Antibiotic prophylaxis is used to reduce the incidence of postoperative wound infections. Patients undergoing procedures associated with high infection rates, those involving implantation of prosthetic material, and those in which the consequences of infection are serious should receive perioperative antibiotics. Treatment, rather than prophylaxis, is indicated for procedures associated with obvious preexisting infection (i.e. abscess, pus, or necrotic tissue). Cephalosporins (such as cefazolin) are appropriate first line agents for most surgical procedures, targeting the most likely organisms while avoiding broad-spectrum antimicrobial therapy that may lead to the development of antimicrobial resistance. Duration of antibiotic prophylaxis should not exceed 24 hours.
Establishing a "prophylaxis indicated" status for a given procedure requires consideration of the likelihood of infection without antibiotics and the morbidity and cost of an infectious complication. Appropriately administered antibiotic prophylaxis reduces the incidence of surgical wound infection. Prophylaxis is uniformly recommended for all clean-contaminated, contaminated and dirty procedures. It is considered optional for most clean procedures, although it may be indicated for certain patients and clean procedures that fulfill specific risk criteria. Timing of antibiotic administration is critical to efficacy. The first dose should always be given before the procedure, preferably within 30 minutes before incision. Re-administration at one to two half-lives of the antibiotic is recommended for the duration of the procedure. In general, postoperative administration is not recommended. Antibiotic selection is influenced by the organism most commonly causing wound infection in the specific procedure and by the relative costs of available agents.
The goal of prophylactic antibiotics is to reduce the incidence of postoperative wound infection. It is important to recognize the difference between prophylactic and empiric therapy. Antibiotic prophylaxis is indicated for procedures associated with high infection rates, those involving implantation of prosthetic material, and those in which the consequences of infection are serious. The antibiotic should cover the most likely contaminating organisms and be present in the tissues when the initial incision is made. Therapeutic concentrations should be maintained throughout the procedure. Empiric therapy is the continued use of antibiotics after the operative procedure based upon the intra-operative findings. Empiric antibiotic therapy is addressed in a separate guideline. Inappropriate prophylaxis is characterized by unnecessary use of broad-spectrum agents and continuation of therapy beyond the recommended time period. These practices increase the risk of adverse effects and promote the emergence of resistant organisms.
Surgical site infections (SSI's) account for approximately 15% of nosocomial infections and are associated with prolonged hospital stays and increased costs. Infection develops when endogenous flora are translocated to a normally sterile site. Seeding of the operative site from a distant site of infection can also occur. Factors influencing the development of SSI's include bacterial inoculum and virulence, host defenses, perioperative care, and intraoperative management. Unfortunately, an increasing number of resistant pathogens, such as MRSA (methicillin-resistant Staphylococcus aureus) and Candida species, are commonly implicated in surgical wound infections. For patients who have demonstrated recent infection with MRSA or vancomycin-resistant Enterococcus (VRE), prophylaxis with vancomycin, linezolid (Zyvoxx®), or quinupristin/dalfopristin (Synercid®) should be considered.
RECOMMENDATIONS AND RISK FACTORS:
HEAD AND NECK PROCEDURES: For procedures entailing entry into the oropharynx or esophagus, coverage of aerobic cocci is indicated. Prophylaxis has been shown to reduce the incidence of severe wound infection by approximately 50%. Either penicillin or cephalosporin-based prophylaxis is effective. Cefazolin is commonly used. Prophylaxis is not indicated for dentoalveolar (denoting that portion of the alveolar bone immediately about the teeth) procedures, although prophylaxis is warranted in immunocompromised patients undergoing these procedures.
GENERAL THORACIC PROCEDURES: Prophylaxis is routinely used for nearly all thoracic procedures, despite the lack of available supportive evidence. In general, the strength of the recommendation is proportionate to the likelihood of encountering high numbers of microorganisms during the procedure. Pulmonary resection in cases of partial or complete obstruction of an airway is a procedure in which prophylaxis is clearly warranted. Likewise, prophylaxis is strongly recommended for procedures entailing entry into the esophagus. Although the range of microorganisms encountered in thoracic procedures is extensive, most are sensitive to cefazolin, which is the recommended agent.
CARDIAC PROCEDURES: Prophylaxis against S. aureus (Staphylococcus aureus) and S. epidermidis (Staphylococcus epidermidis) is indicated for patients undergoing cardiac procedures. Although the risk of infection is low, the morbidity of mediastinitis or a sternal wound infection is great. Numerous studies have evaluated antibiotic regimens based on penicillin, first-generation cephalosporins, second-generation cephalosporins or vancomycin. Although prophylaxis is efficacious, clear superiority of a particular regimen has not been demonstrated. In certain cases, results were institution-dependent, with exceptionally high rates of methicillin-resistant S. aureus or S. epidermidis (Staphylococcus epidermidis). Such exceptions notwithstanding, cefazolin is an appropriate agent. Of particular relevance, cardiopulmonary bypass reduces the elimination of drugs, so additional intraoperative doses typically are not necessary. The optimal duration of prophylaxis remains a debated topic, with many clinicians advocating prophylaxis for more than 24 hours, or until invasive lines and chest tubes are removed. Most surgeons continue therapy for a minimum of 24 hours. Coverage until all lines and tubes are removed is not recommended or supported by data.4
GASTROINTESTINAL TRACT PROCEDURES: Prophylaxis is recommended for most gastrointestinal procedures. The number of organisms and proportion of anaerobic organisms progressively increase along the gastrointestinal tract, so the recommendation depends on the segment of gastrointestinal tract entered during the procedure. Colorectal procedures have a very high intrinsic risk of infection and warrant a strong recommendation for prophylaxis. Prophylaxis is also recommended for appendectomy. Although the intrinsic risk of infection is low for uncomplicated appendicitis, the preoperative status of the patient's appendix is typically not known. Cefotetan or cefoxitin are acceptable agents. Metronidazole combined with an aminoglycoside or a quinolone is also an acceptable regimen. For uncomplicated appendicitis, coverage need not be extended to the postoperative period. Complicated appendicitis (e.g., with accompanying perforation or gangrene) is an indication for antibiotic therapy, thereby rendering any consideration of prophylaxis irrelevant.
OBSTETRIC AND GYNECOLOGIC PROCEDURES: Antibiotic prophylaxis is indicated for C-section (cesarean section) and abdominal and vaginal hysterectomy. Numerous clinical trials have demonstrated a reduction in risk of wound infection or endometritis by as much as 70 percent in patients undergoing C-section. For C-section, the antibiotic is administered immediately after the cord is clamped to avoid exposing the newborn to antibiotics. Despite the theoretic need to cover gram-negative and anaerobic organisms, studies have not demonstrated a superior result with broad-spectrum antibiotics compared with cefazolin. Therefore, cefazolin is the recommended agent.
UROLOGIC PROCEDURES: The range of potential urologic procedures and intrinsic risk of infection varies widely. In general, it is recommended to achieve preoperative sterilization of the urine if clinically feasible. For procedures entailing the creation of urinary conduits, recommendations are similar to those for procedures pertaining to the specific segment of the intestinal tract being used for the conduit. Procedures not requiring entry into the intestinal tract and performed in the context of sterile urine are regarded as clean procedures. It should be recognized, however, that prophylaxis for specific urologic procedures has not been fully evaluated.
ORTHOPEDIC PROCEDURES: Antibiotic prophylaxis is clearly recommended for certain orthopedic procedures. These include the insertion of a prosthetic joint, ankle fusion, revision of a prosthetic joint, reduction of hip fractures, reduction of high-energy closed fractures and reduction of open fractures. Such procedures are associated with a risk of infection of 5 to 15 percent, reduced to less than 3 percent by the use of prophylactic antibiotics. S. aureus and S. epidermidis predominate in wound or joint infections. Cefazolin provides adequate coverage. The additional use of aminoglycosides and extension of coverage beyond the operative period is common but lacks supportive evidence.
CUTANEOUS AND SUPERFICIAL SOFT TISSUE PROCEDURES: Prophylaxis is not indicated for cutaneous and superficial soft tissue procedures. Prophylaxis is acceptable but not strongly indicated. Traumatic wounds require consideration of the status of the patient's tetanus vaccination. Although a single dose of antibiotic is acceptable, mechanical cleansing and adherence to guidelines for open management of wounds created more than 12 hours before treatment are the essential elements of prophylaxis.NEUROSURGICAL PROCEDURES: Studies evaluating the efficacy of antibiotic prophylaxis in neurosurgical procedures have shown variable results. The supportive data have recently been reviewed. Nonetheless, prophylaxis is currently recommended for craniotomy and shunt procedures. Coverage targets S. aureus (Staphylococcus aureus) or Staphylococcus epidermidis. Various regimens have been assessed, ranging from combinations of cefazolin and gentamicin (Garamycin) to single-agent therapy with cefazolin, vancomycin, piperacillin (Pipracil, Zosyn) and cloxacillin (Cloxapen, Tegapen). No particular regimen has been clearly demonstrated to be superior. Until further data are available, therapy with cefazolin is considered appropriate.
Disclaimer: The above information is educational purpose. The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition.
DISCLAIMER: This information should not substitute for seeking responsible, professional medical care.
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