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Timing of Prophylaxis
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The antibiotic should be administered
preoperatively but as close to the time of
the incision as is clinically practical.
Antibiotics should be administered before
induction of anesthesia in most situations.
Recommended time for -lactams is 60
min prior to surgical incision and 120 min
for Vancomycin and Flouroquinolns
Timing of Prophylaxis
 1-
Adequate time for complete antibiotic
infusion and achievement of SS kinetics
 2- Higher serum concentrations during the
surgery
 3- Measurable drug levels at the end of surgery
 4- Adequate tissue concentrations at the time of
first incision and wound
Repeat Dosing
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A single IV dose is recommended for surgical
procedures lasting less than 4 hours
Redosing is recommended for procedures
lasting more than 4 hours or when blood loss
occurs or the patient is obese.
Redosing is indicated every 1 to 2 half lives of
antibiotic in patients with normal renal function
Repeat of Dosing
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Repeat dosing during post-operative period
and after wound closure is not necessary
and even might increase antimicrobial
resistance
Common mistake
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1- broad-spectrum AB
2- extended duration
3- expensive AB
4- timing
Colorectal Surgery
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It is recommended to cover gramΘ bacilli,
anaerobes and enterococci
Oral prophylaxis appears to be as effective as IV
prophylaxis but in USA more than 90% of
surgeons use both of them.
along with administration of mechanical bowel
preparation
Colorectal Surgery
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Oral Neomycin (1g)+ Oral Erythromycin base
(1g)
Oral Neomycin (2g)+ Oral Metronidazole (2g)
Intravenous cefoxitin or cefazolin preoperatively
and continued 2 doses or 24 hrs postoperatively
Billiary Tract Surgery
Prophylaxis is recommended in patients with
such risk factors:
1- Age greater than 60 (70) years
 2- Acute cholesistis
 3- Obestructive jaundice
 4- Bile duct stones
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Billiary Tract Surgery
Recommended antibiotics are :
 Cefazolin (1-2g IV)
 Clindamycin + Anti gramΘ agents
(Gentamicin, Aztreonam, Ciprofloxacin) for
whom are allergic to beta-lactam antibiotics
Appendectomy
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Antibiotic prophylaxis is recommended even in
patients with non-perforated acute appendicitis
1- Cefazolin (1-2g IV)
2- Cefazolin (1-2g IV) + Metronidazole (500
mg IV)
3- Clindamycin (600-900mg IV) + Anti gramΘ
agents
(Gentamicin,
Aztreonam,
Ciprofloxacin)
Vascular Surgery
The recommended drugs are:
 1- Cefazolin (1-2g IV)
 2- Cefuroxime (1.5g IV)
 3- Vancomycin in patients with allergy to betalactam antibiotics (because of the crucial role of
Staphylococci and Streptococci)
Genitourinary Surgery
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Antibiotic prophylaxis is warranted when the
urine culture is positive or urinary catheter is in
place
This decreases not only the risk of sepsis but
also the incidence of postoperative bacteriuria
Ciprofloxacin (500mg PO or 400mgIV) or CoTrimoxazole (2 DS tablets) are recommended
Cesarean Section
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Enteric gram negative rods, anaerobes,
enterococci and group B streptococci are
common pathogens
Antibiotic administration should be undertaken
immediately following umbilical cord clamping
Cefazolin is the drug of choice but Cefoxitin
may also be used.
Neurosurgery
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Antimicrobial prophylaxis can reduce the
incidence of infection mostly due to gram+
bacteria like: Staphylococci and Streptococci
Cefazolin (1-2g IV)
Vancomycin (~1g IV) in selected patients
Cardiac Surgery
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Coronary bypass or heart valve replacement are clean
with low incidence of SSI procedures
In open cardiac surgery, antibiotic prophylaxis is
recommended
Cefazolin, Cefuroxime and Vancomycin are the
drugs of choice for prophylaxis
Naso-pharyngeal and oropharyngeal decontamination
are effcetive to reduce the risk of wound infection after
cardiac surgery especially due to S. aureous
Naso-pharyngeal & Oropharyngeal
Decontamination
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Mupirocin and Chlorhexidine gluconate have
been tested for this purpose
Mupirocin indicates controvertial effectiveness
while for Chlorhexidine the results are beneficial
as follows:
1- Overal reduction in nosocomial infection
(19.8 vs 26.2 %)
2- Reduction in S. aureous nasal carriage (18.1
vs 57.5%)
Hair Removal
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Most studies have shown an increased risk of
SSI in patents undergoing preoperative hair
removal
In one study the rates of SSI were highest when
shaving was used compared to clipping the hairs
or use of depilating creams
Mild hypothermia may promote SSI by
triggering vasoconstriction that in turn may
decrease SC oxygen tension
Hair-Removal Techniques and SSIs
Discharge
Infection, %
30-Day Follow-up
12
8
10%
(26/260)
8.8%
(23/260)
5.2%
(14/271)
7.5%
(18/241)
6.4%
(17/266)
4%
(10/250)
4
3.2%
(7/216)
1.8%
(4/226)
0
PM
Razor
AM
Razor
Alexander JW et al. Arch Surg. 1983;118:347–352.
PM
Clipper
AM
Clipper
Perioperative Normothermia
• 200 CRS patients
– Control: Routine intraoperative thermal care
(mean temperature 34.7°C)
– Treatment: Active warming
(mean temperature 36.6°C)
• Incidence of SSI
– Control
19% (18/96)
– Treatment 6% (6/104); P=0.009
Kurz A et al. N Engl J Med. 1996;334:1209–1215.
Supplemental Oxygen
• 500 CRS patients
– 80% or 30% inspired oxygen during operation
and
for 2 hours post surgery
– All patients received prophylactic antibiotics
• Results
– Arterial and subcutaneous PO higher in
80% oxygen group
2
– Lower incidence of SSIs with higher
supplemental oxygen (5.2% vs 11.2%;
P=0.01)
Greif et al. N Engl J Med. 2000;342:161–167.
SSIs and Glucose Levels (cont)
• 1,000 cardiothoracic surgery patients with
preoperative hemoglobin A1c (HbA1c) levels
measured
– 300 known diabetic patients
– 42 with undiagnosed diabetes
• Incidence of SSI
– Diabetes (known and undiagnosed)5.8%
(20/342)
– Without diabetes
1.5%
(10/658)
– Diabetes with HbA1c ≥8%
7.9%
Latham R et al. Infect Control Hosp Epidemiol. 2001;22:607–612.
(10/126)
SSIs and Post-op Glucose Levels
Glucose level
(mg/dL)
Infected patients
(n=72)
Noninfected
patients (n=902)
Odds
ratio
<200
(referrent)
35 (49%)
651 (72%)
1.00
200–249
21 (29%)
154 (17%)
2.54
250–299
11 (15%)
69 (8%)
2.97
≥300
5 (7%)
28 (3%)
3.32
Latham R et al. Infect Control Hosp Epidemiol. 2001;22:607–612. Adapted with permission from
the University of Chicago Press © 2001.
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