Download Infectious Disease I Antimicrobial Prophylaxis in

Infectious Disease I:
Antimicrobial Prophylaxis in
Surgery
Courses in Therapeutics and Disease State Management
Author: Michael W. Perry PharmD, BCPS, BCCCP; Assistant Clinical Professor of Pharmacy Practice; Mylan School of Pharmacy
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Copyright © 2017 McGraw-Hill Education. All rights reserved
Learning Objectives
• Differentiate between prophylactic, presumptive, and
therapeutic antibiotics in the perioperative patient.
• Identify patient-specific risk factors for surgical site infections
(SSIs).
• Identify procedure-specific risk factors for SSIs.
• List common pathogens responsible for SSIs.
• Explain the importance of timing of antimicrobial prophylaxis for
surgery.
• Choose an evidence-based prophylactic antimicrobial regimen
for specific types of surgeries.
Author: Michael W. Perry PharmD, BCPS, BCCCP; Assistant Clinical Professor of Pharmacy Practice; Mylan School of Pharmacy
http://accesspharmacy.mhmedical.com/qa.aspx#tab6
Copyright © 2017 McGraw-Hill Education. All rights reserved
Learning Objectives
• Individualize prophylactic antimicrobial regimens by considering
the type of surgery, intrinsic patient risk factors, and knowledge
of common pathogenic organisms.
• Recommend an alternative prophylactic antimicrobial regimen
for patients with life-threatening allergies to first-line therapies.
• Identify clinical scenarios where multiple dose regimens of
prophylactic antimicrobials are appropriate as compared to
single dose regimens.
• List nonpharmacological interventions effective at reducing the
risk of postoperative SSIs.
Author: Michael W. Perry PharmD, BCPS, BCCCP; Assistant Clinical Professor of Pharmacy Practice; Mylan School of Pharmacy
http://accesspharmacy.mhmedical.com/qa.aspx#tab6
Copyright © 2017 McGraw-Hill Education. All rights reserved
Required and Recommended Reading
Required Reading
Kanji S. Chapter 101. Antimicrobial Prophylaxis in
Surgery. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG,
Posey L. eds. Pharmacotherapy: A Pathophysiologic Approach,
9e. New York, NY: McGraw-Hill; 2014.
Recommended Readings
Bratzler DW, Dellinger EP, Olsen KM, et al. Clinical practice
guidelines for antimicrobial prophylaxis in surgery. Am J Health
Syst Pharm 2013;70:195-283.
Author: Michael W. Perry PharmD, BCPS, BCCCP; Assistant Clinical Professor of Pharmacy Practice; Mylan School of Pharmacy
http://accesspharmacy.mhmedical.com/qa.aspx#tab6
Copyright © 2017 McGraw-Hill Education. All rights reserved
Overview of Surgical Site Infections
• Surgical site infections (SSI) are a common cause of nosocomial
infections and lead to increased costs and prolonged hospitalization
• Prophylactic administration of antibiotics lowers the risk of a surgical
site infection
• Prevents the contamination of sterile tissues or fluids during surgery
• Timing of antibiotics is important to ensure the antibiotic is at a peak
concentration at the time of the incision
• Infections acquired from surgical procedures and non-surgery related issues
are termed nosocomial infections
• Presumptive antibiotic therapy is administered to patients where an
infection is suspected
• Patients with acute appendicitis, compound fractures, or acute cholecystitis
are presumed to have an infection until proven otherwise
• If no infection is found, the patient will be placed on appropriate prophylactic
therapy
Author: Michael W. Perry PharmD, BCPS, BCCCP; Assistant Clinical Professor of Pharmacy Practice; Mylan School of Pharmacy
http://accesspharmacy.mhmedical.com/qa.aspx#tab6
Copyright © 2017 McGraw-Hill Education. All rights reserved
SSI Categories
• Incisional: Occurs at the site of surgical incision
• Superficial: Skin or subcutaneous tissue
• Deep: fascial and muscle layers
• Organ/space: Can occur in any anatomic site other than the
surgical incision site
Author: Michael W. Perry PharmD, BCPS, BCCCP; Assistant Clinical Professor of Pharmacy Practice; Mylan School of Pharmacy
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Copyright © 2017 McGraw-Hill Education. All rights reserved
Surgical Site Infection Risk Factors
• Risk of SSI depends on both surgical procedure and patient
specific factors
• National Research Council has developed a SSI risk
classification system
Author: Michael W. Perry PharmD, BCPS, BCCCP; Assistant Clinical Professor of Pharmacy Practice; Mylan School of Pharmacy
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Copyright © 2017 McGraw-Hill Education. All rights reserved
National Research Council Wound Classification,
Risk of Surgical Site Infection, and Indication for
Antibiotics
SSI Rate (%)
Classification
Preoperative Antibiotics
No Preoperative Antibiotics
Criteria
Antibiotics
Clean
5.1
0.8
No acute inflammation or transection of GI,
oropharyngeal, genitourinary, biliary, or
respiratory tracts; elective case, no technique
break
Not indicated unless high-risk
a
procedure
Clean–contaminated
10.1
1.3
Controlled opening of aforementioned tracts
with minimal spillage/minor technique break;
clean procedures performed emergently or with
major technique breaks
Prophylactic antibiotics indicated
Contaminated
21.9
10.2
Acute, nonpurulent inflammation present; major
spillage/technique break during clean–
contaminated procedure
Prophylactic antibiotics indicated
Dirty
N/A
N/A
Obvious preexisting infection present (abscess,
pus, or necrotic tissue present)
Therapeutic antibiotics required
N/A, not applicable; SSI, surgical site infection.
aHigh-risk procedures include implantation of prosthetic materials and other procedures where surgical site infection is associated with high morbidity (see the text).
Adapted from references 5 and 11.
Author: Michael W. Perry PharmD, BCPS, BCCCP; Assistant Clinical Professor of Pharmacy Practice; Mylan School of Pharmacy
http://accesspharmacy.mhmedical.com/qa.aspx#tab6
Copyright © 2017 McGraw-Hill Education. All rights reserved
Surgical Site Infection Risk Factors
Patient specific factors must be taken into account when initiation
prophylactic antibiotics prior to a surgical procedure
Patient
Operation
Age
Duration of surgical scrub
Nutritional status
Preoperative skin preparation
Diabetes
Preoperative shaving
Smoking
Duration of operation
Obesity
Antimicrobial prophylaxis
Coexisting infections at distal body sites
Operating room ventilation
Colonization with resistant microorganisms
Sterilization of instruments
Altered immune response
Implantation of prosthetic materials
Length of preoperative stay
Surgical drains Surgical technique
Author: Michael W. Perry PharmD, BCPS, BCCCP; Assistant Clinical Professor of Pharmacy Practice; Mylan School of Pharmacy
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Copyright © 2017 McGraw-Hill Education. All rights reserved
Common Bacteria by Surgical Site
• Organisms causing SSI originate from two main areas
• Endogenously (i.e. normal flora)
• Translocation of Staphylococcus aureus on the skin into the sternum during open
heart surgery
• Exogenously (i.e. contamination during the surgical procedure)
• Perforation of the bowel during an appendectomy causing an acute peritonitis
• Antimicrobial Resistance
• Patients may become colonized with multi drug resistance bacteria
• Prolonged inpatient stay prior to surgery
• Fomite transmission
• Contact with health care providers working in an inpatient setting
• Institution antibiograms will aid in the identification of resistance patterns and
selection of prophylactic antibiotics
Author: Michael W. Perry PharmD, BCPS, BCCCP; Assistant Clinical Professor of Pharmacy Practice; Mylan School of Pharmacy
http://accesspharmacy.mhmedical.com/qa.aspx#tab6
Copyright © 2017 McGraw-Hill Education. All rights reserved
Antimicrobial Selection
• Factors to consider
• Classification of surgical procedure and the most common pathogens
associated with this procedure
• Antimicrobial Specific Factors
• Safety and efficacy
• Current literature evidence supporting its use
• Cost
• Patient Specific Factors
• Normal flora/ colonization with multi drug resistant pathogens
• Allergies
• Drug-drug interactions
• Institutional susceptibility patterns of nosocomial pathogens
Author: Michael W. Perry PharmD, BCPS, BCCCP; Assistant Clinical Professor of Pharmacy Practice; Mylan School of Pharmacy
http://accesspharmacy.mhmedical.com/qa.aspx#tab6
Copyright © 2017 McGraw-Hill Education. All rights reserved
Antimicrobial Selection
• General consideration
• Clean surgical procedures such as vascular, orthopedic, neurosurgery, cardiac, etc. utilize cefazolin
as the first line prophylactic antibiotic
•
•
•
•
Cefazolin covers normal skin flora (Staphylococcus sp. and Streptococci sp)
Cefazolin has a narrow spectrum of coverage
Vancomycin is used second line in patients with allergies to β-lactam agents who cannot take cefazolin
Clindamycin is used third line after the cephalosporins and vancomycin, but does provided additional anaerobic
coverage
• Clean-contaminated surgical procedures such as appendectomy, high risk GI surgery, or
whenever the operation will transect a hollow viscous or mucous membrane that may
contain resident flora require enteric gram negative bacilli and anaerobic coverage
• 2nd Generation Cephalosporins with anaerobic coverage are normally the drugs of first choice
• Cefoxitin
• Cefotetan
• Combinations of agents that cover for gram negative bacilli and anaerobes may utilized
•
•
•
•
•
Cefazolin plus metronidazole
Vancomycin plus metronidazole
Clindamycin plus aminoglycosides
Metronidazole plus aminoglycosides
Aztreonam plus metronidazole
Author: Michael W. Perry PharmD, BCPS, BCCCP; Assistant Clinical Professor of Pharmacy Practice; Mylan School of Pharmacy
http://accesspharmacy.mhmedical.com/qa.aspx#tab6
Copyright © 2017 McGraw-Hill Education. All rights reserved
Most Likely Pathogens and Specific
Recommendations for Surgical
Prophylaxis
Link: Table featuring Most Likely Pathogens and Specific
Recommendations for Surgical Prophylaxis
Author: Michael W. Perry PharmD, BCPS, BCCCP; Assistant Clinical Professor of Pharmacy Practice; Mylan School of Pharmacy
http://accesspharmacy.mhmedical.com/qa.aspx#tab6
Copyright © 2017 McGraw-Hill Education. All rights reserved
Summary
• Identify the risk factors for the Surgical Site Infection (SSI)
• Surgery type
• Most likely pathogens
• Select prophylactic antimicrobial therapy
• Patient factors
• Medication factors
• Local resistance
• Monitoring signs and symptoms of SSI
Author: Michael W. Perry PharmD, BCPS, BCCCP; Assistant Clinical Professor of Pharmacy Practice; Mylan School of Pharmacy
http://accesspharmacy.mhmedical.com/qa.aspx#tab6
Copyright © 2017 McGraw-Hill Education. All rights reserved
References
Kanji S. Chapter 101. Antimicrobial Prophylaxis in
Surgery. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG,
Posey L. eds. Pharmacotherapy: A Pathophysiologic Approach,
9e. New York, NY: McGraw-Hill; 2014.
Bratzler DW, Dellinger EP, Olsen KM, et al. Clinical practice
guidelines for antimicrobial prophylaxis in surgery. Am J Health
Syst Pharm 2013;70:195-283.
Author: Michael W. Perry PharmD, BCPS, BCCCP; Assistant Clinical Professor of Pharmacy Practice; Mylan School of Pharmacy
http://accesspharmacy.mhmedical.com/qa.aspx#tab6
Copyright © 2017 McGraw-Hill Education. All rights reserved