Surgical Antibiotic Prophylaxis

1. See Also
   1. SBE Prophylaxis
2. Epidemiology
   1. Surgical-site infection Incidence: 500,000 per year in United States
      1. Extra-abdominal surgery: 2-5%
      2. Intra-abdominal surgery: 20%
3. Efficacy
   1. Antibiotics do not prevent infection in clean surgery
   2. Antibiotic prophylaxis not recommended in:
      1. Nosocomial Infection Surveillance (NNIS) Class 0 to 1
   3. Knight (2001) Am J Surg 182:682-6
4. Prevention: MRSA
   1. Unclear recommendations regarding MRSA
   2. Consider nasal swab screening for MRSA preoperatively
   3. Consider Vancomycin as prophylactic agent if patient at high risk of MRSA
   4. Some protocols use intranasal Bactroban in the preoperative period to decrease MRSA carriage
5. Management: Postoperative Prosthetic Joint
   1. Antibiotic prophylaxis before procedures for 2 years in all patients
   2. Continue lifelong prophylaxis before procedures for high risk patients
6. Management: Extraabdominal Procedures
   1. Cardiothoracic surgery (duration 24-72 hours)
      1. Organisms: Staphylococcus aureus, coagulase-negative staphylococci
      2. No Beta-lactam allergy: Cefazolin or Cefuroxime
      3. Beta-lactam allergy: Vancomyin or Clindamycin
      4. Keep 6 am postoperative Blood Glucose <200 mg/dl
   2. Vascular surgery
      1. Organisms: Staphylococcus aureus, coagulase-negative staphylococci, enteric Gram Negative Bacilli
      2. No Beta-lactam allergy: Cefazolin or Cefuroxime
      3. Beta-lactam allergy: Vancomyin or Clindamycin
   3. Orthopedic: Hip or Knee surgery
      1. Organisms: Staphylococcus aureus, coagulase-negative staphylococci
      2. Antibiotic infused before tourniquet inflated
      3. No Beta-lactam allergy: Cefazolin or Cefuroxime
      4. Beta-lactam allergy: Vancomyin or Clindamycin
      5. Continue for 24 hours post-surgery
         1. Evidence does NOT support antibiotic continuation while surgical drains are in place
         2. Bosco (2010) J Bone Joint Surg Am 92(1): 232-39
7. Management: Abdominal Surgery - Colon
   1. Organisms
      1. BowelAnaerobes (including Bacteroides)
      2. Enteric Gram Negative Bacteria
      3. Enterococcus
   2. Combination protocol (oral with parenteral antibiotics)
      1. Oral (used with parenteral agent below)
         1. Neomycin with Erythromycin base or
         2. Metronidazole
      2. Parenteral: Anti-AnaerobeCephalosporins
         1. Cefotetan (Cefotan) or
         2. Cefoxitin (Mefoxin) or
         3. Cefotaxime (with Metronidazole for appendectomy) or
         4. Ceftriaxone (may become preferred agent)
            1. Woodfield (2002) Am J Surg 185:45-9
   3. Other prevention
      1. Post-op colorectal surgery patients should be normothermic (96.8 F) within 15 minutes of leaving OR
8. Management: Gynecologic Surgery
   1. Organisms
      1. Enteric Gram Negative Bacteria
      2. Anaerobes
      3. Group B Streptococcus
      4. Enterococcus
   2. Ceserean Section
      1. Cefazolin 1 to 2 grams IV for single dose and
      2. Consider coverage for Ureaplasma urealyticum
         1. Azithromycin and
         2. Doxycycline
      3. Administer after clamping Umbilical Cord
      4. References
         1. Andrews (2003) Obstet Gynecol 101:1183-9
   3. Hysterectomy
      1. Cefazolin 1 to 2 grams IV for single dose or
      2. Cefoxitin 2 grams IV for single dose or
      3. Cefotetan 1 to 2 grams IV for single dose or
      4. Metronidazole 500 mg IV for single dose
   4. Hysterosalpingogram with dilated tubes
      1. Doxycycline 100 mg PO bid for 5 days
   5. Induced abortion or Dilation and Curettage
      1. Doxycycline 100 mg PO before procedure, then
      2. Doxycycline 200 mg PO after procedure, then
      3. Metronidazole 500 mg PO bid for 5 days
   6. Procedures not requiring antibiotics
      1. Laparoscopy
      2. Laparotomy
      3. Hysteroscopy
      4. IUD Insertion
      5. Endometrial Biopsy
      6. Urodynamics
9. Dosing
   1. Dose once immediately before procedure (course completed within 24 hours of surgery)
      1. One hour before the procedure for most antibiotics
      2. Two hours before the procedure for Vancomycin or Fluoroquinolones
   2. Second dose indications (completed within 48 hours of of surgery)
      1. Long Surgery (>4 hours)
      2. Large Estimated Blood Loss (>1500 ml)
      3. Cardiothoracic Surgery
10. Precautions
    1. Avoid Third Generation Cephalosporins for prophylaxis
       1. Expensive
       2. Less active against Staphylococcus than Ancef
       3. Promotes emerging resistance
11. References
    1. (2001) Obstet Gynecol 23:1-9
    2. Bratzler (2004) Clin Infect Dis 38:1706-15
    3. Salkind (2011) Am Fam Physician 83(5): 585-90