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Microsoft word - surgical_prophylaxis_antibiotic_recommendations_for_adult_patients.doc

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SURGICAL PROPHYLAXIS: ANTIBIOTIC RECOMMENDATIONS
FOR ADULT PATIENTS


GUIDELINE:
Antibiotics are administered prior to surgical procedures to prevent surgical site
PURPOSE:

1. To provide antibiotic recommendations for surgical prophylaxis in adult patients taking into account the site of infection, most common organisms, hospital epidemiology and susceptibilities, expert opinion, and cost. 2. To optimize antibiotic use and patient outcomes in the prevention of surgical site infections while limiting the emergence of resistance bacteria. These recommendations are modified from many sources including the Treat Guidel Med Lett 2009; 7(82):47-52 and Clin Infect Dis 2004; 38:1706-15. (For endocarditis prophylaxis, consult the NYPH recommendations for the prevention of endocarditis based on the American Heart Association recommendations, Circulation 2007; 115.)
APPLICABILITY:

All centers

PROCEDURE:

1. Choice of antimicrobial agent (see Table 2 and 3)
A. Drug chosen should be active against the pathogens most commonly associated with wound infections following the specific procedure and against the pathogens endogenous to the region of the body being operated. B. Selection of an appropriate agent for specific patients should take into account not only comparative efficacy but also adverse-effect profiles and C. For most procedures, cefazolin 1 g or cefoxitin 2 g should be the agent of choice because of their relatively long duration of action, their effectiveness against the organisms most commonly encountered in surgery, and their relatively low cost. D. Clindamycin or vancomycin should be used in penicillin-allergic patients. 1) Clindamycin may be preferable for patients not at risk for infections due to resistant-gram positive organisms secondary to its narrower-spectrum and a more rapid infusion time. 2) Routine vancomycin use is discouraged. NewYork-Presbyterian Hospital
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E. Modification of a surgical prophylaxis regimen may be necessary in patients with pre-existing infections prior to surgery, significant length of hospital stay prior to surgery, and previous positive cultures/colonization. Consult Infectious Diseases for specific recommendations. F. For patients already receiving antibiotics prior to surgery, it is often not necessary to administer additional antibiotics for surgical prophylaxis provided the current regimen is appropriate in spectrum for the surgery planned and timing of administration of the current antibiotic regimen is optimized relative to incision time. Consult Infectious Diseases for specific recommendations. G. Maximal doses (e.g. cefazolin 2 g) should be considered for patients weighing 2. Timing
A. Infusion of antibiotics for surgical prophylaxis should begin within 1 hour prior to incision (exceptions are cesarean procedures and oral antimicrobials for colonic procedures). 1) Vancomycin may begin within 2 hours prior to incision due to the longer infusion time and to ensure adequate tissue levels at the time of incision. B. All antibiotic infusions should be completed prior to incision. Recent data suggests that administration “as near to the incision time as possible” may not be optimal. Administration 15-30 minutes to 1 hour prior to the incision may be more ideal. (Garey et al. J Antimicrob Chemother 2006; 58: 645- 650; Weber et al. Annals of Surgery 2008; 247: 918-926) 3. Duration
A. The optimal duration of perioperative prophylaxis is unknown. It is unlikely that further benefit is attained by the administration of additional doses beyond wound closure and post-operative prophylaxis is not recommended. B. Single prophylactic doses +/- additional intraoperative doses in prolonged procedures are strongly recommended. If prophylaxis is extended beyond the operative period, antibiotics should be discontinued within 24 hours unless otherwise specified. C. Additional intraoperative doses are strongly recommended in prolonged procedures at intervals approximating two times the half-life of the drug. This roughly corresponds with redosing antimicrobials at a frequency of one interval shorter than usual (see Table 1). Additional intraoperative doses may not be warranted in patients for whom the half-life of the antimicrobial is prolonged, such as those patients with renal insufficiency. D. The continuation of prophylaxis until all catheters and drains have been NewYork-Presbyterian Hospital
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TABLE 1: Administration and intraoperative redosing

Ampicillin/
Trimethoprim
Cefazolin
Cefoxitin
Clindamycin
Gentamicin
Ampicillin
Vancomycin
Metronidazole
Aztreonam
Fluconazole
Rifampin
sulbactam


TABLE 2:
Adult Gentamicin Dosing for Surgical Prophylaxis Based on Weight
(doses should be rounded to facilitate preparation, administration, and availability of gentamicin)

Weight (kg)
Gentamicin Dose to Administer (1.5 mg/kg/dose)
Use alternative if appropriate: aztreonam 2 g NewYork-Presbyterian Hospital
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TABLE 3: Antibiotic choice and duration

PRIMARY ANTIBIOTIC PROPHYLAXIS
DURATION OF
NATURE OF OPERATION
PATHOGENS
ALTERNATIVE
RECOMMENDED
PROPHYLAXIS
Staphylococcus aureus, S. epidermidis Staphylococcus aureus, S. epidermidis Staphylococcus aureus, S. epidermidis 1a May be switched post-op to oral cephalexin 500 mg PO q6h or cefadroxil 1 g PO q12h or clindamycin (for PCN-allergic patients) 450 mg PO q8h for a total duration not to exceed 48 hours. Enteric gram-negative bacilli, gram-positive Enteric gram-negative bacilli, gram-positive Staphylococcus aureus, Streptococcus sp., Enteric gram-negative bacilli, enterococci, neomycin + erythromycin base (after appropriate diet and catharsis); 1 gram of each at 1pm, 2pm and 11pm the day before an 8am operation (Adjust timing for Enteric gram-negative bacilli, anaerobes, IV: cefazolin 1-2 grams IV + metronidazole 500 mg IV or cefoxitin 2 grams IV
cefoxitin 2 grams IV or
Enteric gram-negative bacilli, anaerobes, 2a High risk only (morbid obesity, esophageal obstruction, decreased gastric acidity or gastrointestinal motility) 2b High risk only (Age>70 yrs, biliary stent, non-functioning gall bladder, obstructive jaundice or common duct stones) NewYork-Presbyterian Hospital
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PRIMARY ANTIBIOTIC
DURATION OF
NATURE OF OPERATION
PATHOGENS
ALTERNATIVE
PROPHYLAXIS RECOMMENDED
PROPHYLAXIS
Enteric gram-negative bacilli, enterococci Enteric gram-negative bacilli, enterococci Enteric gram-negative bacilli, enterococci Enteric gram-negative bacilli, enterococci Enteric gram-negative bacilli, enterococci High risk (urine culture positive or unavailable, pre-operative catheter, placement of prosthetic material); transurethral resection of prostate Enteric gram-negative bacilli, anaerobes, Enteric gram-negative bacilli, anaerobes, Enteric gram-negative bacilli, anaerobes, cefazolin 1 gram IV or Anaerobes, enteric gram negative bacilli, S. 6. NEURO-
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PRIMARY ANTIBIOTIC PROPHYLAXIS
DURATION OF
NATURE OF OPERATION
PATHOGENS
ALTERNATIVE
RECOMMENDED
PROPHYLAXIS
S. epidermidis, S. aureus, streptococci, polymyxin B; multiple drops topically over S. aureus, S. epidermidis, streptococci, 9. THORACIC
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PRIMARY ANTIBIOTIC PROPHYLAXIS
DURATION OF
NATURE OF OPERATION
PATHOGENS
ALTERNATIVE
RECOMMENDED
PROPHYLAXIS
ampicillin/sulbactam (Unasyn) 3 grams ampicillin/sulbactam (Unasyn) 3 grams + vancomycin 1 g IV q12h rifampin 600 mg PO or IV x 1 10. TRANSPL
ampicillin/sulbactam (Unasyn) 3 grams + fluconazole 400 mg IV q24h for up to 48 10a Antibiotics listed are for routine (“non-septic”) lung transplants. Modification of antibiotic regimens is necessary in cases where culture and susceptibility data from the donor and/or recipient are available. S. aureus, S. epidermidis, enteric gram- S. aureus, S. epidermidis, enteric gram- 11. VASCULAR
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Medication Use Manual: Guideline

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RESPONSIBILITY:
Joint Subcommittee on Anti-Infective Use

GUIDELINE DATES:
Issued: March

Source: http://www.crnaconferences.com/presentations/Antibiotic-Article-2-PDF.pdf

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Bio Data : Prof. (Dr.) Ambikanandan Misra Name : Dr. Ambikanandan Rajnarayan Misra Qualification : M.Pharm (Pharmaceutics), Ph.D. (Pharmacy) Designation : Head, Pharmacy Department, Faculty of Technology and Engineering, Kalabhavan, The Maharaja Sayajirao University of Baroda, Date of Birth : 15-11-1955 Address Office: Pharmacy Department, Faculty of Technology and Enginee

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