Surgical Prophylaxis

Question 1

what is the superficial incisional SSI?

Answer 1

skin and subcutaneous tissue

Question 2

what is the deep incisional SSI?

Answer 2

skin, subcutaneous tissue, and deep soft tissue (muscle)

Question 3

what is the organ/space SSI?

Answer 3

skin subq tissue, deep soft tissue, and organ space

Question 4

what is the DOC for most procedures?

Answer 4

Cefazolin 2 g IV, OR 3 g for patients >/= 120 kg

Question 5

when should vanc be used for procedures?

Answer 5

it shouldn’t unless MRSA is at high risk or present. Then use 15 mg/kg IV over 2 hours

Question 6

what alternatives can be used for surgical prophylaxis?

Answer 6

ciprofloxacin over 2 hours
clindamycin over 1 hour
gentamicin over 1 hour
metronidazole over 1 hour

Question 7

why would alternative prophylactic agents be used?

Answer 7

patients have life-threatening allergies to first line agents. alternative agents should only be used for patients with an immunologic reaction to a cephalosporin (anaphylaxis)

Question 8

most common pathogens in MOST procedures?

Answer 8

staph aureus and coagulase-negative staph, and skin flora

Question 9

most common pathogens in upper GI procedures?

Answer 9

gram negative rods and enterococci and skin flora

Question 10

most common pathogens in lower GI (colorectal, hysterectomy)?

Answer 10

staph and gram negative rods and enterococci and skin flora, and add anaerobic coverage

Question 11

most common pathogens ALL TOGETHER?

Answer 11

staph aureus including MRSA, and increased E coli resistance to FQs

Question 12

when is the best time (best odds) to give antimicrobial prophylaxis for surgery?

Answer 12

preoperative; 0-2 hours before the incision

Question 13

when is the second best time (second best odds) to give antimicrobial prophylaxis for surgery?

Answer 13

perioperative; within 3 hours after the incision

Question 14

when should you use repeated dosing?

Answer 14

for procedures that exceed two half-lives of the drug, AND for procedures in which there is excessive blood loss (>1500 mg)

Question 15

what drugs should be redosed?

Answer 15

cefazolin (every 4 hours after preoperative dose)

clindamycin (every 6 hours after preoperative dose)

Question 16

what guidelines state that duration of prophylaxis for ALL procedures should be less than 24 hours?

Answer 16

ASHP/IDSA 2013

Question 17

what guidelines state that antibiotics should be discontinued at the end of incision closure, which is usually 1 dose?

Answer 17

ACS 2016

Question 18

what guidelines state that the panel recommends against prolongation of surgical antimicrobial prophylaxis after the completion of operation?

Answer 18

WHO 2016

Question 19

what guidelines state that antimicrobial prophylaxis after surgical closure (clean and clean contaminated procedures) is unnecessary?

Answer 19

HICPAC-CDC 2017

Question 20

continuation of antimicrobial therapy > 24 hours has been associated with what?

Answer 20

increased risk of C diff and acute kidney injury

Question 21

how should antibiotics be given for bowel prep?

Answer 21

three doses over 10 hours the afternoon and evening before the operation and after mechanical bowel prep

Question 22

preparation for elective surgeries looks like this:

Answer 22

isosmotic mechanical bowel prep (PEG day before surgery) from 9 AM to noon, THEN

oral antibiotic prep (completed day before surgery) of neomycin + erythromycin OR neomycin + metronidazole orally at times 1 pm, 2 pm, 11 pm

Question 23

preferred therapy for cardiothoracic surgery

Answer 23

cefazolin

Question 24

preferred therapy for GI surgery

Answer 24

cefazolin; add metronidazole to lower GI for anaerobes

Question 25

preferred therapy for gynecologic and obstetric surgery

Answer 25

cefazolin; add metronidazole for hysterectomy

Question 26

preferred therapy for head and neck surgery

Answer 26

cefazolin; add metronidazole for clean-contaminated procedures

Question 27

preferred therapy for orthopedics

Answer 27

cefazolin

Question 28

preferred therapy for urological surgery

Answer 28

cefazolin; except transrectal prostate biopsy (use ceftriaxone + cipro) and cystourethroscopy (use bactrim)

Question 29

preferred therapy for other procedures

Answer 29

cefazolin

Question 30

how can the community pharmacist have a role in prevention of surgical site infections?

Answer 30

smoking cessation (stop 4-6 weeks) use nicotine patches, MRSA screening and decolonization, bowel prep

Question 31

how can the hospital pharmacist have a role in prevention ofo surgical site infections?

Answer 31

selection, penicillin allergy assessment, dose, timing, intraoperative redosing, duration; GLUCOSE CONTROL (<200)