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Surgical Decolonization and Prophylaxis
from Antimicrobial Guide
by uri703
SurgicalDecolonization and Prophylaxis DECOLONIZATION Surgical Decolonization and Prophylaxis Surgical Decolonization and Prophylaxis
MRSA Nasal Negative Screening Result MSSA Negative MRSA Negative MRSA Positive MSSA Negative
MRSA Positive
• No decolonization required • Intranasalmupirocin twice dailyx 5days,
AND
• • Chlorhexidine bathingone day priorto surgeryIntranasalmupirocin twice daily x 5 days,
AND
ANTIMICROBIAL PROPHYLAXIS • Chlorhexidine bathing one day prior to surgery
CLINICAL CONSIDERATIONSANTIMICROBIAL PROPHYLAXIS
• Preoperative dose-timing CLINICAL CONSIDERATIONS
Within60 minutesofsurgical incision • Exceptions: vancomycinPreoperative dose-timing and fluoroquinolones within 120minutesof surgical incision Within 60 minutes of surgical incision • Weight-based dosingExceptions: vancomycin and fluoroquinolones within 120 minutes of surgical
Cefazolin incision : 2 gm forpatients <120 kg,and3 gm forpatients≥120 kg • Vancomycin:use ABWWeight-based dosing
Gentamicin: use ABWunless ABWis>120%of their IBW,in whichcaseuse Cefazolin: 2 gm for patients <120 kg, and 3 gm for patients ≥120 kg
AdjBW (see below for equation)Vancomycin: use ABW • Duration of prophylaxis Gentamicin: use ABW unless ABW is >120% of their IBW, in which case use
A single dose,or continuationfor <24hoursisrecommended AdjBW (see below for equation) • Duration of prophylaxis
INTRA-OPERATIVE REDOSING A single dose, or continuation for <24 hours is recommended • Required if theduration of procedure exceedstwohalf-livesof the drugor if thereINTRA-OPERATIVE REDOSING is extensive blood lossduring theprocedure (>1500mL) Ŧ • • Recommendation: usethe sameantibioticdoseand measurethe redosing interval Required if the duration of procedure exceeds two half-lives of the drug or if there from the time of administrationof thepreoperativedose,not the time of incision is extensive blood loss during the procedure (>1500 mL) Ŧ • Recommendation: use the same antibiotic dose and measure the redosing intervalABW= actual body weight; AdjBW= adjustedbody weight;IBW= ideal body weight;MRSA= Methicillin-resistant Staphylococcus aureus;MSSA= Methicillin-susceptible Staphylococcus aureus from the time of administration of the preoperative dose, not the time of incision
ŦRedosingmay notbenecessary forpatientswithpoorrenal function(CrCl <30mL/min)ABW= actual body weight; AdjBW= adjusted body weight; IBW= ideal body weight; MRSA= Methicillin-resistant Staphylococcus aureus; MSSA= Methicillin-susceptible Staphylococcus aureus
IBW Calculation: AdjBWCalculation:
Male = 50 kg + [2.3 kg foreachinchover5feet] AdjBW = 0.4 (ABW-IBW) + IBWŦ Redosing may not be necessary for patients with poor renal function (CrCl <30mL/min) Female = 45 kg + [2.3 kg foreachinchover5 feet]IBW Calculation: AdjBWCalculation: Male = 50 kg + [2.3 kg for each inch over 5 feet] AdjBW = 0.4 (ABW-IBW) + IBW Female = 45 kg + [2.3 kg for each inch over 5 feet]
References:
1. Schweuzer ML, Chiang H, Septimus E, Moody J, Braun B, Hafner J, et al. Association of a Bundled Intervention with Surgical Site Infections Among Patients Undergoing Cardiac, Hip, or Knee Surgery (STOP SSI – Study to Optimally Prevent SSI in Select Cardiac and Orthopedic Procedures). References: JAMA 2015; 313(21): 2162-2171. 2. 1. Chen AF, Wessel CB, RaoSchweuzer ML, Chiang H,N. Staphylococcus aureus Screening and Decolonization in Orthopaedic Surgery and Reduction of Surgical Site Septimus E, Moody J, Braun B, Hafner J, et al. Association of a Bundled Intervention with SurgicalSiteInfections Infections. Clin Orthop Relat Res 2013; 471: 2383-2399. AmongPatientsUndergoingCardiac,Hip,orKnee Surgery (STOP SSI – Studyto OptimallyPreventSSIin Select Cardiacand Orthopedic 3. Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Procedures). JAMA 2015; 313(21):2162-2171. AuwaerterPG, Bolon MK, et al. Clinical practice guidelines for antimicrobial prophylaxis in 2. surgery. Am J Health SystChen AF, Wessel CB, Rao Pharm 2013; 70:195-283.N. Staphylococcus aureus Screeningand Decolonization in Orthopaedic Surgeryand Reduction of SurgicalSite Infections. Clin Orthop Relat Res 2013; 471: 2383-2399. 3. Bratzler DW, DellingerEP, OlsenKM, Perl TM, AuwaerterPG, Bolon MK,et al. Clinical practiceguidelinesfor antimicrobial prophylaxisinPAGE 29 surgery. Am J Health Syst Pharm 2013; 70:195-283.
Antimicrobial Surgical Prophylaxis REDOSING RECOMMENDATIONSAntimicrobial Surgical Prophylaxis Antimicrobial Surgical Prophylaxis
Antibiotic
R Half-life (hours)EDOSING RECOMMENDATIONS RedosingInterval (hours)
Ampicillin/sulbactam Antibiotic 0.8-1.3
Half-life (hours)
2
Redosing Interval (hours)
Cefazolin Ampicillin/sulbactam 1.2-2.2 0.8-1.3
Cefoxitin Cefazolin
0.7-1.1 1.2-2.2
Ciprofloxacin Cefoxitin
3-7 0.7-1.1
Clindamycin Ciprofloxacin Gentamicin Clindamycin Metronidazole Gentamicin
2-4 3-7 2-3 2-4 6-8 2-3
Vancomycin Metronidazole
SURGICAL PROCEDUREVancomycin RECOMMENDED AGENTS ALTERNATIVES FOR PATIENTSWITH ALLERGY BETA-LACTAM
4-8 6-8
4-8
Laparoscopic, low-risk SURGICAL PROCEDURE RECOMMENDED AGENTS ALTERNATIVES FOR PATIENTSWITH ALLERGY BETA-LACTAM
None
Laparoscopic, Laparoscopic, high-risklow-risk Laparoscopic, high-risk Small intestine, nonobstructed Cefazolin, None cefoxitin, cefotetan, ceftriaxone, ampicillin/sulbactamCefazolin, cefoxitin, cefotetan, ceftriaxone, Cefazolin ampicillin/sulbactam
Cefazolin Cefazolin + metronidazole, cefoxitin, cefotetan Small intestine, Cefazolin + metronidazole, Hernia repair obstructed Cefazolin cefoxitin, cefotetan
4 2 2 4 Not necessary 2 6 Not necessary Not necessary 6 Not necessary Not necessary Not necessary Not necessary
Not necessary
None
Clindamycin or vancomycinNone + aminoglycoside or aztreonamor fluoroquinolone Clindamycin or vancomycin + aminoglycoside or aztreonamor fluoroquinoloneClindamycin +aminoglycoside or aztreonamor fluroquinolone Clindamycin + aminoglycoside or Metronidazole +aminoglycoside or aztreonamor fluroquinolone fluoroquinolone Metronidazole + aminoglycoside or Clindamycin, vancomycinfluoroquinolone
Colorectal Hernia repair Cefazolin + Cefazolin metronidazole, cefoxitin, cefotetan, Colorectal ampicillin/sulbactam, Cefazolin + metronidazole, ceftriaxone + cefoxitin, cefotetan, metronidazole, ertapenemampicillin/sulbactam, ceftriaxone + Headand neck, None metronidazole, ertapenem clean Clindamycin +aminoglycoside or Clindamycin, vancomycin aztreonamor fluroquinolone; Metronidazole +aminoglycoside or Clindamycin + aminoglycoside or fluoroquinolone aztreonamor fluroquinolone; Metronidazole + aminoglycoside or fluoroquinolone None
Head and neck, Head and clean neck, placement of prosthetic Head and neck, placement of Cleanprosthetic contaminated cancer surgery Cleancontaminated cancer surgery None
None Cefazolin,cefuroxime Clindamycin
Cefazolin, cefuroxime Clindamycin
Cefazolin + metronidazole, cefuroxime + metronidazole, Cefazolin + metronidazole, ampicillin/sulbactam cefuroxime + metronidazole, ampicillin/sulbactam Clindamycin
Clindamycin
References:
1. Bratzler DW, Dellinger EP, Olsen KM, Perl TM, AuwaerterPG, Bolon MK, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm 2013; 70:195-283.
References:
1. Bratzler surgery. DW, DellingerEP, OlsenKM, Perl TM, AuwaerterPG, Am J Health Syst Pharm 2013; 70:195-283. Bolon MK,et al. Clinical practiceguidelinesfor antimicrobial prophylaxisinPAGE 30
SURGICAL PROCEDURE RECOMMENDED AGENTS ALTERNATIVES FOR PATIENTS BETA-LACTAM ALLERGY Antimicrobial Surgical Prophylaxis Antimicrobial Surgical Prophylaxis WITH
Ortho: clean hand, SURGICAL PROCEDURE None RECOMMENDED AGENTS ALTERNATIVES FOR PATIENTS BETA-LACTAM ALLERGY WITH knee, or foot not involving implantation Ortho: clean hand, None of foreign materials knee, or foot not involving implantation Ortho:implantation of of foreign materials Cefazolin foreignmaterial and/or total joints Ortho: implantation of Cefazolin foreign material and/or Urologic with risktotal joints Fluoroquinolone, factors for infection TMP/SMX, cefazolin Urologic with risk Urologic, cleanwithout factors for infection entryinto urinarytract Urologic, clean without Urologic involving entry into urinary tract implanted prosthesis Urologic involving implanted prosthesis
Urologic, cleanwith entryinto urinarytract Urologic, clean with Urologic, cleanentry into urinary tract contaminated Fluoroquinolone, Cefazolin* TMP/SMX, cefazolin
Cefazolin* Cefazolin ± aminoglycoside, cefazolin ±Cefazolin ±aztreonam, ampicillin/sulbactam aminoglycoside, cefazolin ± aztreonam, Cefazolin* ampicillin/sulbactam
Cefazolin* Cefazolin + metronidazole, cefoxitin Urologic, clean- Cefazolin + TMP/SMX= trimethoprim/ contaminated sulfamethoxazolemetronidazole, cefoxitin *Addition of asingle dose ofan aminoglycosidemay be recommendedfor placement of prosthetic material (e.g.penile prosthesis) None
None
Clindamycin, vancomycin
Clindamycin, vancomycin
Aminoglycoside +/- clindamycin
Clindamycin, vancomycinClindamycin ± aminoglycoside or aztreonam, vancomycin ± aminoglycoside or aztreonamClindamycin ± aminoglycoside or aztreonam, vancomycin ± aminoglycoside or aztreonam Fluoroquinolone, aminoglycoside ± clindamycin Fluoroquinolone, aminoglycoside ± Fluoroquinolone clindamycin , aminoglycoside + metronidazoleor clindamycin Fluoroquinolone, aminoglycoside + metronidazoleor clindamycin
TMP/SMX= trimethoprim/sulfamethoxazole *Addition of a single dose of an aminoglycoside may be recommended for placement of prosthetic material (e.g. penile prosthesis)
References:
1. Bratzler DW, Dellinger EP, Olsen KM, Perl TM, AuwaerterPG, Bolon MK, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm 2013; 70:195-283.
References:
1. Bratzler surgery. DW, DellingerEP, OlsenKM, Perl TM, AuwaerterPG, Am J Health Syst Pharm 2013; 70:195-283. Bolon MK,et al. Clinical practiceguidelinesfor antimicrobial prophylaxisinPAGE 31
