II. Epidemiology
- Surgical-site infection Incidence: 500,000 per year in United States (24% of Health Care-Associated Infections)
- Extra-abdominal surgery: 2-5%
- Intra-abdominal surgery: 20%
III. Pathophysiology
- Most Surgical Site Infections start with surgical site contamination from adjacent skin or fecal flora
IV. Efficacy
- Antibiotics do not prevent infection in clean surgery
- Antibiotic prophylaxis not recommended in:
- Nosocomial Infection Surveillance (NNIS) Class 0 to 1
- Knight (2001) Am J Surg 182:682-6 [PubMed]
V. Prevention: MRSA
VI. Management: Postoperative Prosthetic Joint
- Antibiotic prophylaxis before procedures for 2 years in all patients
- Continue lifelong prophylaxis before procedures for high risk patients
- Prophylactic antibiotic indication tool (AAOS)
- Indications for prophylaxis after dental procedures
- No evidence supports this practice and not recommended by infectious disease specialists
- American Dental Association no longer recommends antibiotics for prosthetic joint (as of 2015)
- American Academy of Orthopedic Surgeons recommends considering not prophylaxing
- Previously recommended antibiotic prophylaxis following TKA or THA
- Consider consulting orthopedic surgery for patients at higher risk of infection
- Previous joint infection
- Immunocompromised
- References
- (2015) Presc Lett 22(10): 58
- Other preventive strategies against perioperative infections
- Chlorhexidine scrub in advance of the procedure
- Intranasal Bactroban
- Maximize Blood Glucose control in Diabetes Mellitus
- Use of antibiotics in prosthesis cement (or in prosthesis)
VII. Management: Extraabdominal Procedures
- Cardiothoracic surgery (duration 24-72 hours)
- Organisms: Staphylococcus aureus, coagulase-negative staphylococci
- No Beta-lactam allergy: Cefazolin or Cefuroxime
- Beta-lactam allergy: Vancomyin or Clindamycin
- Keep 6 am postoperative Blood Glucose <200 mg/dl
- Vascular surgery
- Organisms: Staphylococcus aureus, coagulase-negative staphylococci, enteric Gram Negative Bacilli
- No Beta-lactam allergy: Cefazolin or Cefuroxime
- Beta-lactam allergy: Vancomyin or Clindamycin
- Orthopedic: Hip or Knee surgery
- Organisms: Staphylococcus aureus, coagulase-negative staphylococci
- Antibiotic infused before Tourniquet inflated
- No Beta-lactam allergy: Cefazolin or Cefuroxime
- Beta-lactam allergy: Vancomyin or Clindamycin
- Continue for 24 hours post-surgery
- Evidence does NOT support antibiotic continuation while surgical drains are in place
- Bosco (2010) J Bone Joint Surg Am 92(1): 232-39 [PubMed]
VIII. Management: Abdominal Surgery - Colon
- Organisms
- Bowel Anaerobes (including Bacteroides)
- Enteric Gram Negative Bacteria
- Enterococcus
- Combination protocol (oral with parenteral antibiotics)
- Oral (used with parenteral agent below)
- Neomycin with Erythromycin base or
- Metronidazole
- Parenteral: Anti-anaerobe Cephalosporins
- Cefotetan (Cefotan) or
- Cefoxitin (Mefoxin) or
- Cefotaxime (with Metronidazole for appendectomy) or
- Ceftriaxone (may become preferred agent)
- Oral (used with parenteral agent below)
- Other prevention
- Post-op colorectal surgery patients should be normothermic (96.8 F) within 15 minutes of leaving OR
IX. Management: Gynecologic Surgery
- Organisms
- Ceserean Section
- Cefazolin 1 to 2 grams IV for single dose and
- Consider coverage for Ureaplasma urealyticum
- Administer after clamping Umbilical Cord
- References
-
Hysterectomy
- Cefazolin 1 to 2 grams IV for single dose or
- Cefoxitin 2 grams IV for single dose or
- Cefotetan 1 to 2 grams IV for single dose or
- Metronidazole 500 mg IV for single dose
- Hysterosalpingogram with dilated tubes
- Doxycycline 100 mg PO bid for 5 days
- Induced abortion or Dilation and Curettage
- Doxycycline 100 mg PO before procedure, then
- Doxycycline 200 mg PO after procedure, then
- Metronidazole 500 mg PO bid for 5 days
- Procedures not requiring antibiotics
- Laparoscopy
- Laparotomy
- Hysteroscopy
- IUD Insertion
- Endometrial Biopsy
- Urodynamics
X. Dosing
- Dose once immediately before procedure (course completed within 24 hours of surgery)
- One hour before the procedure for most antibiotics
- Two hours before the procedure for Vancomycin or Fluoroquinolones
- Second dose indications (completed within 48 hours of of surgery)
- Long Surgery (>4 hours)
- Large Estimated Blood Loss (>1500 ml)
- Cardiothoracic Surgery
XI. Precautions
- Avoid Third Generation Cephalosporins for prophylaxis
- Expensive
- Less active against Staphylococcus than Ancef
- Promotes emerging resistance
XII. Prevention: Surgical Site Infection
- Remove hair in the region of surgical incision with scissors (avoid shaving which increases infection risk)
- Postpone surgery until concurrent infections have resolved (if possible)
- Skin preparation with chlorhexidine
- Some protocols enlist the patient to wash the surgical site with chlorhexidine prior to presentation
- Optimize Glucose control
- Even well controlled Diabetes Mellitus with a Hemoglobin A1C <7% has a 2 fold increased infection risk
- Postpone elective surgery in poorly controlled Diabetes Mellitus to allow for optimization
- Keep Glucose controlled in the perioperative period (Glucose <180 mg/dl), especially in higher risk surgeries