 80 mg IV al Ciprofluxacin 500 mg 30-120 minutes
thopaedics Arthroplasty, including replacements, Cefazolin 1 2 g IV preopera vely and q 6 h 3 doses or Open reduction of fractures Lower extremity amputation (non ischemic) Vancomycin 1 g IV preoperatively Cefazolin 1 g IV preopera vely and q 6 h for 3 doses, or Ce riaxone 2gr IV/IM, once. Cefoxci n 2 g IV preopera vely and q 6 h 4 doses
Vascular Lower extremity or abdominal arterial surgery or lower extremity amputation for ischemia, or any vascular procedure that inserts prosthesis/foreign body Cefazolin 1 2 g IV preopera vely and q 6 h for 24 h Cefuroxime 1.5 g preopera vely and q 4 hrs, 3 doses Vancomycin 1 g IV preopera vely and 12 h after procedure