As a hospital pharmacist, you will see changes for antibiotic prophylaxis in surgery. This is a big focus of quality initiatives in hospitals and the first big guideline update in almost a decade. Here's a summary of what's generally required, along with what's new from the guidelines...
- Timing. Start most pre-op antibiotics within 60 minutes before incision or "cut time" or within 120 minutes for drugs with longer infusion times, such as quinolones and vancomycin.
- Redosing. Give another dose during surgery if more than 1.5 L of blood is lost or when two half-lives of the antibiotic have passed. For example, redose cefoxitin or penicillins after 2 hours, cefotaxime after 3 hours while aztreonam, cefazolin, or cefuroxime after 4 hours and cefotetan and clindamycin after 6 hours.
- Drug choice. Continue to use cefazolin as the workhorse for most clean and clean-contaminated procedures. Substitute or add vancomycin for those with MRSA colonization or an increased risk of MRSA, such as dialysis patients. For patients with a serious reaction to beta-lactams, use an appropriate alternative, such as clindamycin, vancomycin, or aztreonam.
- Dosing. Use higher doses of cefazolin 2 g for all adults and now 3 g for those over 120 kg. Obese patients have a higher risk of surgical infections and increasing the cefazolin dose helps reduce this risk.
- Duration of therapy. Avoid continuing antibiotic prophylaxis for longer than 24 hours after ANY surgery, even after cardiothoracic surgeries or if the patient has a drain or indwelling catheter. There's no good evidence that a longer duration is better, plus it increases the risk of C. diff infections and antimicrobial resistance.
- Decolonization. Use intranasal mupirocin before cardiac and orthopedic surgery in patients colonized with S. aureus. Recent data suggest it can halve their risk of surgical site infections
Preferred empiric agents by surgical type are documented in Table 1. This TABLE is based upon the 2013 consensus guidelines from American Society of Health-System Pharmacists (ASHP), the Infectious Diseases Society of America (IDSA), the Surgical Infection Society (SIS) and the Society for Healthcare Epidemiology of America (SHEA).
| Table (1). Preferred Empiric Agent by Surgical Type. | ||
|---|---|---|
| Preferred Agent | Beta-lactam allergy | |
| Cardiac Surgery/ Vascular/Thoracic | Cefazolin | Vancomycin |
| Cardiac Surgery with prosthetic material | Cefazolin + vancomycin | Vancomycin |
| Cardiac device insertion (e.g., pacemaker implantation) |
Cefazolin | Vancomycin |
| Gastroduodenal | Cefazolin | Vancomycin + gentamicin |
| Biliary Tract | Cefazolin | Metronidazole + Levofloxacin |
| Colorectal, appendectomy | Cefazolin + metronidazole | Metronidazole + Levofloxacin |
| Other general surgery (e.g., hernia repair, breast) |
Cefazolin | Vancomycin |
| Cesarean delivery | Cefazolin | Clindamycin + gentamicin |
| Gynecological (e.g., hysterectomy) | Cefazolin | Clindamycin + gentamicin |
| Head & Neck | Clean (incision through skin): Cefazolin Clean-contaminated:
Contaminated: Cefazolin + metronidazole |
Clindamycin |
| Neurosurgery | Cefazolin | Vancomycin |
| Orthopedics | Cefazolin | Vancomycin |
| Plastic Surgery | Cefazolin | Vancomycin |
| Urology These are empiric recommendations when no pre-op urine culture data is available or cultures were negative. |
Cefazolin Open/laparoscopic involving intestine (clean-contaminated, e.g., radical cystectomy with ileal conduit): Cefoxitin If prosthetic material involved in urologic procedures, should add one-time dose of gentamicin |
Gentamicin + Clindamycin Open/laproscopic (clean:skin incision, does not involve GU tract): Clindamycin Open/laparoscopic involving intestine (clean-contaminated, e.g., radical cystectomy with ileal conduit) Metronidazole + Levofloxacin If prosthetic material involved in urologic procedures, should add one-time dose of gentamicin if not already given |
| Heart Transplant | Vancomycin + cefazolin | Vancomycin + levofloxacin |
| Lung or Heart-Lung Transplant | Vancomycin + cefepime | Vancomycin + aztreonam |
| Liver Transplant | Piperacillin/tazobactam | Vancomycin or clindamycin + ciprofloxacin |
| This informatiom from, https://med.stanford.edu/content/dam/sm/bugsanddrugs/documents/clinicalpathways/SHC-Surgical-Prophylaxis-ABX-Guideline.pdf | ||
REFERENCES
-
Antimicrobial Resistance. [online] Available at: https://www.idsociety.org/Antimicrobial_Agents/#Antimicrobial
Clinical practice guidelines for antimicrobial prophylaxis in surgeryAmerican Journal of Health-System Pharmacy February 2013, 70 (3) 195-283; DOI: https://doi.org/10.2146/ajhp120568
W. Bratzler Dale, M. Houck Peter, for the Surgical Infection Prevention Guidelines Writers Workgroup, Antimicrobial Prophylaxis for Surgery: An Advisory Statement from the National Surgical Infection Prevention Project, Clinical Infectious Diseases, Volume 38, Issue 12, 15 June 2004, Pages 1706–1715, https://doi.org/10.1086/421095