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What is a disadvantage of using combination antimicrobial therapy?
What is a disadvantage of using combination antimicrobial therapy?
What is the primary purpose of thromboprophylaxis in patients undergoing major surgery?
What is the primary purpose of thromboprophylaxis in patients undergoing major surgery?
Which patient group is at highest risk for developing deep vein thrombosis (DVT)?
Which patient group is at highest risk for developing deep vein thrombosis (DVT)?
Which of the following is a method of mechanical thromboprophylaxis?
Which of the following is a method of mechanical thromboprophylaxis?
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What is the main purpose of using low molecular weight heparin (LMWH) in thromboprophylaxis?
What is the main purpose of using low molecular weight heparin (LMWH) in thromboprophylaxis?
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What percentage of patients will develop DVT if no prophylaxis is provided following major surgery?
What percentage of patients will develop DVT if no prophylaxis is provided following major surgery?
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What is the primary goal of administering prophylactic antibiotics during surgical procedures?
What is the primary goal of administering prophylactic antibiotics during surgical procedures?
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Which organisms are primarily responsible for surgical site infections (SSIs) after clean surgical procedures?
Which organisms are primarily responsible for surgical site infections (SSIs) after clean surgical procedures?
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What is the preferred type of antibiotic for clean surgical procedures?
What is the preferred type of antibiotic for clean surgical procedures?
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Which of the following procedures would most likely require broad-spectrum anaerobic coverage in its prophylactic antibiotic therapy?
Which of the following procedures would most likely require broad-spectrum anaerobic coverage in its prophylactic antibiotic therapy?
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In what situation should vancomycin be considered for prophylactic therapy?
In what situation should vancomycin be considered for prophylactic therapy?
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What types of surgical operations typically justify the use of antimicrobial prophylaxis?
What types of surgical operations typically justify the use of antimicrobial prophylaxis?
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When is the use of antimicrobials for treatment, rather than prophylaxis, appropriate?
When is the use of antimicrobials for treatment, rather than prophylaxis, appropriate?
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Why is parenteral administration of antibiotics favored in surgical prophylaxis?
Why is parenteral administration of antibiotics favored in surgical prophylaxis?
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What is often included in the choice of surgical prophylaxis to combat common skin flora?
What is often included in the choice of surgical prophylaxis to combat common skin flora?
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What is the preferred route of administration for antimicrobial prophylaxis?
What is the preferred route of administration for antimicrobial prophylaxis?
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When should the first dose of antibiotics for surgical prophylaxis ideally be administered?
When should the first dose of antibiotics for surgical prophylaxis ideally be administered?
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What should clinicians do if an operation exceeds two half-lives of the selected antimicrobial?
What should clinicians do if an operation exceeds two half-lives of the selected antimicrobial?
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How long should antimicrobial prophylaxis generally be continued after wound closure?
How long should antimicrobial prophylaxis generally be continued after wound closure?
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Which of the following antibiotics can be infused up to 120 minutes prior to surgery?
Which of the following antibiotics can be infused up to 120 minutes prior to surgery?
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What is the primary goal of antimicrobial dosing for surgical prophylaxis?
What is the primary goal of antimicrobial dosing for surgical prophylaxis?
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What is an exception regarding the timing of administering antimicrobial agents?
What is an exception regarding the timing of administering antimicrobial agents?
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What is a common misconception about the continuation of antibiotics after surgery?
What is a common misconception about the continuation of antibiotics after surgery?
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What should be done if a surgical procedure lasts longer than planned?
What should be done if a surgical procedure lasts longer than planned?
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What is the maximum recommended duration for antimicrobial prophylaxis in cardiac surgery?
What is the maximum recommended duration for antimicrobial prophylaxis in cardiac surgery?
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Study Notes
Surgical Prophylaxis
- Antibiotics are administered before contamination of previously sterile tissues or fluids to prevent infection development.
- Common surgical pathogens after clean procedures include skin flora like S. Aureus and coagulase-negative staphylococci (e.g., Staphylococcus epidermidis).
- Clean-contaminated procedures, such as abdominal, heart, kidney, and liver transplantations, involve gram-negative rods and enterococci alongside skin flora.
- Antimicrobial selection depends on surgical procedure, likely pathogens, antimicrobial safety, efficacy, current evidence, and cost.
- Gram-positive coverage, such as S. aureus and S. epidermidis, is typically included in surgical prophylaxis.
- Parenteral antibiotic administration is preferred due to reliable tissue concentrations.
- First-generation cephalosporins (especially cefazolin) are often the choice for clean surgical procedures.
- Cefoxitin or cefotetan are suitable for broad-spectrum anaerobic and gram-negative coverage.
- Vancomycin may be considered for procedures with high MRSA risk; clindamycin can be used instead of cefazolin if MRSA risk is low and B-lactam hypersensitivity is present.
Types of Surgical Operations
- Surgical operations are classified as clean, clean-contaminated, contaminated, or dirty.
- Clean operations involve uninfected wounds without inflammation.
- Clean-contaminated operations involve entry into the respiratory, alimentary, genital, or urinary tracts under controlled conditions.
- Contaminated operations involve open wounds with breaks in sterile technique.
- Dirty operations are those with existing infection.
Principles of Antimicrobial Prophylaxis
- Intravenous (IV) administration is preferred for antibiotic prophylaxis due to more reliable serum and tissue concentration compared to intramuscular (IM) administration.
- Oral antibiotics, like erythromycin base and neomycin, are sometimes used prior to surgery to reduce bowel microbes but do not replace IV antibiotics.
Timing of First Dose
- Antibiotic administration timing is crucial to maintain therapeutic blood and wound tissue concentrations throughout the operation.
- Antimicrobials should be infused within 60 minutes of the first incision (15-60 minutes before procedure in general)
- Exceptions for antibiotics infused 120 minutes before incision include fluoroquinolones and vancomycin to avoid infusion-related reactions.
Dosing and Redosing
- The aim is to maintain antibiotic concentrations above the minimum inhibitory concentration (MIC) of suspected organisms throughout the operation.
- If the operation exceeds the antimicrobial's half-life, another dose should be administered to sustain the necessary therapeutic concentration.
Duration
- Continuing antimicrobial prophylaxis beyond wound closure is unnecessary, usually not exceeding 24 hours (48 hours for cardiac procedures)
- Early discontinuation of antibiotics is preferred rather than prolonged administration.
- Prolonged prophylaxis can promote resistant micro-organisms and is unnecessarily expensive.
Combination Antimicrobial Therapy
- Combining antimicrobials broader the spectrum, achieve synergistic activity against pathogens, prevent resistance development.
- Multiple organisms (e.g., intraabdominal or female pelvic infections, nosocomial infections) necessitate a broader spectrum of antimicrobial coverage.
- Including increased cost, risk of drug toxicity, and superinfection are downsides of combination regimens.
Likely Pathogens and Specific Recommendations
- Common pathogens are listed for various surgical operations.
- Appropriate regimens are given for different procedures with high-risk patients noted.
Thromboprophylaxis
- Deep vein thrombosis (DVT) is a common concern in patients undergoing major surgery, especially those over 40 years old.
- Postoperative platelet increase, venous endothelial trauma, and stasis contribute to DVT risk.
- Mechanical devices (e.g., thromboembolic deterrent stockings) and drugs affecting the clotting cascade (e.g., heparin and low-molecular-weight heparin) are used for thromboprophylaxis.
Regimen
- Risk factors for DVT are evaluated in surgical patients.
- Heparin or low-molecular-weight heparin (LMWH) are common preventive measures for DVT.
- Factor Xa inhibitors like fondaparinux are an alternative.
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Description
This quiz covers the essential principles of surgical prophylaxis including the rationale for antibiotic use prior to surgery, common pathogens involved in infections, and the selection of appropriate antimicrobial agents. It specifically focuses on antibiotics like cephalosporins and considerations for different surgical scenarios.
