Surgical Infections + PPX

Surgical Infections + PPX Tuesday, October 29, 2024 12:19 AM Patient-Specific Risk Factors • Age • Nutritional status (preoperative albumin <3.5 g/dL) ○ Malnutrition contributes to impaired wound healing and prolonged hospital stay • Diabetes and preoperative glycemic control • Smoking and alcohol use ○ Nicotine impairs wound healing • Obesity • Coexisting infections at distal body sites ○ Should be resolved prior to surgery whenever possible • Colonization with resistant microorganisms ○ Decolonization of S. aureus using intranasal mupirocin and chlorhexidine • Altered immune response ○ E.g. corticosteroid use, HIV, hepatitis C • Length of preoperative stay Scheduling ABx Administration • Considerations for antimicrobial surgical prophylaxis: ○ Distributed to the surgical site prior to the initial incision ○ Bactericidal concentrations of antibiotics maintained at the surgical site throughout the surgical procedure • Antibiotic administration - initiated within 60 minutes prior to the initial incision ○ Drug distribution throughout the tissues involved in surgery ○ Exception: vancomycin and fluoroquinolones (120 minutes prior to the initial incision) • Re-dose prophylactic antibiotic when surgery lasts longer than two half-lives of the antibiotic ○ 4 hours for cefazolin • Duration of prophylactic antibiotics after surgery does not typically exceed 24 hours ○ Increased risk for C. difficile infection and acute kidney injury Choice of Antibiotic • Parenteral route preferred • Gram-positive coverage ○ Skin flora: S. aureus, S. epidermidis • Gram-negative and anaerobic coverage if warranted ○ Based on surgical site ○ Operation involves transection of a hollow viscous/mucous membrane that may contain resident flora • Cephalosporins most commonly prescribed ○ Cefazolin preferred ○ Cefotetan or cefoxitin for broader gram-negative and anaerobic coverage • Vancomycin or clindamycin for Type I penicillin allergy (anaphylaxis) • Vancomycin for prosthetic implantation and high MRSA risk Type of Surgery Hepatobiliary Operation Cholecystectomy NRC: clean/clean-contaminated Gastrointestinal Gastroduodenal Likely Pathogens Recommended PPX Regimen Alternative for B-lactam Allergy Enteric gram(-) bacilli • E. coli, Klebsiella, enterococci Cefazolin 1 g x1 (Clindamycin or vancomycin) + (aztreonam, AG, or FQ) • High risk patients ONLY Enteric gram(-) bacilli, gram(+) cocci Cefazolin 1 g x1 (Clindamycin or vancomycin) + (aztreonam, AG, or FQ) • High risk patients ONLY Enteric gram(-) bacilli, anaerobes Cefotetan or cefoxitin 1 g x 1 or Clindamycin + NRC: clean/clean-contaminated Appendectomy Notes/Comments • Re-dose cefoxitin if procedure lasts > 2 hours NRC: Contaminated Colorectal Enteric gram(-) bacilli, anaerobes NRC: Contaminated Urologic Cefazolin 1 g x1 + Metronidazole 1 g x1 (aztreonam, AG, or FQ) OR Metronidazole + AG or FQ Cefotetan or cefoxitin 1 g x1 Clindamycin + (aztreonam, AG, or FQ) OR Metronidazole + AG or FQ PO: neomycin 1 g + erythromycin base 1 g + mechanical bowel preparation (e.g. polyethylene glycol or sodium phosphate solutions) Gastrointestinal Endoscopy Enteric gram(-) bacilli, gram(+) cocci, oral anaerobes Cefazolin 1 g x1 or ampicillin 2 g x1 (Clindamycin or vancomycin) + (aztreonam, AG, or FQ) Prostate resection, shockwave lithotripsy, ureteroscopy E. coli Ciprofloxacin 500 mg PO or Bactrim DS 1 tablet PO Aminoglycoside with or without clindamycin E. coli Cefazolin 1 g x1 Clindamycin or vancomycin Cefazolin* 2 g x1 and azithromycin 500 mg IV x1 Clindamycin + AG • bowel preparation is controversial, but still widely used • High risk patients ONLY • All patients with positive preoperative urine cultures should receive a course of antibiotic treatment * Invasive Removal of external urinary catheters, cystography, urodynamic studies, simple cystourethroscopy • Consider only in patients with risk factors * Less invasive Gynecological Cesarean section (C-section) Enteric gram(-) bacilli, anaerobes, group B streptococci, enterococci • Antimicrobial administration should be prior to the initial incision; decreases antibiotic exposure to neonate *2g dose produces adequate concentrations to inhibit anaerobes Antibiotics are given to prevent endometritis Hysterectomy Head + Neck Maxillofacial surgery • Prophylaxis necessary if incision is made through NRC: Clean to cleana mucosal layer contaminated S. aureus, streptococci spp., oral anaerobes Head and neck cancer resection Vaginal or abdominal: • cefazolin 1 g x1 • cefotetan 1 g x1 (Clindamycin or vancomycin) + (aztreonam, AG, or FQ) OR Metronidazole + AG or FQ Cefazolin 2 g x1 or clindamycin 600 mg x1 Clindamycin Clindamycin 600 mg at induction and every 8 hours for 2 more doses • Add gentamicin for clean-contaminated procedures NRC: Clean to cleancontaminated Cardiothoracic Cardiac surgery NRC: Clean S. aureus, S. epidermidis, Corynebacterium Cefazolin 1 g Q8H for 48 hours Intranasal mupirocin BID for 5 days preoperatively for patients colonized with S. aureus Clindamycin or vancomycin • Decolonize patients against S. aureus with intranasal mupirocin and chlorhexidine bath for up to 5 days prior to surgery • DOC: Cefazolin for cardiac surgeries • Cefuroxime superior to cefazolin for pulmonary surgeries • Patients > 80 kg should receive 2 g of cefazolin Thoracic surgery NRC: Clean Orthopedic Joint replacement S. aureus, S. epidermidis, Corynebacterium, enteric gram(-) bacilli Cefuroxime 750 mg IV Q8H for 48 hours Clindamycin or vancomycin • First-generation cephalosporins are inadequate Cefazolin 1 g x1 preoperatively, then every 8 hours x2 more doses (24 hours) Clindamycin or vancomycin • Prophylactic antibiotics indicated only when prosthetic materials are implanted • DOC: cefazolin • Vancomycin for penicillin allergy or high MRSA prevalence • Duration of PPX: 24 hours • Exception: hip fracture repair (48 hours) Cefazolin 1 g x1 preoperatively, then every 8 hours for 48 hours Clindamycin or vancomycin S. aureus, S. epidermidis, gramnegative bacilli, polymicrobial Cefazolin 1 g x1 preoperatively, then every 8 hours for a course of presumed infection Clindamycin or vancomycin S. aureus, S. epidermidis Cefazolin 1 g Q8H x3 doses or ceftriaxone 2 g x1 Clindamycin or vancomycin Cefazolin 1 g x1 Clindamycin or vancomycin Cefazolin 1 g x1 or cefotaxime 1 g x1 Clindamycin or vancomycin S. aureus, S. epidermidis NRC: Clean Hip fracture repair NRC: Clean Open/compound fractures Infection presumed Neurosurgery CSF shunt procedures Spinal surgery Craniotomy Cefazolin 1g x1 • • • • • • • • Cholecystectomy Gastroduodenal Gastrointestinal Endoscopy Removal of external urinary catheters, cystography, urodynamic studies, simple cystourethroscopy Hysterectomy Cardiac surgery Orthopedic surgery Neurosurgery Cefazolin 2g • Cesarean section (C-section) [+ Z-pak] • Maxillofacial surgery • Cardiac surgery • If patients weigh > 80 kg Inadequate for Cefazolin Monotherapy • • • • • • Appendectomy Colorectal Prostate resection, shockwave lithotripsy, ureteroscopy Cesarean section (C-section) Head and neck cancer resection Thoracic surgery Surgical Site Infections • Signs of Significant Systemic Response ○ Erythema and induration extending > 5 cm from the wound edge ○ Temperature >38.5°C ○ Heart rate >110 beats/min ○ WBC >12K • IDSA Practice Guidelines for SSTIs (2014) ○ All SSIs: suture removal plus incision and drainage ○ Antibiotics not routinely indicated; may be beneficial in conjunction with I/D and signs of significant systemic response ○ Short course (24-48 hours) of antibiotics ▪ Especially in operations on the trunk, head and neck, or extremities ○ MSSA: 1st-generation cephalosporin, anti-staph penicillin ○ MRSA: vancomycin, linezolid, daptomycin, telavancin, ceftaroline ○ Gram-negatives + anaerobes: cephalosporin or FQ + metronidazole ▪ SSIs following operations on the axilla, GI tract, perineum, or female genital tract • Gram-negative coverage (i.e. gentamicin) often indicated for severe open fractures • Vancomycin 1 g IV x1 for penicillin allergy