Surgical Prophylaxis and Antimicrobial Selection

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Questions and Answers

Antibiotics administered before contamination of previously sterile tissues are considered prophylactic.

True (A)

S.aureus and coagulase-negative staphylococci are known as common surgical pathogens after clean procedures.

True (A)

Vancomycin is the preferred choice of prophylactic antibiotic for all types of surgical procedures.

False (B)

Antimicrobial prophylaxis is appropriate for dirty surgical operations.

<p>False (B)</p> Signup and view all the answers

The choice of prophylactic antimicrobial depends solely on the cost of the medication.

<p>False (B)</p> Signup and view all the answers

First-generation cephalosporins are preferred for clean surgical procedures.

<p>True (A)</p> Signup and view all the answers

Prolonged antibiotic prophylaxis can encourage the proliferation of resistant micro-organisms.

<p>True (A)</p> Signup and view all the answers

Gö-β-lactam hypersensitivity can lead to the use of clindamycin instead of cefazolin.

<p>True (A)</p> Signup and view all the answers

Deep venous thrombosis (DVT) is most common in patients under 40 years of age who undergo major surgery.

<p>False (B)</p> Signup and view all the answers

Gram-positive coverage is not typically included in surgical prophylaxis choices.

<p>False (B)</p> Signup and view all the answers

Combination antimicrobial therapy is mainly used to narrow the spectrum of coverage.

<p>False (B)</p> Signup and view all the answers

Clean-contaminated procedures primarily involve gram-negative rods and enterococci along with skin flora.

<p>True (A)</p> Signup and view all the answers

Mechanical devices such as Thromboembolic deterrent stockings (TEDS) are one type of thromboprophylaxis.

<p>True (A)</p> Signup and view all the answers

Fondaparinux increases the risk of bleeding compared to low molecular weight heparin (LMWH).

<p>False (B)</p> Signup and view all the answers

The risk of developing DVT is assessed for all patients upon admission to the hospital.

<p>True (A)</p> Signup and view all the answers

Intravenous administration of antimicrobials is preferred over intramuscular administration for its reliability.

<p>True (A)</p> Signup and view all the answers

Oral administration of non-absorbable compounds is sufficient on its own and can replace intravenous agents.

<p>False (B)</p> Signup and view all the answers

The first dose of antimicrobial for surgical prophylaxis should be given 60-120 minutes before the first incision.

<p>False (B)</p> Signup and view all the answers

Exceptions to the timing rule for antimicrobial infusion include fluoroquinolones and vancomycin, which can be infused 120 minutes prior.

<p>True (A)</p> Signup and view all the answers

Repeat dosing during an operation is unnecessary if it exceeds two half-lives of the selected antimicrobial.

<p>False (B)</p> Signup and view all the answers

Cefazolin has a half-life of about 4 hours, thus requiring a repeat dose if the operation exceeds 4 hours.

<p>False (B)</p> Signup and view all the answers

The continuation of antimicrobial prophylaxis beyond wound closure is generally necessary.

<p>False (B)</p> Signup and view all the answers

Antimicrobial prophylaxis should not exceed 24 hours, except for cardiac surgery where it can be extended to 48 hours.

<p>True (A)</p> Signup and view all the answers

Continuing antibiotics until all drains are removed effectively reduces the infection rate.

<p>False (B)</p> Signup and view all the answers

The goal of antimicrobial dosing is to maintain antibiotic concentrations below the MIC of suspected organisms during surgery.

<p>False (B)</p> Signup and view all the answers

Flashcards

Surgical Prophylaxis

Administration of antibiotics before a surgical procedure to prevent infection.

Common Surgical Pathogens (clean procedures)

Skin bacteria, such as Staphylococcus aureus and coagulase-negative staphylococci (like Staphylococcus epidermidis).

Common Surgical Pathogens (clean-contaminated)

Gram-negative bacteria (rods) and enterococci, along with skin bacteria.

Antimicrobial Selection Factors

Factors influencing choice of antibiotic, such as procedure type, likely pathogens, antibiotic safety/effectiveness, evidence, and cost.

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Gram-positive coverage

Antibiotics that target gram-positive bacteria are usually included because of common skin bacteria.

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Parenteral Antibiotics

Antibiotics given by injection (e.g., IV) to reliably reach infection sites.

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First-generation Cephalosporins (e.g., Cefazolin)

Preferred choice for clean surgical procedures due to good effectiveness and safety.

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Surgical Operation Types

Surgical procedures categorized as clean, clean-contaminated, contaminated, or dirty, influencing antibiotic use.

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Antibiotics for dirty operations

Used for treating existing infections, not for prevention.

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Antibiotic Prophylaxis Duration

Prolonged use of antibiotics to prevent infection.

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Combination Antimicrobial Therapy

Using multiple antibiotics together to treat infections.

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Deep Vein Thrombosis (DVT)

Blood clot in a deep vein, usually in the legs.

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Thromboprophylaxis

Measures to prevent blood clots in patients at risk.

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Mechanical Thromboprophylaxis

Using devices to prevent blood clots, such as compression stockings.

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Risk Factors for DVT

Factors that increase the likelihood of developing a deep vein thrombosis.

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IV Administration for Prophylaxis

Intravenous administration of antibiotics is preferred for surgical prophylaxis due to more reliable and predictable blood and tissue concentrations.

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Oral Antibiotic use

Oral antibiotics may be used as an adjunct to intravenous antibiotics in some surgical procedures, such as bowel surgeries. Non-absorbable oral antibiotics can decrease bowel bacteria.

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Timing of First Antibiotic Dose

Antibiotics are ideally given within 60 minutes of the first incision to maintain therapeutic concentration in blood and tissues during surgery.

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Antibiotic Infusion Timing Exceptions

Infusion of fluoroquinolones and vancomycin can begin 120 minutes prior to incision to avoid infusion-related side effects.

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Antibiotic Dosing Goal

Antibiotic doses need to maintain blood concentrations above the minimum inhibitory concentration (MIC) of bacteria throughout the surgery.

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Repeat Dosing

If a surgical procedure exceeds the antibiotic's half-life period, additional doses will help maintain the desired effect

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Cefazolin, Half-Life and Redosing

Cefazolin's half-life is about 2 hours, necessitating repeat doses if the surgery exceeds 4 hours.

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Antibiotic Duration

Continuing antibiotics after wound closure generally isn't needed, except for cardiac surgery (up to 48 hours).

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Unnecessary Antibiotic Duration

Administering antibiotics until all drains are removed isn't supported by evidence and doesn't improve outcomes

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Surgical Site Infections (SSIs) Prevention

Surgical site infections prevention focuses on delivering the correct antibiotic dose at the right time via proper routes for the duration of the procedure to prevent infections.

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Study Notes

Surgical Prophylaxis

  • Antibiotics administered before contamination of sterile tissues or fluids are considered prophylactic, aiming to prevent infection.
  • Skin flora (including S. Aureus and coagulase-negative staphylococci, e.g., Staphylococcus epidermidis) are predominant organisms causing Surgical Site Infections (SSIs) after clean procedures.
  • In clean-contaminated procedures (e.g., abdominal, heart, kidney, and liver transplantations), gram-negative rods and enterococci, alongside skin flora, are the primary organisms.

Antimicrobial Selection

  • Prophylactic antimicrobial choice depends on surgical procedure, pathogen likelihood, antimicrobial safety, efficacy, current evidence, and cost.
  • Gram-positive coverage (e.g., S. aureus, S. epidermidis) is usually included in surgical prophylaxis.
  • Parenteral antibiotic administration is preferred for reliable tissue concentration.
  • First-generation cephalosporins (e.g., cefazolin) are the preferred choice for clean procedures.
  • Broad-spectrum coverage (e.g., cefoxitin, or cefotetan) may be needed for anaerobic or gram-negative coverage cases.
  • Vancomycin can be considered if methicillin-resistant S. aureus (MRSA) risk is high.
  • Clindamycin can be an alternative to cefazolin for certain cases.

Types of Surgical Operations

  • Surgical operations are classified as clean, clean-contaminated, contaminated, or dirty.

  • Antimicrobial prophylaxis is suitable for clean, clean-contaminated, and contaminated procedures.

  • Non-prophylactic antibiotics are used for treatment in operations with existing infections.

  • Table 1 (in the provided text) outlines classification, surgical site infection risk, and antibiotic indication.

  • Clean: Uninfected wounds with no inflammation in closed procedures

  • Clean-Contaminated: Wounds involving organs (e.g., biliary tract) under controlled conditions

  • Contaminated: Open wounds or wounds with gross spillage from the gastrointestinal tract

  • Dirty: Wounds with obvious preexisting infection (e.g., abscess, pus)

Principles of Antimicrobial Prophylaxis

  • Intravenous (IV) administration is preferred for reliable serum/tissue concentration over intramuscular.
  • Oral antibiotics can be used adjunctively in some cases (e.g., bowel operations) to reduce microbial counts in the bowel.
  • Oral agents are not typically a replacement for IV agents.

Timing of First Dose

  • A single dose of antimicrobial is ideal 30 minutes to 1 hour before incision, providing sustained levels in the blood and wound.
  • For fluoroquinolones and vancomycin, administration may occur up to 2 hours before incision to avoid complications.

Dosing and Redosing

  • Maintaining antibiotic concentrations above the minimum inhibitory concentration (MIC) is crucial for the duration of the surgery.
  • Redosing is required when the duration of surgery exceeds the drug's half-life to maintain needed antimicrobial concentrations.
  • Clinicians should have necessary extra doses for longer-than-expected surgeries.

Duration

  • Antimicrobial prophylaxis beyond wound closure or 24 hrs (48 hrs for cardiac surgery) is generally unnecessary.
  • Preventing the unnecessary use of antibiotics beyond needed time frames is promoted.

Combination Antimicrobial Therapy

  • Using combinations of antimicrobials broadens the spectrum of coverage to tackle mixed infections, optimize effectiveness, and prevent resistant organisms.
  • Effective in cases of various infections (intra-abdominal, female pelvic).
  • Increased spectrum of activity is beneficial for nosocomial infections.

Thromboprophylaxis

  • Deep vein thrombosis (DVT) is frequent in major surgery, particularly in patients older than 40.
  • Postoperative increases in platelets, and venous trauma contribute to DVT risk.
  • Thromboprophylaxis (prevention of DVT) is given to reduce the occurrence of DVT and associated risks.
  • Mechanical devices (e.g., thromboembolic deterrent stockings) and drugs (e.g., heparin, LMWH) are used for prophylaxis.

Regimen

  • National guidelines exist for VTE prophylaxis, which involve assessing risk factors and using anticoagulants (e.g., heparin, enoxaparin, fondaparinux) preoperatively and during the initial stages of the postoperative phase.

  • Various factors like surgery type and the patient's medical history are considered to manage the risk of VTE.

Table 2

  • The table provides likely pathogens and recommended prophylaxis regimens for common surgical procedures (e.g., gastroduodenal, biliary tract procedures) in the table. High-risk patients, specific to each procedure, are highlighted in the comments section.

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