Antibiotic Prophylaxis Update Choosing Surgical Antimicrobial Prophylaxis Peri-Procedural Administration Surgical Prophylaxis and AMS at Epworth HealthCare Mr Glenn Valoppi Dr Trisha Peel Dr Joseph Doyle 1
Choosing Surgical Antimicrobial Prophylaxis (SAP) Right Drug Right Dose Glenn Valoppi 2
Therapeutic Guidelines: Antibiotic Who are the authors of the guidelines? What are the guidelines, and how are they produced? What the guidelines are not designed to be? Role as a reference against which appropriateness is judged 3
Therapeutic Guidelines: Antibiotic 4
Therapeutic Guidelines: Antibiotic 5
Therapeutic Guidelines: Antibiotic 6
Therapeutic Guidelines: Antibiotic 7
When SAP is indicated Consider prophylaxis if there is a significant risk of postoperative infection (e.g. colonic resection) or if postoperative infection would have serious consequences (e.g. infection associated with a prosthetic implant), even when such infection is uncommon. Use of SAP reduces risk of infections, but also carries a risk of harms. These may include - Allergic reactions - Adverse drug reactions - Selection of resistant organisms (C. difficile) - Promotion of antimicrobial resistance 8
Selection of agent The prophylactic antibiotic regimen should be directed against the organism(s) most likely to cause postoperative infection. Most clean procedures: Skin flora with which patient is colonized Staphylococcus aureus Clean-contaminated procedures: As for clean procedures, plus Gram-negative rods Coagulase-negative staphylococci Enterococci 9
Selection of agent For most procedures, cephazolin is the drug of choice for prophylaxis because it is - the most widely studied antimicrobial agent, with proven efficacy - it has a desirable duration of action, - spectrum of activity against organisms commonly encountered in surgery, - reasonable safety - low cost Vancomycin is not as effective as cephazolin for preventing postoperative infections caused by MSSA. Bratzler DW, Dellinger EP, Olsen KM, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health-Syst Pharm. 2013; 70:195 283 10
Immediate beta-lactam hypersensitivity When all penicillins and cephalosporins are to be avoided Gram-positive organisms Gram-negative organisms Usual substitute vancomycin gentamicin Other possibilities teicoplanin clindamycin ciprofloxacin aztreonam 11
Selection of dose (in adults) 12
Selection of dose (in adults) Drug Cephazolin Dose 2g Consider 3g If weight >120kg Vancomycin 15mg/kg Use actual body weight Teicoplanin* Gentamicin 400mg-800mg 2mg/kg To cover procedure only 5mg/kg For extended duration coverage Use adjusted body weight if actual body weight >20% higher than ideal body weight Adapted from Therapeutic Guidelines: Antibiotic Version 15, and Bratzler DW, Dellinger EP, Olsen KM, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health-Syst Pharm. 2013; 70:195 283 13
Insertion of urinary catheters It is not appropriate to administer an antibiotic (e.g. gentamicin) at the time of catheter insertion; this practice is not supported by evidence and may cause adverse effects. Standard SAP - using cephazolin - provides adequate coverage against most bacteria that are implicated in peri-operative urinary tract infections. If using vancomycin as a substitute for SAP (eg in beta-lactam allergy), consider inclusion agent with coverage of urinary pathogens 14
Bacteriuria and risk of PJI 15
Bacteriuria and risk of PJI 16
Special Cases When the guidelines don t apply. 17
Cardiac conditions associated with risk for infective endocarditis International guidelines for using SAP for prevention of IE have been progressively reducing the list of indications for prophylaxis. 2008 NICE guidelines in UK had recommended that antibiotic prophylaxis is not required for any person before dental or other procedures. 2014 review published in Lancet, showed increase in the incidence of infective endocarditis in the UK unclear if due to adherence to new guidance 18
Cardiac conditions associated with risk for infective endocarditis Cardiac Risk Factors prosthetic cardiac valve or prosthetic material used for cardiac valve repair previous infective endocarditis congenital heart disease but only if it involves: a) unrepaired cyanotic defects, b) completely repaired defects with prosthetic material or devices, during the first 6 months after the procedure c) repaired defects with residual defects at or adjacent to the site of a prosthetic patch or device (which inhibit endothelialisation) rheumatic heart disease in high-risk patients 19
Procedures associated with risk for infective endocarditis Dental Procedures (examples) extraction periodontal procedures including surgery, subgingival scaling and root planing replanting avulsed teeth other surgical procedures (eg apicoectomy) Other Procedures and conditions suspected or confirmed genitourinary tract or intra-abdominal infection genitourinary or gastrointestinal tract procedure where surgical antibiotic prophylaxis is routinely indicated SAP should include coverage of enterococci (ampicillin / vancomycin) 20
Colonisation with MROs MDR Gram negative organisms Consider screening patients undergoing complex GI surgery, or trans-rectal biopsy of prostate, if increased likelihood of faecal carriage of MDR GN; - Previous colonisation - International travel (esp. with healthcare contact) Selection of SAP is determined by results of susceptibility testing 21
Questions? 22