5 - Surgery Prophylaxis Flashcards
Surgical site infection (SSI):
-Superficial or deep incisional or organ/space infection within _____ days of surgery or within ____ year if placement of prosthetic implant
30 days
1 year
SSI’s occur in ___% of surgeries
2
SSI’s account for __% of hospital-acquired infections
15
Significance of SSI’s?
- increases hospital stay 7-10 days, readmissions 5x, mortality 2-3x
- significant healthcare resources and cost
What are some patient-related risk factors for SSI’s?
- advanced age, obesity, malnutrition
- hypoxia associated with smoking or COPD
- diabetes, perioperative hyperglycemia
- immunocompromised
- co-exisitng infection
- colonization with resistant organism (ex. MRSA)
What are some surgery related risk factors for SSI’s?
- operating room sterilization and ventilation
- skin preparation
- surgical equipment, personnel and technique
- surgical wound classification
- placement of foreign material ex. prosthetic implant, drain
- thermoregulation, glucose control, O2 supplementation
- duration of surgery
What is the most common pathogens in SSI’s?
- S. aureus (20-30%)
- Streptococcus (15-20%)
- CoNS, most commonly S. epidermis (15%)
- E. coli, Klebsiella, P. aeruginosa, Enterobacter (<10% each)
Goals of antimicrobial prophylaxis for surgery ?
- reduce bacterial burden at incision site
- prevent SSIs and associated morbidity, mortality & costs
- minimize collateral resistance (ex. MRSA, ESBL, VRE)
- avoid adverse effects including C. difficile
What % of SSI’s are preventable ?
50%
What are the optimal characteristics of an agents used as AP for surgery?
- spectrum and bactericidal to cover most likely pathogens, but sufficiently narrow to minimize collateral resistance
- pharmacokinetics to provide adequate tissue concentrations for duration of surgery from incision to closure
- safety profile
- low cost
List the key decisions in providing optimal AP for surgery
1) selecting an appropriate antimicrobial
2) selecting an appropriate dose (remember we are dosing to prevent an infection, not dosing to treat an infection)
3) optimizing timing of the preoperative dose, and re-dosing during surgery as required
4) using AP for the shortest effective duration
Describe when we should give surgery prophylaxis ?
- the antibiotic should be given 1 hour before surgery
- the best way of giving it is to do it with the anesthesia
- if the antibiotic has a short half life or the surgery is really long, we may need to give another dose during surgery
Is continuing AP (antimicrobial prophylaxis) warranted?
no - usually unnecessary
AP for Head and Neck prophylaxis for clean with prosthesis placement
Cefazolin
AP for Head and Neck prophylaxis for clean-contaminated with mucosal incision (ex. cancer-related, radical dissection, trauma, reconstruction)
Cefazolin + Metro x < 24 hours
We add metro to cover anaerobes
AP for thoracic surgery
Cefazolin
AP for open heart surgery (CABG or valve replacement)
Cefazolin x < 24-48 hours
AP for cardiac device insertion (ex. pacemaker)
Cefazolin
AP for small intestine surgery (non-obstructed)
Cefazolin
AP for small intestine surgery (obstructed)
Cefazolin + Metro
AP for large intestine surgery
Cefazolin + Metro
(Avoid Cefoxitin - short half life, poor aerobic-anaerobic coverage
AP for biliary tract surgery (open)
Cefazolin
AP for biliary tract surgery
high risk laparoscopic
Cefazolin
What would make a laparoscopic biliary tract surgery high risk ?
- emergency
- acute cholecystitis
- prior biliary surgery < 1 month
- stones
- obstruction
- prosthesis
- over 70 yo
- DM
- pregnancy
- IS
