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835 > Surgical Prophylaxis > Flashcards

Surgical Prophylaxis Flashcards

1
Q

SSI

A
  • Surgical site infections
  • 2-5% of procedures are complicated by SSI
  • Complex, multifactorial
  • Increase risk of death, costs, and LOS
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2
Q

SSI Contributing Factor Categories

A
  • Procedural factors
  • Microbial factors
  • Antimicrobial prophylaxis factors
  • Patient Factors
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3
Q

Procedural Factors

A
  • Type of surgery
  • Length of procedure
  • Break in sterile technique
  • Preoperative shaving
  • Perioperative shaving
  • Foreign materials
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4
Q

Microbial Factors

A
  • Inoculum size
  • Tissue adherence
  • Virulence Factors
  • Resistance
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5
Q

Antimicrobial Prophylaxis Factors

A
  • Drug
  • Dose
  • Delivery time
  • Duration
  • Appropriate coverage
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6
Q

Patient Factors

A
  • Age
  • Immunosuppression
  • Endogenous flora
  • Nutritional status and BMI
  • Presence of diabetes
  • Smoking status
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7
Q

Sources of Infection

A
  • Operating room environment: surgical instruments, material, clothing
  • Patients endogenous flora: skin, mucous membranes, GI tract
  • Hematogenous seeding from preexisting infection
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8
Q

Major pathogens

A
  • S. aureus
  • Enterobacteriacea
  • Coag-neg. Staph
  • Strept. spp.
  • Other/no organism isolated
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9
Q

Assessment of Risk

A
  • Done through NRC Wound classification
  • Dependent on: microbiology, surgical site, contamination liklihood, presence of preexisting infection, events during/after surgery
  • Risk index developed
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10
Q

NRC: Clean

A
  • Uninfected wound (no inflammation)
  • Infection rate: <5%
  • Primary wound closure with no break in technique AND no involvement of GI, biliary, oropharyngeal, tracheobronchial, or GU tracts
  • Surgical prophylaxis in high morbidity/mortality cases
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11
Q

NRC: Clean-contaminated

A
  • Uninfected wound (no inflammation)
  • Infection Rate: 5-10%
  • Minor break in technique OR GI, biliary, oropharyngeal, tracheobronchial, or GU tracts are transected under controlled conditions
  • Surgical prophylaxis
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12
Q

NRC: Contaminated

A
  • Uninfected wound (no inflammation)
  • Rate of infection: 15-30%
  • Infection discovered OR open traumatic wound OR break in aseptic technique
  • Surgical prophylaxis
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13
Q

NRC: Dirty

A
  • Rate of infection: >30%
  • Existing infection OR perforated viscera
  • Surgical prophylaxis if antibiotics aren’t broad enough for prophylaxis
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14
Q

Antimicrobial Prophylaxis

A
  • Adjunctive preventive measure to aseptic technique
  • Administered before contaminated to prevent SSI from developing (usually only one dose)
  • Associated with 5x decrease in SSI rates
  • Use in high-risk procedures or in increased morbidity/mortality cases
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15
Q

Antimicrobial Choice

A
  • Based on procedure/frequent pathogens, allergy and patient factors, local resistance patterns, cost
  • Cephalosporins: commonly used due to spectrum, safety, and cost
  • IV prefered due to rapid acting, reliable, predictable
  • Extended infusion necessary for certain antibiotics (vanco, cipro)
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16
Q

Cephalosporin SE

A
  • Rash
  • Pruritis
  • Rare anaphylaxis
  • C. diff colitis
17
Q

Clean Procedure Prophylaxis

A
  • Recc: Cefazolin 2g

- Alt: Cefuroxime 1.5g

18
Q

Clean-Contaminated Prophylaxis

A

-Recc: Cefotetan 2g OR Cefoxitin 2g
-Alt: Cefazolin 2g + Metronidazole 500 mg
OR
-Cefuroxime 1.5g + Metronidazole 500 mg
-Added coverage for anaerobes

19
Q

Cefazolin Dosing

A
  • Obesity is risk factor for SSI
  • Need to adjust for BW
  • <80 kg: 1g
  • 80-120 kg: 2g
  • > 120 kg: 3g
20
Q

Prophylaxis + Beta Lactam Allergies

A
  • Clean procedures: Vanco 15 mg/kg OR Clinda 900 mg

- Clean-contaminated: Clinda + Aminoglycoside/aztreonam2g/FQ

21
Q

AMG/FQ

A
  • AMG: Genta 5mg/kg OR Tobra 5mg/kg

- FQ: Cipro 400 mg OR Levo 500 mg

22
Q

Administration Timing

A
  • Give 0-60 minutes before incision for most abx

- 60-120 minutes beforehand if extended infusion times are required (FQ, vancos)

23
Q

Prophylaxis Duration

A
  • Typically just one dose
  • Long procedures may need additional administration
  • Recommend <24 hours
  • Lack of evidence for longer duration in cardiothoracic surgery
24
Q

Readministration Times

A
  • From initial dosing
  • Varies by abx
  • Cefazolin/Cefuroxime: q4h
  • Cefoxitin: q2h
  • Cefotetan: q6h
  • Clinda: q6h
  • All others NA
25
Q

Continuous Infusion

A
  • Limited data
  • Dosen’t have better outcomes when compared to intermittent
  • Benefit may be decreased readministration error for cephs
26
Q

Vanco Use

A
  • Routine use isn’t recommended for any procedure
  • Lack of proven efficacy
  • Narrow spectrum, poor tissue perforation, long infusion times, SE, concern for resistance
27
Q

Vanco Restrictions

A
  • Appropriate use: MRSA documentations, life-threatening Beta-lactam allergy, surgeries involving foreign material placement
  • Use with B-lactams whenever possibly over solely
  • Screen in high-risk patients and procedures
28
Q

Cardiac Procedures

A
  • Clean
  • Routine implementation of prosthetics increases risk
  • Pathogens: Skin flora (S. aureus, CoNS)
  • Recc Prophylaxis: Cefazolin 2g x 1 (up to 24-48 hours)
  • Vanco additionally can be considered in high-risk MRSA
  • Mupirocin in MRSA nasal carriers
  • Routine use of topical abx not established
29
Q

Neurosurgery

A
  • Clean procedures
  • Low SSI but high mortality
  • Pathogens: Skin flora (S. aureus, CoNS)
  • Recc Prophylaxis: Cefazolin 2g x 1
  • Routine topical abx use isn’t established
30
Q

Orthopedic Procedures

A
  • Clean procedures
  • Prophylaxis ONLY in spinal and knee/hypreplacement/fracture procedures
  • Pathogens: Skin flora, Gram “-“ bacilli, beta-hemolytic strept
  • Recc Prophylaxis: Cefazolin 2g x1
31
Q

Gastroduodenal Procedures

A
  • Recommended for high risk cases like obstruction, perforation, malignancy, avid suppression therapy
  • Pathogens: Gram ‘-“ and “+”, less frequently anaerobes
  • Recc prophylaxis: Cefazolin 2g x 1
32
Q

Colorectal/Uncomplicated Appendectomy Procedures

A
  • Clean-contaminated or contaminated
  • Pathogens: Enteric Gram “-“ and anaerobes
  • Prophylaxis divided by oral and IV
  • IV Prophylaxis: Cefotetan 2g x1 OR Cefoxitin 2g x1
33
Q

Colorectal/Appendectomy Oral Prophylaxis

A
  • Added for ELECTIVE colorectal surgery
  • NEomycin 1g + Erythromycin 1g at 1 PM, 2PM, and 11PM preop day
  • NOT for bowel obstruction, colostomy reversal, or rectal resection
  • Mechanical bowel prep should be given BEFORE oral abx
34
Q

C-section Procedures

A
  • Clean or clean-contaminated
  • Endometritis is most common and usually polymicrobial
  • Prophylaxis BEFORE initial incision
  • Pathogens: Strept, entero, enteric Gram “-“, peptostrept
  • Recc Prophylaxis: Cefazolin 2g x1
35
Q

Urologic Procedures

A
  • Clean or clean-contaminated
  • Pathogen: E. Coli
  • Therapeutic antibiotics warranted if peroperative UA and use prophylaxis in high-risk circumstances
  • Recc prophylaxis: Cefazolin 2g IV x1 (add AMG if clean-contaminated)
36
Q

Urologic High-Risk Circumstances

A
  • Positive UA but no therapeutic abx
  • High-risk procedures: prostatectomy, tumor resection, transrectal prostate biopsy
  • Prolonged indwelling catheter
  • Urinary stone/obstruction
  • Anatomic abnormalities
  • Neutropenia

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