Download Pre-operative prophylaxis shojaei

Pre-Operative
Antibiotic prophylaxis
Dr.E.Shojaei
Assistant Prof. of Infectious Diseases
T.U.M.S
Patient factors
Ascites
Environmental factors
Contaminated medications
Inadequate
Chronic inflammation
disinfection/sterilization
Coexistent remote infection
Inadequate skin antisepsis
Colonization with microorganisms Inadequate ventilation
Corticosteroid therapy
Diabetes
Treatment factors
Emergency procedure
Extended preoperative admission
Poor hemostasis
Hypocholesterolemia
Hypoxemia
Malnutrition
Obesity
Peripheral vascular disease
Perioperative anemia
Preoperative shaving
Prior site irradiation
Recent operation
Skin disease in the area of
infection (e.g., psoriasis)
Prolonged operative time
Surgical drains
Tissue trauma
Failure to obliterate dead space
Hypothermia
Inadequate antibiotic prophylaxis
Intraoperative blood transfusion
Oxygenation
Am J Infect Control 29:404-421, 2001;
Infect Control Hosp Epidemiol 20(4):247-278, 1999.
• Antimicrobial prophylaxis may be beneficial in surgical
procedures associated with a high rate of infection (i.e., cleancontaminated or contaminated procedures) and in certain
clean procedures where there are severe consequences of
infection (e.g., prosthetic implants), even if infection is
unlikely.
Which antibiotic use?
• Active against the pathogens most likely to contaminate the
surgical site
• Given in an appropriate dosage and at a time that ensures
adequate serum and tissue concentrations during the period
of potential contamination
• Safe administered for the shortest effective period to
minimize adverse effects, the development of resistance, and
costs
• Routine use of vancomycin prophylaxis is
not recommended for any procedure
• Vancomycin may be included in the
regimen of choice when a cluster of MRSA
cases or methicillin resistant coagulasenegative staphylococci SSIs have been
detected at an institution
• Although vancomycin is commonly used when
the risk for MRSA is high, data suggest that
vancomycin is less effective than cefazolin for
preventing SSIs caused by methicillin-susceptible
S. aureus (MSSA)
• vancomycin is used in combination with cefazolin
at some institutions with both MSSA and MRSA
SSIs
• Surgical prophylaxis can also predispose
patients to Clostridium difficile-associated
colitis
• Limiting the duration of antimicrobial
prophylaxis to a single preoperative dose
can reduce the risk of C. difficile disease
MDR gram Neg colonizers:
• There is no evidence on the management
of surgical antimicrobial prophylaxis in a
patient with past infection or colonization
with a resistant gram-negative pathogen
Known colonizers for MRSA
• It is logical to provide prophylaxis with an
agent active against MRSA for any patient
known to be colonized with this grampositive pathogen who will have a skin
incision
VRE colonizers:
• case-by-case basis
• A patient colonized with vancomycinresistant enterococci (VRE) should receive
prophylaxis effective against VRE when
undergoing liver transplantation but
probably not when undergoing an
umbilical hernia repair without mesh
placement.
• Administration of the first dose of
antimicrobial beginning within 60 minutes
before surgical incision is recommended
• Administration of vancomycin and
fluoroquinolones should begin within 120
minutes before surgical incision because of
the prolonged infusion times required for
these drugs
Redosing
• The redosing interval should be measured
from the time of administration of the
preoperative dose, not from the beginning
of the procedure
• If the duration of the procedure exceeds
two half-lives of the antimicrobial or there
is excessive blood loss (i.e., >1500 mL).
Duration
• Postoperative antimicrobial
administration is not necessary for most
procedures
• The duration of antimicrobial prophylaxis
should be less than 24 hours for most
procedures
Common surgical pathogens
• SSIs after clean procedures are skin flora,
including S. aureus and coagulasenegative staphylococci
• Clean-contaminated procedures,
including abdominal procedures and
heart, kidney, and liver transplantations,
the predominant organisms include gram
negative rods and enterococci in addition
to skin flora
Common surgical pathogens
• If there are surveillance data showing that
gram-negative organisms are a cause of
SSIs for the procedure, practitioners may
consider combining vancomycin with
another agent (cefazolin if the patient does
not have a b-lactam allergy; an
aminoglycoside [gentamicin or tobramycin],
aztreonam, or single-dose fluoroquinolone if
the patient has a b-lactam allergy).
Appendectomy procedures
• The most common microorganisms
isolated from SSIs after appendectomy
are anaerobic and aerobic gramnegative enteric organisms.
• Bacteroides fragilis is the most
commonly cultured anaerobe, and E.
coli is the most frequent aerobe
Appendectomy procedures
• single dose of a cephalosporin with
anaerobic activity (cefoxitin or
cefotetan)
Or
• single dose of a first-generation
cephalosporin (cefazolin) plus
metronidazole
Small intestine procedures
• For small bowel surgery without obstruction, the
recommended regimen is a first-generation
cephalosporin (cefazolin)
• For small bowel surgery with intestinal obstruction,
the recommended regimen is a cephalosporin with
anaerobic activity (cefoxitin or cefotetan) or the
combination of a first-generation cephalosporin
(cefazolin) plus metronidazole.
Colorectal procedures
• Bacteroides fragilis and other obligate
anaerobes are the most frequently
isolated organisms from the bowel,
with concentrations 1,000–10,000
times higher than those of aerobes
Colorectal procedures
• A single dose of second-generation
cephalosporin with both aerobic and
anaerobic activities (cefoxitin or
cefotetan) or
• Cefazolin plus metronidazole is
recommended for colon procedures
Colorectal procedures
• In institutions where there is
increasing resistance to first- and
second-generation cephalosporins
among gram-negative isolates from
SSIs, the expert panel recommends a
single dose of ceftriaxone plus
metronidazole
• An alternative regimen is ampicillin–
sulbactam.
Colorectal procedures
• The efficacy of oral prophylactic antimicrobial agents
has been established in studies only when used with
mechanical bowel preparation (MBP).
• Combination of oral neomycin sulfate(1gr) plus oral
erythromycin base (1gr)
• Or
• Oral neomycin sulfate(1gr) plus oral
metronidazole(1gr) should be given in addition to i.v.
prophylaxis
Head and neck procedures
• Clean-contaminated procedures
• (1) cefazolin or cefuroxime plus metronidazole
Or
• (2) ampicillin–sulbactam.
Urologic procedures
• Patients with preoperative bacteriuria
or UTI should be treated before the
procedure, when possible, to reduce
the risk of postoperative infection
Urologic procedures
• For patients undergoing lower urinary
tract instrumentation with risk
factors for infection, the use of a
fluoroquinolone or trimethoprim–
sulfamethoxazole (oral or i.v.) or
cefazolin (i.v. or intramuscular) is
recommended
Liver transplantation
• The pathogens most commonly associated with
early SSIs and intraabdominal infections are those
derived from the normal flora of the intestinal
lumen and the skin. Aerobic gram-negative bacilli,
including E. coli ,Klebsiella species, Enterobacter
species, A. baumannii and Citrobacter species
• Staphylococcus aureus (frequently MRSA) and
coagulase-negative staphylococci are also common
causes of postoperative SSIs
• Candida species commonly cause both early and
late postoperative infections
Liver transplantation
• Majority of recent studies have limited
the duration of prophylaxis to 72 h
• (1) piperacillin–tazobactam
or
• (2) cefotaxime plus ampicillin
Liver transplantation
• For patients at high risk of Candida
infection, fluconazole may be
considered. (Strength of evidence
B.)
Cesarean delivery procedures
• The infection rate after cesarean delivery
has been reported to be 4–15%
• Endometritis (infection of the uterine
lining) is usually identified by fever,
malaise, tachycardia, abdominal pain,
uterine tenderness, and sometimes
abnormal or foul-smelling lochia .
• Fever may also be the only symptomof
endometritis.
• The recommended regimen for all women
undergoing cesarean delivery is a single
dose of cefazolin administered before
surgical incision .(Strength of evidence for
prophylaxis = A.)
• For patients with b-lactam allergies, an
alternative regimen is clindamycin plus
gentamicin
Induced (Therapeutic) Abortion
• All women undergoing an induced
(therapeutic) surgical abortion should
receive prophylactic antibiotics to reduce
the risk of postabortal infection. (I-A)
Missed or Incomplete Abortion
• Prophylactic antibiotics are not suggested
to reduce infectious morbidity following
surgery for a missed or incomplete
abortion.
Intrauterine Device Insertion
• Antibiotic prophylaxis is not recommended
for insertion of an intrauterine device. (I-E)
However, health care professionals could
consider screening for sexually transmitted
infections in high-risk populations. (III-C)
Endometrial Biopsy
• There is insufficient evidence to
support the use of antibiotic
prophylaxis for an endometrial biopsy.