- cardio-thoracic cavity - vascular - orthopedic - neurosurgery

- bullet wound - surgical mishap - GI spillage trauma <4h before

- nausea - abdominal distention - profuse watery diarrhea - possible bloody streaks

Surgical prophylaxis and C.diff therapeutics Flashcards by Tim Pulleyn

patients at high risk for surgical infection

obese
extremes of age
smoking history
malnutrition
underlying illness
bacterial colonization
immunosuppressive therapy

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primary prophylaxis agent

cefazolin

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drug to use for prophylaxis if PCN allergy is present in pts at risk of GPC or MRSA

vancomycin

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general prophylaxis treatment strategy

start Abx w/in 1 hr of incision
if surgery is > 2 half lives then redose
no more than 24 hr prophylaxis
CDI risks

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clean surgeries

cardio-thoracic cavity
vascular
orthopedic
neurosurgery

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drugs to use in clean prophylaxis

cefazolin 1-2g IV q8h
cefuroxime 1.5 IV q12h for CABG
vancomycin 15 mg/kg IV q12h

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clean-contaminated surgeries

head/neck
gastroduodenal
colorectal
appendectomy
biliary
high risk genitourinary
OB/GYN

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anaerobes in which clean-contaminated

head/neck
appendectomy
OB/GYN

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drugs for clean-contaminated prophylaxis

cefazolin (anaerobes in upper airway and GNB)

- cefoxitin (anaerobes in GI)

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contaminated wounds

bullet wound
surgical mishap
GI spillage
trauma <4h before*

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signs of a dirty wound

purulence
abscess
tissue perforation
trauma >4h before*

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empiric treatment for contaminated wound

Vanco +

Zosyn
cefotasime + metronidazole
ertapenem
imipenem
cipro +metronidazole
levo+metronidazole

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complications of C.diff

pseudomembranous colitis
toxic megacolon (friable colon)
sepsis
death

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risks for C.difficile

antibiotic use in past month

- contamination on health care workers hands

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antibiotic that causes the most C.diff

clindamycin

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strain name of C.diff

NAP

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C.diff is resistant to what abx

fluoroquinolones

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symptoms of C.diff

nausea
abdominal distention
profuse watery diarrhea
possible bloody streaks

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lab signs of C.diff

WBC > 15,000

- fever > 100 F

initial treatment for mild-moderate CDI

metronidazole 500 mg PO TID x 10-14

<15,000 WBC and stable SCr

initial treatment episode of severe CDI

vanco 125 mg PO QID x 10-14

>15,000 WBC and 50% increase in SCr

initial treatment episode for severe CDI with toxic megacolon

-vanco 500 mg PO QID
+ vanco retention enema 500 mg in 100 mL NS PR q6h
+/- metronidazole 500 mg IV q6h

treatment for 2nd episode of C.diff

initial regimen x 14
for severe symptoms PO vanco
may still use metronidazole

treatment of 3rd episode of C.diff

vanco 125 PO QID x 10-14d
vanco taper over 6 weeks
NO METRONIDAZOLE

vancomycin taper

- all doses 125 mg - 1st week QID - 2nd week BID - 3rd week q24h - 4th week every other day - 5th-6th week q72h

options when vancomycin is ineffective

- rifaximin - fidaxomicin - fecal transplant

avoid drugs that do what when treating C.diff

inhibit peristalsis

role of probiotics in preventing CDI

unclear, need larger trials

normal mouth flora

- anaerobic strep (peptococcus) | - strep

normal stomach flora

- oral flora - strep - lactobacillus

normal small intestine duodenum, jejunum flora

- lacatobacillus - strep - enterobacteriaceae (E.coli, klebsiella, enterbacter)

normal Ileum flora

- enterobacteriaceae | - anaerobes (bacteroides)

normal large intestine flora

- lactobacilli - strep - enterococcus

why does fidaxomicin work well for C.diff

it has minimal systemic absorption so it stays in gut

most common bacteria in biliary tract

enterobacteriaceae

monotherapy treatment options for mild-mod abdominal infections outside biliary tract

- cefoxitin 2g IV q6h - ertapenem 1g IV q24h - moxifloxacin 400 mg IV q24h - tigecycline 100 mg IV load then 50 mg q12h - ticarcillin/clavulanate 3.1 g q6h

combos to use in mild-moderate intraabdominal infection

metronidazole 500 mg q8h + - cefazolin 1-2g q8h - cefuroxime 1.5g q12h - ceftriaxone 1-2g q12-24h - levofloxacin 750mg q24h - ciprofloxacin 400 mg q12h

examples of higher severity intraabdominal infection

- severely ill - advanced age - immunocompromised pts.

monotherapies for severe intraabdominal infection

- imipenem-cilastatin 500 mg q6h - meropenem 1g q8h - piperacillin/tazobactam 3.375g q6h

combination therapies for severe intraabdominal infections

metronidazole + - cefepime - ceftazidime - ciprofloxacin - levofloxacin

treatment for biliary infections

normal severe intraabdominal infection drugs PLUS vancomycin

use of metronidazole and carbapenems

probably don't do it since carbapenems do have anaerobic activity

duration of therapy for intraabdominal infection

4-7 days unless it can't be controlled

duration of therapy for intraabdominal infection if bacteremia is present

14 days

how long to treat following cholecystectomy

24 hours unless infection is beyond gallbladder wall

oral options for oral antibiotics in intraabdominal infections when no resistance noted

- moxi - cipro + metro - levo + metro - cephalosporin + metro - augmentin

resistance of bacteroides

- cefoxitin 5-30% - cefotetan 17-87% - clindamycin 19-35%