Antimicrobial prophylaxis for surgery

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Antimicrobial Prophylaxis for Surgery

Tables

1 Antimicrobial Prophylaxis for Surgery Pages 74-75

Treatment Guidelines

Published by The Medical Letter, Inc • 145 Huguenot Street, New Rochelle, NY 10801 • A Nonprofit Publication Volume 10 (Issue 122) October 2012

(supercedes vol 7 [Issue 82] June 2009)

www.medicalletter.org

Take CME Exams

Antimicrobial prophylaxis can decrease the incidence

of postoperative infection, particularly surgical site

infection, after some procedures Recommendations

for such prophylaxis are listed in the table that begins

on page 74 Antimicrobial prophylaxis for dental

pro-cedures to prevent endocarditis was recently discussed

in The Medical Letter.1

CHOICE OF AGENT — Antimicrobial prophylaxis

for surgery should be directed against the most likely

infecting organisms, but it does not need to eradicate

every potential pathogen to be effective Cefazolin

(Ancef, and others), a first-generation cephalosporin

active against many staphylococci and streptococci,

can be used for most procedures

For procedures that might involve exposure to bowel

anaerobes, including Bacteroides fragilis, the

second-generation cephalosporins cefoxitin (Mefoxin, and

others) and cefotetan (Cefotan, and others) are more

active than cefazolin, but anaerobic resistance to these

drugs is increasing.2 Cefazolin plus metronidazole

(Flagyl, and others) and ampicillin/sulbactam

(Unasyn, and others) may be reasonable alternatives

depending on local susceptibility patterns of

Escherichia coli.3

In institutions where surgical site infections are

frequently due to methicillin-resistant

staphylo-cocci, vancomycin (Vancocin, and others) could be

used for prophylaxis, but such use could lead to

emergence of vancomycin-resistant organisms If

vancomycin is used for procedures in which gram

negatives or anaerobes are also likely pathogens, an

additional agent with activity against these

organ-isms could be added.4

Most experts do not recommend use of

broad-spectrum antibiotics such as ertapenem (Invanz) or

extended-spectrum cephalosporins such as cefotaxime

(Claforan, and others), ceftriaxone (Rocephin, and others), ceftazidime (Fortaz, and others), cefepime (Maxipime) or ceftaroline (Teflaro) for routine

surgical prophylaxis because they are expensive, some are less active than first- or second-generation cephalosporins against staphylococci, and their spec-trum of activity includes organisms rarely encountered

in elective surgery.5

operative Screening and Decolonization –

Pre-operative identification of patients who are nasal

carriers of methicillin-resistant Staphylococcus aureus (MRSA) or methicillin-sensitive S aureus (MSSA)

and decolonization using intranasal mupirocin

(Bactroban Nasal, and others) have been shown to

decrease surgical site infections following some pro-cedures (primarily cardiac and orthopedic), but resist-ance to mupirocin could become a problem if it is used routinely.6 One randomized, double-blind, placebo-controlled, multicenter trial found that combined use

of mupirocin nasal ointment and chlorhexidine

(Peridex, and others) baths within the first 24 hours

after hospital admission in identified carriers reduced the risk of hospital-acquired MSSA infection.7

DOSAGE AND DURATION — Administration of

the first dose of the prophylactic antibiotic within 60 minutes before the initial surgical incision is recommended to ensure adequate serum and tissue levels If vancomycin or a fluoroquinolone is used, the infusion should begin within 60-120 minutes before the incision because of the prolonged infusion times required for these drugs.8

The duration of antimicrobial prophylaxis should be

<24 hours for most procedures There are no data to support continuation of prophylaxis after wound clo-sure or until all indwelling drains and intravascular catheters have been removed

Forwarding, copying or any other distribution of this material is strictly prohibited.

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Antimicrobial Prophylaxis for Surgery

Treatment Guidelines from The Medical Letter • Vol 10 ( Issue 122) • October 2012

CARDIAC SURGERY — Preoperative antibiotics

can decrease the incidence of infection after cardiac

surgery, and intraoperative redosing has decreased

the risk of postoperative infection in procedures

last-ing >400 minutes.9 Various data support a duration

ranging from a single dose to up to 24 hours

postop-eratively; there is no evidence of benefit beyond 48

hours

74

Antimicrobial prophylaxis for prevention of

device-related infections is recommended before placement

of electrophysiologic devices, ventricular assist devices, ventriculoatrial shunts and arterial patches

Prophylaxis prior to implantation of permanent pace-makers and cardioverter-defibrillators has been shown

to significantly reduce the incidence of wound infec-tion, inflammation and skin erosion.10

Table 1 Antimicrobial Prophylaxis for Surgery

Cardiac

Staphylococcus epidermidis OR cefuroxime 1.5 g IV 3

Gastrointestinal

Esophageal, gastroduodenal Enteric gram-negative bacilli, High-risk 5 only:

Biliary tract Enteric gram-negative bacilli, High-risk 7 only:

anaerobes, enterococci + erythromycin base 9 or

metronidazole 9

Parenteral:

cefoxitin 6 or cefotetan 6 1-2 g IV

OR ampicillin/sulbactam 6,10 3 g IV Appendectomy, non-perforated 11 Same as for colorectal cefoxitin 6 or cefotetan 6 1-2 g IV

Genitourinary

Cystoscopy alone Enteric gram-negative bacilli, High-risk 12 only:

400 mg IV

sulfamethoxazole Cystoscopy with manipulation or Enteric gram-negative bacilli, ciprofloxacin 10 500 mg PO or

sulfamethoxazole Open or laparoscopic surgery 14 Enteric gram-negative bacilli, cefazolin 6 1-2 g IV 2

enterococci

Gynecologic and Obstetric

Vaginal, abdominal or Enteric gram-negative bacilli, cefazolin, 6 cefoxitin 6 or cefotetan 6 1-2 g IV 2

laparoscopic hysterectomy anaerobes, Gp B strep, OR ampicillin/sulbactam 6,10 3 g IV

enterococci

1 Parenteral prophylactic antimicrobials can be given as a single IV dose begun within 60 minutes before the procedure For prolonged procedures (>3

hours) or those with major blood loss, or in patients with extensive burns, additional intraoperative doses should be given at intervals 1-2 times the

half-life of the drug (ampicillin/sulbactam q2 hours, cefazolin q4 hours, cefuroxime q4 hours, cefoxitin q2 hours, clindamycin q6 hours, vancomycin

q12 hours) for the duration of the procedure in patients with normal renal function If vancomycin or a fluoroquinolone is used, the infusion should be

started within 60-120 minutes before the initial incision to have adequate tissue levels at the time of incision and to minimize the possibility of an

infu-sion reaction close to the time of induction of anesthesia.

2 The recommended dose of cefazolin is 1 g for patients who weigh <80 kg and 2 g for those >80 kg Morbidly obese patients may need higher doses.

3 Some experts recommend an additional dose when patients are removed from bypass during open-heart surgery.

4 Vancomycin can be used in hospitals in which methicillin-resistant S aureus and S epidermidis are a frequent cause of postoperative wound

infec-tion, in patients previously colonized with MRSA, or for those who are allergic to penicillins or cephalosporins Rapid IV administration may cause

GASTROINTESTINAL SURGERY —

Antimicro-bial prophylaxis is recommended for high-risk patients

undergoing esophageal or gastroduodenal

proce-dures Patients considered high-risk include those with

GI obstruction, increased gastric pH, decreased GI

motility, gastric bleeding, malignancy or perforation,

and those with morbid obesity or immunosuppression

Prophylaxis is not recommended for routine

gastro-esophageal endoscopy.11

Preoperative antibiotics are used routinely for

bariatric surgery, including adjustable gastric

band-ing, vertical banded gastroplasty, Roux-en-y gastric bypass and biliopancreatic diversion, but no con-trolled trials supporting such use are available Higher doses of antibiotics may be needed for ade-quate serum and tissue concentrations in morbidly obese patients.12

Head and Neck Surgery

OR ampicillin/sulbactam 10 3 g IV

Neurosurgery

Ophthalmic

S epidermidis, S aureus, gentamicin, tobramycin, multiple drops streptococci, enteric gram- ciprofloxacin, gatifloxacin topically over 2 negative bacilli, Pseudomonas levofloxacin, moxifloxacin, to 24 hours

neomycin-gramicidin-polymyxin B

subcon-junctivally

Orthopedic

S aureus, S epidermidis cefazolin 16 1-2 g IV 2

Thoracic (Non-Cardiac)

streptococci, enteric gram- OR ampicillin/sulbactam 10 3 g IV

Vascular

Arterial surgery involving a S aureus, S epidermidis, cefazolin 1-2 g IV 2

prosthesis, the abdominal enteric gram-negative bacilli OR vancomycin 4 1 g IV

aorta, or a groin incision

amputation for ischemia enteric gram-negative bacilli, OR vancomycin 4 1 g IV

clostridia hypotension, which could be especially dangerous during induction of anesthesia Even when the drug is given over 60 minutes, hypotension may occur; treatment with diphenhydramine (Benadryl, and others) and further slowing of the infusion rate may be helpful Some experts would give 15 mg/kg of vancomycin to patients weighing more than 75 kg, up to a maximum of 1.5 g, with a slower infusion rate (90 minutes for 1.5 g) For proce-dures in which enteric gram-negative bacilli are common pathogens, many experts would add another drug such as an aminoglycoside (gentamicin, tobramycin or amikacin), aztreonam or a fluoroquinolone.

5 Morbid obesity, GI obstruction, decreased gastric acidity or GI motility, gastric bleeding, malignancy or perforation, or immunosuppression.

6 For patients allergic to penicillins and cephalosporins, clindamycin or vancomycin with either gentamicin, ciprofloxacin, levofloxacin or aztreonam is

a reasonable alternative Fluoroquinolones should not be used for prophylaxis in cesarean section.

7 Age >70 years, acute cholecystitis, non-functioning gall bladder, obstructive jaundice or common bile duct stones.

8 Cefotetan, cefoxitin and ampicillin-sulbactam are reasonable alternatives.

9 In addition to mechanical bowel preparation, 1 g of neomycin plus 1 g of erythromycin at 1 PM, 2 PM and 11 PM or 2 g of neomycin plus 2 g of metronidazole at 7 PM and 11 PM the day before an 8 AM operation.

10 Due to increasing resistance of E coli to fluoroquinolones and ampicillin/sulbactam, local sensitivity profiles should be reviewed prior to use.

11 For a ruptured viscus, therapy is often continued for about five days.

12 Urine culture positive or unavailable, preoperative catheter, transrectal prostatic biopsy, or placement of prosthetic material.

13 Shock wave lithotripsy, ureteroscopy.

14 Including percutaneous renal surgery, procedures with entry into the urinary tract, and those involving implantation of a prosthesis If manipulation

of bowel is involved, prophylaxis is given according to colorectal guidelines.

15 Divided into 100 mg before the procedure and 200 mg after.

16 If a tourniquet is to be used in the procedure, the entire dose of antibiotic must be infused prior to its inflation.

Table 1 Antimicrobial Prophylaxis for Surgery (cont’d)

Antimicrobial Prophylaxis for Surgery

Treatment Guidelines from The Medical Letter • Vol 10 ( Issue 122) • October 2012

Antimicrobial prophylaxis is recommended before

bil-iary tract surgery for patients at high risk for

infec-tion, including those >70 years old and those with

acute cholecystitis, a non-functioning gallbladder,

obstructive jaundice, or common bile duct stones

Antibiotic prophylaxis for endoscopic retrograde

cholangiopancreatography (ERCP) is recommended

only if complete biliary drainage is unlikely to be

achieved.13 Prophylactic antibiotics are generally not

necessary for low-risk patients undergoing elective

laparoscopic cholecystectomy.14

Preoperative antibiotics can decrease the incidence of

infection after colorectal surgery Many US surgeons

use a combination of oral neomycin, either oral

eryth-romycin or oral metronidazole, and parenteral agents;

one meta-analysis suggests that combined intravenous

and oral prophylaxis (with mechanical bowel

prepara-tion) is more effective than parenteral prophylaxis

alone in preventing surgical site infection.15

Ertapenem (Invanz) is a broad-spectrum carbapenem

that has been approved by the FDA for prevention of

infection after elective colorectal procedures, but many

experts advise against using it for this purpose Like

other broad-spectrum agents, if ertapenem is to remain

useful, it should be reserved for treatment of serious

infections, particularly those caused by organisms

resistant to other antimicrobials.5,16

Antimicrobial prophylaxis can decrease the incidence

of infection after surgery for acute appendicitis.17,18If

perforation has occurred, antibiotics are often

contin-ued for >5 days

GENITOURINARY SURGERY — Most experts do

not recommend antimicrobial prophylaxis before

cystoscopy without manipulation in patients with

sterile urine When cystoscopy with manipulation

(dilation, biopsy, fulguration, resection or ureteral

instrumentation) is planned, the urine culture is

posi-tive or unavailable, or an indwelling urinary catheter is

present, patients should either be treated to sterilize the

urine before surgery or receive a single preoperative

dose of an agent that is usually active against the

like-ly microorganisms

Antimicrobial prophylaxis decreases the incidence of

postoperative bacteriuria and septicemia in patients

with sterile preoperative urine undergoing transurethral

prostatectomy and transrectal prostatic biopsies.19-21

Prophylaxis is also recommended for ureteroscopy,

shock wave lithotripsy, percutaneous renal surgery,

open laparoscopic procedures, and for placement of a

urologic prosthesis (penile implant, artificial sphincter,

synthetic pubovaginal sling, bone anchors for pelvic

floor reconstruction).22 While the efficacy of

fluoro-quinolones for prophylaxis in urologic procedures has

76

been well established, resistance has emerged.23Local resistance patterns to the fluoroquinolones, particularly

with E coli, should be evaluated to guide appropriate

selection of antimicrobials

Antimicrobial prophylaxis decreases the incidence of

infection after vaginal or abdominal hysterectomy.24

Prophylaxis is also recommended for laparoscopic hysterectomies Antimicrobials can prevent infection

after elective and non-elective cesarean section;

administration of the dose prior to the initial skin inci-sion appears to be more effective than giving it after cord clamping.25Antimicrobial prophylaxis can also

prevent infection following elective abortion.26

HEAD AND NECK SURGERY — Prophylaxis with

antimicrobials has decreased the incidence of surgical site infection after clean-contaminated oncologic head and neck operations that involve an incision through the oral or pharyngeal mucosa.27 Prophylaxis is not beneficial in tonsillectomy or nasal septoplasty.28,29

NEUROSURGERY — An antistaphylococcal

antibi-otic can decrease the incidence of infection after

cran-iotomy.30 In spinal surgery, the infection rate after

conventional lumbar discectomy is low, but the serious consequences of postoperative infection at this site have led many surgeons to use perioperative antibi-otics Infection rates are higher after prolonged spinal surgery or spinal procedures involving fusion or inser-tion of foreign material, and prophylactic antibiotics are generally used for these.31 Studies have shown lower infection rates with use of prophylactic antibiotics for

implantation of permanent cerebrospinal fluid shunts

and for intrathecal pump placement.32The benefits of antimicrobial prophylaxis for ventriculostomy place-ment remain uncertain.33

OPHTHALMIC SURGERY — There is no

consen-sus supporting a particular choice, route or duration of antimicrobial prophylaxis for ophthalmic procedures, but based on available evidence, preoperative povidone-iodine applied to the skin and conjunctiva lowers the incidence of endophthalmitis.34Other pro-phylactic strategies include pre- and post-operative topical antibiotic eye drops, addition of antibiotics to the irrigating solution, and subconjunctival injections Use of intracameral injections is limited by lack

of commercial availability and potential toxicity if inaccurately dosed.35 There is no evidence that pro-phylactic antibiotics are needed for procedures that do not invade the globe

ORTHOPEDIC SURGERY — Antistaphylococcal

drugs administered prophylactically can decrease the incidence of both early and delayed infection after

joint replacement and surgical repair of closed

frac-tures.36-38 They also decrease the rate of infection

when hip and other closed fractures are treated with

internal fixation by nails, plates, screws or wires, and

in compound or open fractures.39Whether orthopedic

prophylaxis should be with a single dose or with

multiple doses for up to 24 hours is unclear.38-40A

ret-rospective review of patients undergoing arthroscopic

surgery concluded that antibiotic prophylaxis is not

indicated.41

THORACIC SURGERY — Antibiotic prophylaxis is

used routinely in thoracic surgery, but supporting data

are sparse In one study, a single preoperative dose of

cefazolin before pulmonary resection led to a decrease

in surgical site infection, but not in pneumonia or

empyema.42Insertion of chest tubes for non-traumatic

indications, such as spontaneous pneumothorax, does

not require antimicrobial prophylaxis

VASCULAR SURGERY — Preoperative

prophylax-is decreases the incidence of postoperative surgical site

infection after arterial reconstructive surgery on the

abdominal aorta, vascular operations on the leg that

include a groin incision, and amputation of the lower

extremity for ischemia.43,44Many experts also

recom-mend prophylaxis for implantation of any vascular

prosthetic material, such as grafts for vascular access

in hemodialysis Prophylaxis is not indicated for

carotid endarterectomy or brachial artery repair

with-out prosthetic material Prophylactic antibiotics are not

routinely recommended for endovascular stenting,

but risk factors that may justify using them include

repeat intervention within 7 days, prolonged

indwelling arterial sheath, prolonged procedure

dura-tion (>2 hours), presence of other infected implants or

immunosuppression.45,46

OTHER PROCEDURES — Antimicrobial

prophy-laxis is generally not indicated for cardiac

catheteriza-tion, varicose vein surgery, most dermatologic47 and

plastic surgery, arterial puncture, thoracentesis,

para-centesis, repair of simple lacerations, outpatient

treat-ment of burns, or dental extractions or root canal

ther-apy because the incidence of surgical site infections is

low

The need for prophylaxis in breast surgery (other than

for breast cancer),48hernia repair,49and other “clean”

surgical procedures has been controversial Most

experts generally do not recommend antibacterial

pro-phylaxis for these procedures because of the low rate

of infection and the potential for adverse effects with

prophylaxis; it may be considered for procedures with

high consequences of infection, such as those

involv-ing placement of prosthetic material (e.g., synthetic

mesh, saline implants, tissue expanders)

1 Endocarditis prophylaxis for dental procedures Med Lett Drugs Ther 2012; 54:73.

2 DR Snydman et al National survey on the susceptibility of Bacteroides fragilis group: report and analysis of trends in the United States from

1997 to 2004 Antimicrob Agents Chemother 2007; 51:1649.

3 F Baquero et al In vitro susceptibilities of aerobic and facultatively anaerobic gram-negative bacilli isolated from patients with intra-abdominal infections worldwide: 2005 results from Study for Monitoring Antimicrobial Resistance Trends (SMART) Surg Infect (Larchmt) 2009; 10:99.

4 T Crawford et al Vancomycin for surgical prophylaxis? Clin Infect Dis 2012; 54:1474.

5 Why not ertapenem for surgical prophylaxis? Med Lett Drugs Ther 2009; 51:72.

6 C Hebert and A Robicsek Decolonization therapy in infection control Curr Opin Infect Dis 2010; 23:340.

7 LG Bode et al Preventing surgical-site infections in nasal carriers of Staphylococcus aureus N Engl J Med 2010; 362:9.

8 DW Bratzler et al Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project Clin Infect Dis 2004; 38:1706.

9 G Zanetti et al Intraoperative redosing of cefazolin and risk for surgi-cal site infection in cardiac surgery Emerg Infect Dis 2001; 7:828.

10 JC de Oliveira et al Efficacy of antibiotic prophylaxis before the implantation of pacemakers and cardioverter-defibrillators: results of a large, prospective, randomized, double-blinded, placebo-controlled trial Circ Arrhythm Electrophysiol 2009; 2:29.

11 S Banerjee et al Antibiotic prophylaxis for GI endoscopy Gastrointest Endosc 2008; 67:791.

12 CE Edmiston et al Perioperative antibiotic prophylaxis in the gastric bypass patient: do we achieve therapeutic levels? Surgery 2004; 136:738.

13 MC Allison et al Antibiotic prophylaxis in gastrointestinal endoscopy Gut 2009; 58:869.

14 RC Yan et al The role of prophylactic antibiotics in laparoscopic cholecystectomy in preventing postoperative infection: a meta analy-sis J Laparoendosc Adv Surg Tech A 2011; 21:301.

15 RL Nelson et al Antimicrobial prophylaxis for colorectal surgery Cochrane Database Syst Rev 2009; (1):CD001181.

16 KM Itani et al Ertapenem versus cefotetan prophylaxis in elective col-orectal surgery N Engl J Med 2006; 355:2640.

17 BR Andersen et al Antibiotics versus placebo for prevention of post-operative infection after appendicectomy Cochrane Database Syst Rev 2005; (3):CD001439.

18 LM Mui et al Optimum duration of prophylactic antibiotics in acute non-perforated appendicitis ANZ J Surg 2005; 75:425.

19 A Berry and A Barratt Prophylactic antibiotic use in transurethral pro-static resection: a meta-analysis J Urol 2002; 167:571.

20 W Qiang et al Antibiotic prophylaxis for transurethral prostatic resec-tion in men with preoperative urine containing less than 100,000 bac-teria per ml: a systematic review J Urol 2005; 173:1175.

21 M Aron et al Antibiotic prophylaxis for transrectal needle biopsy of the prostate: a randomized controlled study BJU Int 2000; 85:682.

22 JS Wolf Jr et al Best practice policy statement on urologic surgery antimicrobial prophylaxis J Urol 2008; 179:1379.

23 DA Williamson et al Escherichia coli bloodstream infection after tran-srectal ultrasound-guided prostate biopsy: implications of fluoro-quinolone-resistant sequence type 131 as a major causative pathogen Clin Infect Dis 2012; 54:1406.

24 ACOG Practice Bulletin no 104: antibiotic prophylaxis for gyneco-logic procedures Obstet Gynecol 2009; 113:1180.

25 ACOG Committee Opinion no 465: antimicrobial prophylaxis for

cesare-an delivery: timing of administration Obstet Gynecol 2010; 116:791.

26 SL Achilles and MF Reeves Prevention of infection after induced abortion: release date October 2010: SFP guideline 20102 Contraception 2011; 83:295.

27 R Simo and G French The use of prophylactic antibiotics in head and neck oncological surgery Curr Opin Otolaryngol Head Neck Surg 2006; 14:55.

Treatment Guidelines from The Medical Letter • Vol 10 ( Issue 122) • October 2012 78

Antimicrobial Prophylaxis for Surgery

Coming Soon in Treatment Guidelines:

Drugs Some Common Eye Disorders – Nov 2012 Screening Tests for Cancer – Dec 2012

28 BJ O’Reilly et al Is the routine use of antibiotics justified in adult

ton-sillectomy? J Laryngol Otol 2003; 117:382.

29 M Caniello et al Antibiotics in septoplasty: is it necessary? Braz J

Otorhinolaryngol 2005; 71:734.

30 FG Barker 2nd Efficacy of prophylactic antibiotics against

meningi-tis after craniotomy: a meta-analysis Neurosurgery 2007; 60:887.

31 EM Brown et al Spine update: prevention of postoperative infection

in patients undergoing spinal surgery Spine 2004; 29:938.

32 KA Follett et al Prevention and management of intrathecal drug

deliv-ery and spinal cord stimulation system infections Anesthesiology

2004; 100:1582.

33 PJ McCarthy et al International and specialty trends in the use of

pro-phylactic antibiotics to prevent infectious complications after

inser-tion of external ventricular drainage devices Neurocrit Care 2010;

12:220.

34 TA Ciulla et al Bacterial endophthalmitis prophylaxis for cataract

sur-gery: an evidence-based update Ophthalmology 2002; 109:13.

35 G Yiu et al Prophylaxis against postoperative endophthalmitis in

cataract surgery Int Ophthalmol Clin 2011; 51:67.

36 B Al Buhairan et al Antibiotic prophylaxis for wound infections in

total joint arthroplasty: a systematic review J Bone Joint Surg Br

2008; 90:915.

37 L Prokuski Prophylactic antibiotics in orthopaedic surgery J Am

Acad Orthop Surg 2008; 16:283.

38 WJ Gillespie and GH Walenkamp Antibiotic prophylaxis for surgery

for proximal femoral and other closed long bone fractures Cochrane

Database Syst Rev 2010; (3):CD000244.

39 JP Southwell-Keely et al Antibiotic prophylaxis in hip fracture

sur-gery: a metaanalysis Clin Orthop Relat Res 2004; 419:179.

40 GP Slobogean et al Single- versus multiple-dose antibiotic

prophy-laxis in the surgical treatment of closed fractures: a meta-analysis J

Orthop Trauma 2008; 22:264.

41 JM Bert et al Antibiotic prophylaxis for arthroscopy of the knee: is it

necessary? Arthroscopy 2007; 23:4.

42 R Aznar et al Antibiotic prophylaxis in non-cardiac thoracic surgery:

cefazolin versus placebo Eur J Cardiothorac Surg 1991; 5:515.

43 AH Stewart et al Prevention of infection in peripheral arterial

recon-struction: a systematic review and meta-analysis J Vasc Surg 2007;

46:148.

44 S Homer-Vanniasinkam Surgical site and vascular infections:

treat-ment and prophylaxis Int J Infect Dis 2007; 11:S17.

45 P Beddy and JM Ryan Antibiotic prophylaxis in interventional

radi-ology—anything new? Tech Vasc Interv Radiol 2006; 9:69.

46 AM Venkatesan et al Practice guidelines for adult antibiotic

prophy-laxis during vascular and interventional radiology procedures Written

by the Standards of Practice Committee for the Society of Interventional

Radiology and Endorsed by the Cardiovascular Interventional

Radiological Society of Europe and Canadian Interventional Radiology

Association [corrected] J Vasc Interv Radiol 2010; 21:1611.

47 TI Wright et al Antibiotic prophylaxis in dermatologic surgery:

advi-sory statement 2008 J Am Acad Dermatol 2008; 59:464.

48 F Bunn et al Prophylactic antibiotics to prevent surgical site infection

after breast cancer surgery Cochrane Database Syst Rev 2012;

1:CD005360.

49 FJ Sanchez-Manuel et al Antibiotic prophylaxis for hernia repair.

Cochrane Database Syst Rev 2012; 2:CD003769.

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Treatment Guidelines

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Upon completion of this program, the participant will be able to:

1 Explain the current approach for antimicrobial prophylaxis for surgery.

2 Discuss the pharmacologic agents available for antimicrobial prophylaxis for patients undergoing various operations and compare them based on their

effica-cy, dosage and administration.

3 Determine the most appropriate prophylactic regimen given the clinical presentation and planned surgical procedure of an individual patient.

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Treatment Guidelines from The Medical Letter • Vol 10 ( Issue 122) • October 2012

1 To ensure adequate serum and tissue levels before surgery, the

first dose of cefazolin should be administered:

a >60 minutes after the incision

b <60 minutes before the incision

c >2 hours after the incision

d <3 hours before the incision

Issue 122

2 A 55-year-old man is undergoing percutaneous renal surgery to

remove large kidney stones Which antibiotic would be the best

choice for routine surgical prophylaxis?

a ertapenem

b cefotaxime

c cefazolin

d ceftazadime

Issue 122

3 Intraoperative redosing of a prophylactic antibiotic is

recommend-ed if:

a the duration of the procedure exceeds 1-2 half-lives of the

antimicrobial agent

b there is excessive blood loss

c there are extensive burns

d all of the above

Issue 122

4 The duration of antimicrobial prophylaxis for most procedures

should be:

a <24 hours

b <48 hours

c >4 days

d >7 days

Issue 122

5 A 51-year-old-woman is scheduled for a routine gastroesophageal

endoscopy She asks if she should take any antibiotics before or

after the procedure You could tell her that:

a antimicrobial prophylaxis is not recommended for this

proce-dure

b she should take a 3-day course of antibiotic therapy after the

procedure

c she should take a 5-day course of antibiotic therapy before

the procedure

d she should take antibiotics 1 day before and 2 days after the

procedure

Issue 122

6 Antimicrobial prophylaxis is recommended before biliary tract

sur-gery for patients:

a >70 years old

b with acute acute cholecystitis

c with common duct stones

d all of the above

Issue 122

7 Which of the following antibiotics has been approved for prophy-laxis of surgical site infections following elective colorectal proce-dures, but its routine use for this indication is controversial?

a piperacillin/tazobactam

b cefazolin

c ampicillin/sulbactam

d ertapenem

Issue 122

8 A 38-year-old-woman is undergoing an abortion She asks if she should take any medication before or after the procedure You could tell her that:

a she should take 100 mg of doxycycline before and 200 mg after the procedure

b antimicrobial prophylaxis is not recommended

c she should take 300 mg of doxycycline after the procedure

d none of the above

Issue 122

9 Administration of prophylactic antibiotics is recommended for:

a prolonged spinal surgery

b spinal procedures involving insertion of foreign material

c implantation of permanent cerebrospinal fluid shunts

d all of the above

Issue 122

10 Prophylactic administration of antistaphylococcal drugs can decrease the rate of infection after:

a joint replacement

b surgical repair of closed fractures

c internal fixation of hip fractures with nails or screws

d all of the above

11 Prophylaxis is not recommended for patients undergoing:

a arterial reconstructive surgery

b implantation of vascular prosthetic material

c carotid endarterectomy

d amputation of the lower extremity

Issue 122

12 Antimicrobial prophylaxis is generally not recommended for:

a varicose vein surgery

b thoracentesis

c dental extractions

d all of the above

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Issue 122 Questions

ACPE UPN: 0379-0000-12-122-H01-P; Release: September 2012, Expire: September 2013