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
2
Q
SSI Contributing Factor Categories
A
- Procedural factors
- Microbial factors
- Antimicrobial prophylaxis factors
- Patient Factors
3
Q
Procedural Factors
A
- Type of surgery
- Length of procedure
- Break in sterile technique
- Preoperative shaving
- Perioperative shaving
- Foreign materials
4
Q
Microbial Factors
A
- Inoculum size
- Tissue adherence
- Virulence Factors
- Resistance
5
Q
Antimicrobial Prophylaxis Factors
A
- Drug
- Dose
- Delivery time
- Duration
- Appropriate coverage
6
Q
Patient Factors
A
- Age
- Immunosuppression
- Endogenous flora
- Nutritional status and BMI
- Presence of diabetes
- Smoking status
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
8
Q
Major pathogens
A
- S. aureus
- Enterobacteriacea
- Coag-neg. Staph
- Strept. spp.
- Other/no organism isolated
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
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
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
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
13
Q
NRC: Dirty
A
- Rate of infection: >30%
- Existing infection OR perforated viscera
- Surgical prophylaxis if antibiotics aren’t broad enough for prophylaxis
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
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)
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
