Antimicrobial Prophylaxis in Surgery Fall 2024-2025 PDF

Antimicrobial Prophylaxis in Surgery Dr Nisreen Mourad Dr Fouad Sakr Dr Fadi Hdeab School of Pharmacy LIU  Objectives  Impact of surgical site infections (SSI)  Different types of wound classificati...

Antimicrobial Prophylaxis in Surgery Dr Nisreen Mourad Dr Fouad Sakr Dr Fadi Hdeab School of Pharmacy LIU  Objectives  Impact of surgical site infections (SSI)  Different types of wound classifications  Risk factors for postoperative surgical site infections  Likely pathogens associated with different surgical operations  Antimicrobial prophylaxis  Importance of timing, duration, and re-dosing Recommend appropriate prophylactic antimicrobial(s) given a surgical operation PHAR615 Fall 2024-2025  Introduction  Clinical use of antibiotics: o Prophylactic therapy: given to patients before contamination or infection has occurred o Anticipatory therapy: includes situations where contamination has already occurred and therapy is aimed at minimizing post-op infection o Empiric therapy: non-directed therapy in absence of pathogen identification o Directed therapy: pathogen identified PHAR615 Fall 2024-2025  Surgical site infection(SSI): o Defined as infection related to incision occurring within 30 days of operative procedure or within 90 days if prosthetic material implanted o Occurs when a pathogenic organism multiplies in a surgical wound o Can lead to local and some times systemic signs and symptoms o Associated with: ✓ Increase morbidity ✓ Extended duration of hospitalization PHAR615 Fall 2024-2025  By definition: o SSI must occur within 30 days of surgery o If a prosthetic implant is involved, a deep incisional or organ/space SSI can be reported up to 1 year from the date of surgery o Prophylactic antibiotics: Purpose is to reduce the prevalence of postoperative wound infection at or around the surgical site  Antibiotic prophylaxis is the pre-operative and/or intra- operative administration of antibiotics to patients to reduce the risk of postoperative infection PHAR615 Fall 2024-2025 PHAR615 Fall 2024-2025  Pathogenesis of SSI  Endogenous  Exogenous o Patient Flora o Surgical personnel flora Skin o Breaks in aseptic GI tract techniques Mucous membranes o Inadequate hand hygiene ▪ Seeding from pre-existing o Equipment, surgical tools, sites of infection materials within operative field o OR environment, including ventilation PHAR615 Fall 2024-2025  SSI pathogens: oStaphylococcus aureus – 20-30.0% oCoagulase-negative staphylococci - 13.7% oEnterococcus spp - 11.2% oEscherichia coli – 8-9.6% oPseudomonas aeruginosa - 5.6-8% oEnterobacter spp - 4.2-7% oKlebsiella pneumonia - 3.0% oCandida spp - 2.0% oKlebsiella oxytoca - 0.7% o Acinetobacter baumannii - 0.6% PHAR615 Fall 2024-2025  Risk Factors for SSI There are many risk factors for SSI, which can be classified as: o Patient characteristics o Operation characteristics PHAR615 Fall 2024-2025  Patient Characteristics -Extremes of age -Comorbid states: -Obesity.Diabetes mellitus - Tobacco use.Remote infection - Malnutrition.Ischemia -Prolong.Colonization with postoperative stay microorganisms.Immunosuppressive therapy PHAR615 Fall 2024-2025  Operation characteristics -Surgical wound class -Length of surgical -Length of operation scrub - ASA score -Inadequate instrument -Skin antisepsis - Unexpected contamination sterilization -Preoperative - Operation room ventilation -Foreign material in surgical site shaving -Surgical technique -Preoperative skin preparation PHAR615 Fall 2024-2025  American Society of Anesthesiologists (ASA): Devised a preoperative risk score based on the presence of co-morbidities at the time of surgery o An ASA score >2 is associated with increased risk of wound infection PHAR615 Fall 2024-2025 ASA Score Physical Status 1 A normal healthy patient 2 A patient with a mild systemic disease 3 A patient with a severe systemic disease that limit activity, but is not incapacitating 4 A patient with an incapacitating systemic disease that is constant threat to life 5 A moribund patient not expected to survive 24 hours with or without operation PHAR615 Fall 2024-2025  Wound Class: o Operations can be categorized into four classes with an increasing incidence of bacterial contamination and subsequent incidence of postoperative infection o National Research Council Wound Classification: ✓ Clean ✓ Clean contaminated ✓ Contaminated ✓ Dirty PHAR615 Fall 2024-2025  Uninfected operative wound with no inflammation No entry into the respiratory, alimentary, genital, or urinary tract Clean No break in aseptic technique occurs Wounds primarily closed Operation following non- penetrating trauma Infection Rate : >5% PHAR615 Fall 2024-2025  Operation with controlled opening respiratory, alimentary, genital, or urinary tracts No evidence of infection, no Clean- major break in technique, no Contaminated unusual contamination encountered Operation involving biliary tract, appendix, vagina, and oropharynx Infection Rate: >10% PHAR615 Fall 2024-2025  Penetrating trauma Operation following open, fresh, accidental wounds Operation with major breaks in sterile technique Contaminated Includes operation where acute, non-purulent inflammation encountered Infection Rate: 15–20% PHAR615 Fall 2024-2025  Definition suggests the organisms causing post-op infection were present before the operation Operation involving old traumatic wounds Dirty with retained devitalized tissue, or existing clinical infection or perforated viscera Obvious preexisting infection present (abscess, puss, or necrotic tissue present) Infection Rate: 30–40 % PHAR615 Fall 2024-2025  Recommendations for surgical prophylaxis Clean surgeries involving Clean- Selected implantation of contaminated contaminated prosthetic surgeries wounds material Dirty: prophylaxis is not indicated Antibiotics are used for treatment PHAR615 Fall 2024-2025 Antibiotic Prophylaxis Goals  Goals of antibiotic prophylaxis in surgery: o prevent infection and related morbidity and mortality o reduce duration and cost of healthcare o minimize adverse effects o have minimal effects on microbial flora of patient and hospital  Aim of prophylaxis: o Augment host defense mechanisms at the time of bacterial invasion, thereby decreasing the size of the inoculum  The use of prophylactic antibiotics is an adjunct to and not a substitute for good surgical technique PHAR615 Fall 2024-2025 Benefits Risks Decreased incidence Toxic reactions of infection Allergic reactions (wound/distal) Drug interactions Emergence of Reduce overall costs resistant bacteria - Prolonged stay PHAR615 Fall 2024-2025 Super infection  Principles of Surgical Antimicrobial Prophylaxis  Principle1: o Use antibiotic when the risk of infection is high or sequalae is significant  Principle 2: Give the right/appropriate antibiotic o Be effective against microorganisms anticipated to cause infection o Need not eradicate every potential pathogen o Achieve adequate local tissue levels o Cause minimal side effects o Be relatively inexpensive o Have no adverse effect on the microbial flora of the patient or hospital o Current literature evidence support its use o PHAR615 Fall 2024-2025  Principle 3 o Don't start too early, don't start too late o Tissue levels should peak when the knife goes in  Administration must occur 30 - 45 minutes prior to incision or with the induction of anesthesia  Principle 4 o Give the drug intravenously as oral absorption may be unreliable o The effective dose should be governed by the patient's weight PHAR615 Fall 2024-2025  Prophylactic antibiotics are most effective when given with in the 1-hour window before surgical incision  A review of the literature indicated that intravenous antibiotic should be given ≤30 minutes pre-operatively for all categories of surgery except caesarean section Rates of infection increase significantly if antibiotics are administered more than1 hour before incision or postoperatively  Vancomycin and fluoroquinolones: administer first dose within 120 minutes of surgical incision due to prolonged infusion times PHAR615 Fall 2024-2025  Principle 5 o Use additional intra-operative dose only when necessary  long procedures (> 2-3 hours)  high blood loss (cardiac, liver procedures)  Principle 6 o Keep post-operative doses to a minimum : 0 doses adequate for most procedures o Further doses Up to 48 hours for selected procedures PHAR615 Fall 2024-2025  The duration of the surgical procedure and the half-life of the administered antibiotic should be considered when determining the need for an additional intra operative dose ✓ The longer the duration of the surgical procedure the greater the incidence of postoperative infection  Example: ✓ Cefazolin: half-life of ~1.8 hours ✓ Effective in a single preoperative dose for most surgical procedures ✓ For procedures lasting >2-3 hours, or those with major blood loss, additional intra-operative doses should be administered every one to two times the half-life of the drug during the procedure PHAR615 Fall 2024-2025  In practice, cardiothoracic antimicrobial prophylaxis often is continued up to 48 hours after surgery  No benefit is seen to prolonging prophylaxis to more than 48 hours: such use should be discouraged  In arthroplasty there is evidence from a very large observational cohort that 24 hours of antimicrobial prophylaxis is associated with lower rates of re-operation than a single dose.  In the past, 5- or 6-day antimicrobial regimens were commonly used for cesarean section, but 24-hour regimens have been proven to be as effective as these longer regimens PHAR615 Fall 2024-2025  Recommended agents and dosing for antimicrobial prophylaxis in adults with normal renal function  Reference: American Society of Health-System Pharmacists (ASHP), Infectious Diseases Society of America (IDSA), Surgical Infection Society (SIS), and Society for Healthcare Epidemiology of America (SHEA) joint clinical practice guideline on antimicrobial prophylaxis PHAR615 Fall 2024-2025  Alternative Agents in Recommended Agent Patients with Beta- Procedure and Dose a Lactam Allergy Clindamycin 900 mg c Cardiac (coronary Vancomycin 15 mg/kg c artery bypass, Cefazolin 1 g every 8 (in areas with high device hours × 48 hoursb prevalence of S. aureus insertion,….) resistance, vancomycin Patients >80 kg should receive should be considered) 2 g of cefazolin Cefuroxime 750 mg IV Clindamycin 900 mg Thoracic every 8 hours × 48 hours Vancomycin 15 mg/kg Thoracic: First-generation cephalosporins are deemed inadequate, and shorter durations PHAR615 Fall 2024-2025 of prophylaxis have not been adequately studied  Important Notes a.For patients known to be colonized with methicillin-resistant Staphylococcus aureus, it is reasonable to add a single preoperative dose of vancomycin to the recommended agent(s).  MRSA risk o Defined as history of MRSA colonisation or infection, OR inpatient of high risk hospital or unit (where MRSA is endemic) for more than the last 5 days ❖ Vancomycin administration  Give vancomycin 1g (1.5g for patients >80kg actual body weight) by IV infusion started 30-120 minutes before surgical incision and given at a recommended rate of 1g per hour (1.5g over 90 minutes) PHAR615 Fall 2024-2025  Alternative Agents in Recommended Agent Patients with Beta- Procedure and Dose a Lactam Allergy Clindamycin 900 mg or vancomycin 15 mg/kg plus Gastroduodenal ( Cefazolin 2 g aminoglycosidedor high risk only) aztreonam 2 g or fluoroquinolonee High risk: obstruction, hemorrhage, malignancy, acid suppression therapy, morbid obesity PHAR615 Fall 2024-2025  Alternative Agents in Recommended Agent Patients with Beta-Lactam Procedure and Dose Allergy Clindamycin 900 mg or Biliary tract (high vancomycin 15 mg/kg, plus 1 risk only): Cefazolin 2 g of aminoglycoside or -age>70 yrs Cefoxitin 2 g aztreonam 2 g or -Acute cholecystitis Cefotetan 2 g fluoroquinolone -Duct stones Ceftriaxone 2 ga Metronidazole 500 mg plus - laparoscopic Ampicillin-sulbactam 3 g procedure aminoglycoside or fluoroquinolone Clindamycin 900 mg, plus 1 of aminoglycoside or Appendectomy Cefoxitin 2 g aztreonam 2 g or for Cefotetan 2 g fluoroquinolone uncomplicated Cefazolin 2 g plus Metronidazole 500 mg plus appendicitis metronidazole 500 mg PHAR615 Fall 2024-2025 aminoglycoside or fluoroquinolone  Alternative Agents in Recommended Agent and Patients with Beta- Procedure Dose Lactam Allergy Nonobstructed: Clindamycin 900 mg, plus 1 Nonobstructed: Cefazolin 2 g of aminoglycoside or Obstructed: aztreonam 2 g or Cefazolin 2 g plus Small intestine fluoroquinolone metronidazole 500 mg Obstructed: Cefoxitin 2 g Metronidazole 500 mg plus Cefotetan 2 g aminoglycoside or fluoroquinolone Clindamycin 900 mg Hernia repair Cefazolin 2 g Vancomycin 15 mg/kg PHAR615 Fall 2024-2025  Alternative Agents in Recommended Agent Patients with Beta- Procedure and Dose Lactam Allergy Cefazolin 2 g plus Clindamycin 900 mg, plus metronidazole 500 mg 1 of aminoglycoside or Cefoxitin 2 g aztreonam 2 g or Cefotetan 2 g Colorectal fluoroquinolone Ampicillin-sulbactam 3 g Metronidazole 500 mg Ceftriaxone 2 g plus plus aminoglycoside or metronidazole 500 mg a fluoroquinolone Ertapenem 1 g Clean with placement of Head and neck ( prosthesis: Clindamycin 900 mg clean: none) Cefazolin 2 g PHAR615 Fall 2024-2025 Cefuroxime 1.5 g  Alternative Agents in Recommended Agent Patients with Beta- Procedure and Dose Lactam Allergy Clean-contaminated cancer surgery or other clean- contaminated Head and neck ( Cefazolin 2 g plus clean: none) Clindamycin 900 mg metronidazole 500 mg Cefuroxime 1.5 g plus metronidazole 500 mg Ampicillin-sulbactam 3 g Clindamycin 900 mg Neurosurgery Cefazolin 2 g Vancomycin 15 mg/kg Cefazolin 2 g × 1 and Clindamycin 900 mg plus Cesarean deliver PHAR615 azithromycin 500 mg IV x 1 aminoglycoside Fall 2024-2025  Alternative Agents in Recommended Agent Patients with Beta- Procedure and Dose Lactam Allergy Clindamycin 900 mg or vancomycin 15 mg/kg, plus Cefazolin 2 g 1 of aminoglycoside or Hysterectomy (vaginal Cefotetan 2 g aztreonam 2 g or or abdominal) Cefoxitin 2 g fluoroquinolone Ampicillin-sulbactam 3 g Metronidazole 500 mg plus aminoglycoside or fluoroquinolone Orthopedic: Spinal procedures, hip fracture repair, Clindamycin 900 mg implantation of internal Cefazolin 2 g Vancomycin 15 fixation devices, total joint mg/kg replacement PHAR615 Fall 2024-2025  Alternative Agents in Recommended Agent Patients with Beta- Procedure and Dose a Lactam Allergy Urologic: Fluoroquinolone such aminoglycoside with or Lower tract as ciprofloxacin without clindamycin 900 instrumentation with 500mg mg risk factors for Trimethoprim- infection: sulfamethoxazole Cefazolin 2 g Urologic: Clean Cefazolin 2 g Clindamycin 900 mg without entry into Vancomycin 15 mg/kg urinary tract: -Cefazolin 2 g with or without consider adding aminoglycoside If involving implanted aminoglycoside or -Cefazolin with or without prosthesis aztreonam 2 g to either one PHAR615 aztreonam 2g Fall 2024-2025 - Ampicillin-sulbactam 3 g of the above regimen  Alternative Agents in Recommended Agent Patients with Beta- Procedure and Dose a Lactam Allergy Clindamycin 900 mg Vascular Cefazolin 2 g Vancomycin 15 mg/kg Heart, lung, heart- Clindamycin 900 mg Cefazolin 2 g lung transplantation Vancomycin 15 mg/kg Clindamycin 900 mg or Piperacillin-tazobactam vancomycin 15 mg/kg, plus 3.375 g Liver transplantation 1 of aminoglycoside or Cefotaxime 1 g plus aztreonam 2 g or PHAR615 ampicillin 2 g Fall 2024-2025 fluoroquinolone  Alternative Agents in Recommended Agent Patients with Beta- Procedure and Dose a Lactam Allergy Clindamycin 900 mg or Cefazolin 2 g Pancreas and vancomycin 15 mg/kg, plus Fluconazole 400 mg for pancreas-kidney 1 of aminoglycoside or patients at high risk of fungal transplantation aztreonam 2 g or infection fluoroquinolone Clindamycin 900 mg or vancomycin 15 mg/kg, plus Kidney Cefazolin 2 g 1 of aminoglycoside or transplantation aztreonam 2 g or fluoroquinolone Plastic surgery - Clean with risk Cefazolin 2 g Clindamycin 900 mg factors orPHAR615 Ampicillin-sulbactam 3 g clean- Fall 2024-2025 Vancomycin 15 mg/kg contaminated  Specific cases: o Cardiothoracic: ✓ Cefazolin 2 g IV every 8 hrs for a total of 48 hrs or ✓ Cefuroxime 1.5g IV every 12 hrs for a total of 48 hrs PHAR615 Fall 2024-2025  Summary  Select antibiotics specific to patient and surgery characteristics.  Cefazolin 2 g (30 mg/kg in children, 3 g in adults ≥ 120 kg) as single IV dose within 60 minutes prior to surgical incision is preferred regimen  Clindamycin or vancomycin may be used if patient has beta- lactam allergy. PHAR615 Fall 2024-2025  Summary  Repeat doses o A single pre-operative dose is sufficient for most procedures; however, repeat intra-operative doses are advisable: ✓ for prolonged surgery (> 4 hours from the time of the first pre- operative dose) when a short- acting agent is used (e.g. cefazolin); or ✓ if major blood loss occurs, following fluid resuscitation  Obese patients o Consider increased dose of cefazolin if patient is obese (>120kg) PHAR615 Fall 2024-2025