ANTIBIOTICPROPHYLAXISFORSURGERYGUIDELINE

PURPOSE The overall goal of surgical prophylaxis is to prevent surgical site infections by using an antimicrobialagentthatissafe,costeffective,andhasaspectrumofactivitythatcoversthe most common pathogens for surgical procedures. Achieving adequate serum and tissue concentrations of the antimicrobial agent is important prior to the time of incision and throughout the duration of the surgical procedure. This guideline was established to ensureantimicrobialprophylaxisforsurgeryatCHOCChildrensHospitalisconsistentwith publishedliterature. PROCEDURE 1. Documentation of antimicrobial administration must include date, time of administration, name of medication, dose, and route of administration. Do not abbreviatenameofmedicationanddonotuseunapprovedabbreviations. 2. Antibiotic prophylaxis for surgery is given within one hour prior to surgical incision exceptforVancomycin,whichisgivenwithintwohourspriortosurgicalincision. 3. AllparenteralantibioticslistedinthisguidelinemaybeinfusedasindicatedinTable1. PleasenotethatVancomycinmustbeadministeredoveraminimumof60minutes. 4. If a tourniquet is to be used in the procedure, the entire dose of antibiotic must be infusedpriortotourniquetinflation. 5. Intraoperativeredosingmaybenecessaryduringprocedures(>4hours)tomaintain adequateserumandtissueconcentrations. 6. Antibioticprophylaxisforsurgerymustbediscontinuedwithin24hoursofsurgicalend time except for cardiac surgery, in which case antibiotic prophylaxis must be discontinued within 4872 hours of surgical end time. Use of antibiotics beyond the recommended postoperative duration requires proper documentation of infection or suspectedinfection. 7. Vancomycinuserequiresdocumentationofthereasonforuseinthemedicalrecordby theprescribingphysicianorhis(her)designee.Reasonsforuseinclude: a. Betalactam(penicillinorcephalosporin)allergy b. Known Methicillin resistant Staphylococcus aureus (MRSA) colonization or infectionorhighriskforMRSA(i.e.recentinpatienthospitalization,residesinan extendedcarefacility/grouphome,receivesdialysis)

UpdatedSept2,2010

Table1.DosingandTimingofAntibioticAgentsusedforSurgicalProphylaxis ANTIBIOTICAGENT PEDIATRIC INFUSION TIMINGOF INTRAVENOUS TIME FIRST (MINUTES) DOSE DOSE (ADULTDOSE) 50mg/kg Begin60 (1.53gm) minorless 30 before incision 25mg/kg Begin60 (max1gm; minorless ifgreaterthan 30 before 80kg,use2 incision gm) 40mg/kg (12gm) Begin60 minorless before incision Begin60 minorless before incision Begin60 minorless before incision Begin60 minorless before incision Begin60 minorless before incision Begin60to 120min before incision INTRAOPERATIVE REDOSINGFOR NORMALRENAL FUNCTION Every3hrs

Ampicillin/Sulbactam

Cefazolin

Every4hrs Every3hrs Every4hrs

Cefoxitin

30

Cefepime Clindamycin Gentamicin

50mg/kg (12gm)

30

10mg/kg (600900mg)

30

Every6hrs

2.5mg/kg (120mgif>80 kg)

30

Every8hrs

Metronidazole

10mg/kg (500mg) 15mg/kg (1gmif>50 kg)

30

Every6hrs

Vancomycin

60

Every12hrs

UpdatedSept2,2010

Table2.RecommendedIntravenousAntibioticsforSurgicalProcedures
PROCEDURE
CARDIAC Heartsurgery+,PDA(patentductus arteriosis),ASD/VSD(atrial/ventricular septaldefect),GlennShunt,valve replair/replacement, Aorticreconstruction,prostheticgraft insertion GASTROINTESTINAL Esophageal,gastroduodenal PEGplacement/revision/conversionto otherfeedingtubesORhighriskconditions Biliary,includinglapcholecystectomy Colorectal** Appendectomyorrupturedviscus

COMMON PATHOGENS
S.epidermidis, S.aureus

RECOMMENDEDANTIBIOTIC PROPHYLAXIS CefazolinOR VancomycinforknownMRSAor highriskforMRSA,ormajor reactiontobetalactams++

POST OPERATIVE DURATION

Discontinue within4872 hrsofsurgical endtime

Entericgram negativebacilli, grampositive cocci Entericgram negativebacilli, grampositive cocci,clostridia Entericgram negativebacilli, anaerobes, enterococci

HEADandNECKSURGERY Incisionthroughoralorpharyngealmucosa, lowerjawfraction,removalofesophagus pouch NEUROSURGERY## Craniotomy,shuntplacement/revision, insertionofpump/reservoir,spinal procedure(laminectomy,fusionorcord decompression) ORTHOPEDIC Spinalproceduresorimplantationof hardware Iftourniquetisused,giveantibioticbefore tourniquetinflation THORACIC Lungresection,VATS

Anaerobes, entericgram negativebacilli, S.aureus S.aureus, S.epidermidis

Forhighrisk+++:Cefazolin Ifmajorreactiontobeta lactams++:Clindamycinplus Gentamicin Forhighrisk*:Cefazolin Ifmajorreactiontobeta lactam++:Clindamycinplus Gentamicin CefoxitinOR Ampicillin/sulbactamOR CefazolinplusMetronidazole Ifmajorreactiontobeta lactams++:Clindamycinplus Gentamicin CefazolinOR Ifmajorreactiontobeta lactams++:Clindamycinplus Gentamicin CefazolinOR VancomycinforknownMRSAor highriskforMRSA,ormajor reactiontobetalactams++ CefazolinorCefepimeand VancomycinforknownMRSAor highriskforMRSA,ormajor reactiontobetalactams++ CefazolinOR VancomycinorClindamycin forknownMRSAorhighriskfor MRSA,ormajorreactiontobeta lactams++

Discontinue within24hrs ofsurgicalend time

Discontinue within24hrs ofsurgicalend time Discontinue within24hrs ofsurgicalend time Discontinue within24hrs ofsurgicalend time Discontinue within24hrs ofsurgicalend time

S.epidermidis, S.aureus

S.aureus, S.epidermidis, streptococci, entericgram negativebacilli##

UpdatedSept2,2010

VASCULAR(seeCardiac) Extremityamputationforischemia, vascularaccessforhemodialysis GYNECOLOGIC GENITOURINARY Bladderaugmentation,pyeloplasty

S.aureus, S.epidermidis, entericgram negativebacilli#

CefazolinOR VancomycinORClindamycin forknownMRSAorhighriskfor MRSA,ormajorreactiontobeta lactams++

Entericgram negativebacilli, anaerobes,GpB strep,enterococci

Entericgram negativebacilli, anaerobes, enterococci

CefoxitinOR AmpicillinplusMetronidazole plusGentamicin Ifmajorreactiontobeta lactam++:Clindamycinplus Gentamicin Forhighriskonly***:Cefazolin ORCefoxitinORAmpicillin plusMetronidazoleplus Gentamicin Ifmajorreactiontobeta lactam++:Clindamycinplus Gentamicin

Discontinue within24hrs ofsurgicalend time Discontinue within24hrs ofsurgicalend time Discontinue within24hrs ofsurgicalend time

+For openheart surgery only: use maximum cefazolin 2 gm; redose cefazolin when patient is removed from bypass; alternative to

cefazolinmonotherapyiscefazolinplusvancomycinforpatientsathighriskforMRSA.(procedureinvolvesinsertionofprostheticvalve orvasculargraft). ++Majorreactionsincludeanaphylaxis,hives,shortnessofbreath,wheezing,edema.Forminorreactions(nausea,vomiting,diarrhea, mildrash,itching),cephalosporinsmaystillbeused. +++Highriskgastroduodenal:morbidobesity,esophagealobstruction,decreasedgastricacidityordecreasedgastrointestinalmotility *Highriskbiliary:acutecholecystitis,nonfunctioninggallbladder,obstructivejaundiceorcommonductstones **Colorectal procedures: Oral prophylaxis prior to surgery After appropriate diet and catharsis, 1 gram of neomycin plus 1 gram of erythromycinat1pm,2pm,and11pmor2gramsofneomycinplus2gramsofmetronidazoleat7pmand11pmthedaybeforean8am dayoperation ***High risk genitourinary: urine culture positive or unavailable, preoperative catheter, transrectal prosthetic biopsy, placement of prostheticmaterial ##Vascularprocedures:Clostridiacanalsobepresentinlowerextremityamputationforischemia.

REFERENCES
1. AmericanSocietyofHealthSystemPharmacists.ASHPtherapeuticguidelinesonantibioticprophylaxisin surgery.AmJHealthSystPharm.1999;56:183988

2.

AntibioticProphylaxisforSurgery:TreatmentGuidelinesfromtheMedicalLetter.Vol4(Issue52)December 2006;8388 BratzlerDWetal.Antibioticprophylaxisforsurgery:AnadvisorystatementfromtheNationalSurgicalInfection PreventionProject.ClinInfectDis2004;38:1706 BratzlerDWandHuntDR.Thesurgicalinfectionpreventionandsurgicalcareimprovementprojects:Nationalinitiativesto improveoutcomesforpatientshavingsurgery.ClinInfectDis2006;43:322 EngelmanR,ShahianD,SheminR,etal.TheSocietyofThoracicSurgeonsPracticeGuidelineSeries:Antibioticprophylaxisin cardiacsurgery,PartyII:antibioticChoice.AnnThorcSurg2007;83:156976 TalbotTR,KaiserAB.Postoperativeinfectionsandantibioticprophylaxis,inMandellGL,BennettJE,DolinR,PrinciplesandPractice ofInfectiousDiseasesElsevierInc.2005,pages35333547 IHISurgicalSiteInfections;HowtoGuidePediatricSupplement. SurgicalCareImprovementProject.LiteratureReview,January2005Update.http://www.medqic.org/scip

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UpdatedSept2,2010