Antibiotic prophylaxis in surgery

Start most pre-op antibiotics within 60 minutes before incision or "cut time" or within 120 minutes for drugs with longer infusion times...

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...

RECOMMENDATION...
  • 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:
  • Ear/sinonasal procedure: Cefazolin
  • Procedures w/ oral mucosa breach: Cefazolin + Metronidazole

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