Surgical Antibiotic Prophylaxis

1. See Also
   1. SBE Prophylaxis
   2. Health Care-Associated Infection
2. Definitions
   1. Surgical Site Infection
      1. Infection following surgery, involving the surgical incision, organ or space
3. Epidemiology
   1. Surgical-site infection Incidence: 500,000 per year in United States (24% of Health Care-Associated Infections)
      1. Extra-abdominal surgery: 2-5%
      2. Intra-abdominal surgery: 20%
4. Pathophysiology
   1. Most Surgical Site Infections start with surgical site contamination from adjacent skin or fecal flora
5. Efficacy
   1. Antibiotics do not prevent infection in clean surgery
   2. Antibiotic prophylaxis not recommended in:
      1. Nosocomial Infection Surveillance (NNIS) Class 0 to 1
   3. Knight (2001) Am J Surg 182:682-6 [PubMed]
6. Prevention: MRSA
   1. Unclear recommendations regarding MRSA
   2. Consider nasal swab screening for MRSA preoperatively
   3. Consider Vancomycin as prophylactic agent if patient at high risk of MRSA
   4. Some protocols use intranasal Bactroban in the preoperative period to decrease MRSA carriage
7. Management: Postoperative Prosthetic Joint
   1. Antibiotic prophylaxis before procedures for 2 years in all patients
   2. Continue lifelong prophylaxis before procedures for high risk patients
   3. Prophylactic antibiotic indication tool (AAOS)
      1. http://www.orthoguidelines.org/go/auc/default.cfm?auc_id=224995&actionxm=Terms
   4. Indications for prophylaxis perio-operative dental procedures
      1. No evidence supports this practice and not recommended by infectious disease specialists
      2. American Dental Association no longer recommends antibiotics for prosthetic joint (as of 2015)
      3. American Academy of Orthopedic Surgeons recommends considering not prophylaxing
         1. Previously recommended antibiotic prophylaxis following TKA or THA
         2. Consider consulting orthopedic surgery for patients at higher risk of infection
            1. Previous joint infection
            2. Immunocompromised
      4. References
         1. (2015) Presc Lett 22(10): 58
   5. Other preventive strategies against perioperative infections
      1. Chlorhexidine scrub in advance of the procedure
      2. Intranasal Bactroban
      3. Maximize Blood Glucose control in Diabetes Mellitus
      4. Use of antibiotics in prosthesis cement (or in prosthesis)
8. Management: Extraabdominal Procedures
   1. Cardiothoracic surgery (duration 24-72 hours)
      1. Organisms: Staphylococcus aureus, coagulase-negative staphylococci
      2. No Beta-lactam allergy: Cefazolin or Cefuroxime
      3. Beta-lactam allergy: Vancomyin or Clindamycin
      4. Keep 6 am postoperative Blood Glucose <200 mg/dl
   2. Vascular surgery
      1. Organisms: Staphylococcus aureus, coagulase-negative staphylococci, enteric Gram Negative Bacilli
      2. No Beta-lactam allergy: Cefazolin or Cefuroxime
      3. Beta-lactam allergy: Vancomyin or Clindamycin
   3. Orthopedic: Hip or Knee surgery
      1. Organisms: Staphylococcus aureus, coagulase-negative staphylococci
      2. Antibiotic infused before Tourniquet inflated
      3. No Beta-lactam allergy: Cefazolin or Cefuroxime
      4. Beta-lactam allergy: Vancomyin or Clindamycin
      5. Continue for 24 hours post-surgery
         1. Evidence does NOT support antibiotic continuation while surgical drains are in place
         2. Bosco (2010) J Bone Joint Surg Am 92(1): 232-39 [PubMed]
9. Management: Abdominal Surgery - Colon
   1. Organisms
      1. Bowel Anaerobes (including Bacteroides)
      2. Enteric Gram Negative Bacteria
      3. Enterococcus
   2. Combination protocol (oral with parenteral antibiotics)
      1. Oral (used with parenteral agent below)
         1. Neomycin with Erythromycin base or
         2. Metronidazole
      2. Parenteral: Anti-anaerobe Cephalosporins
         1. Cefotetan (Cefotan) or
         2. Cefoxitin (Mefoxin) or
         3. Cefotaxime (with Metronidazole for appendectomy) or
         4. Ceftriaxone (may become preferred agent)
            1. Woodfield (2002) Am J Surg 185:45-9 [PubMed]
   3. Other prevention
      1. Post-op colorectal surgery patients should be normothermic (96.8 F) within 15 minutes of leaving OR
10. Management: Gynecologic Surgery
    1. Organisms
       1. Enteric Gram Negative Bacteria
       2. Anaerobes
       3. Group B Streptococcus
       4. Enterococcus
    2. Ceserean Section
       1. Cefazolin 1 to 2 grams IV for single dose and
       2. Consider coverage for Ureaplasma urealyticum
          1. Azithromycin and
          2. Doxycycline
       3. Administer after clamping Umbilical Cord
       4. References
          1. Andrews (2003) Obstet Gynecol 101:1183-9 [PubMed]
    3. Hysterectomy
       1. Cefazolin 1 to 2 grams IV for single dose or
       2. Cefoxitin 2 grams IV for single dose or
       3. Cefotetan 1 to 2 grams IV for single dose or
       4. Metronidazole 500 mg IV for single dose
    4. Hysterosalpingogram with dilated tubes
       1. Doxycycline 100 mg PO bid for 5 days
    5. Induced abortion or Dilation and Curettage
       1. Doxycycline 100 mg PO before procedure, then
       2. Doxycycline 200 mg PO after procedure, then
       3. Metronidazole 500 mg PO bid for 5 days
    6. Procedures not requiring antibiotics
       1. Laparoscopy
       2. Laparotomy
       3. Hysteroscopy
       4. IUD Insertion
       5. Endometrial Biopsy
       6. Urodynamics
11. Dosing
    1. Dose once immediately before procedure (course completed within 24 hours of surgery)
       1. One hour before the procedure for most antibiotics
       2. Two hours before the procedure for Vancomycin or Fluoroquinolones
    2. Second dose indications (completed within 48 hours of of surgery)
       1. Long Surgery (>4 hours)
       2. Large Estimated Blood Loss (>1500 ml)
       3. Cardiothoracic Surgery
12. Precautions
    1. Avoid Third Generation Cephalosporins for prophylaxis
       1. Expensive
       2. Less active against Staphylococcus than Ancef
       3. Promotes emerging resistance
13. Prevention: Surgical Site Infection
    1. Remove hair in the region of surgical incision with scissors (avoid shaving which increases infection risk)
    2. Postpone surgery until concurrent infections have resolved (if possible)
    3. Full body bathing the night before surgery
    4. Consider nasal MRSA screening prior to surgery
       1. May help direct decolonization (e.g. Chlorhexidine wash)
    5. Skin Preparation with Chlorhexidine
       1. Some protocols enlist the patient to wash the surgical site with Chlorhexidine prior to presentation
    6. Optimize perioperative Glucose control
       1. Even well controlled Diabetes Mellitus with a Hemoglobin A1C <7% has a 2 fold increased infection risk
       2. Postpone elective surgery in poorly controlled Diabetes Mellitus to allow for optimization
       3. Keep Glucose controlled in the perioperative period (Glucose <180 mg/dl), especially in higher risk surgeries
    7. Antimicrobial Suture indications
       1. Surgeries at high risk of infection (e.g. intracolorectal surgery)
       2. Surgeries in which infection is associated with devastating complications (e.g. cardiothoracic surgery)
14. References
    1. (2001) Obstet Gynecol 23:1-9 [PubMed]
    2. Bratzler (2004) Clin Infect Dis 38:1706-15 [PubMed]
    3. Cagle (2022) Am Fam Physician 105(3): 262-70 [PubMed]
    4. Hsu (2014) Am Fam Physician 90(6): 377-82 [PubMed]
    5. Salkind (2011) Am Fam Physician 83(5): 585-90 [PubMed]