APPENDIX B: UWHC SURGICAL ANTIMICROBIAL PROPHYLAXIS GUIDELINES

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1 APPENDIX B: UWHC SURGICAL ANTIMICROBIAL PROPHYLAXIS GUIDELINES Principles of prophylaxis 1) Use antimicrobials for surgical procedures where prophylactic antimicrobials have been found to be beneficial. 2) Time antimicrobial administration so that the agent is present in the potentially contaminated tissue before the bacteria enter the site (i.e. at the time of surgical incision and persisting in tissues throughout the period of potential contamination). Antimicrobials vary in their distribution pharmacokinetics. The goal is begin delivery of the antimicrobial minutes before incision to ensure infusion is complete prior to incision. Vancomycin and ciprofloxacin, which must be infused over 60 minutes, may be begun 120 minutes prior to incision). 3) For longer cases, appropriate antibiotics should be redosed according to their t ½ lives. 4) Appropriate antibiotics should be redosed after significant blood loss (4 units or 1000 ml). 5) Limit the duration of antimicrobial prophylaxis. Studies document that postoperative antimicrobial administration is not necessary for many surgeries. 6) Plan the route of antimicrobial administration, for example, use oral antimicrobials for gut decontamination 7) Select an antimicrobial which is active against the most common surgical wound pathogens. Clean - Contaminated Head and Neck 3 LIKELY PATHOGENS ANTIMICROBIAL REGIMEN OR REDOSING COMMENTS Basic Case Normal flora of the mouth, Cefuroxime g IV preop Major head and neck surgical cases where mouth or pharynx is entered 3 various streptococci (including aerobic and anaerobic species), Staph aureus, Peptostreptococcus, Neisseria and numerous anaerobic Gram- negative bacteria including Porphyromonas (Bacteroides), Prevotella (Bacteroides), Fusobacterium and Veillonella. Nasal flora includes Staphylococcus, Streptococcus pyogenes, Strep pneumoniae, Moraxella and Haemophilus species. Clindamycin 900 mg IV plus gentamicin 1.7 mg/kg IV preop 1.5 g-3 g IV preop Cefuroxime 1.5 g IV plus Metronidazole 500 mg IV pre-op Cefoxitin 4 1 g IV preop Unasyn every 4 Metronidazole every 6 Risk is high for mixed infections of anaerobes, staphylococci and some Gram-negative rods. Risk is high for mixed infections of anaerobes and staphylococci but not Pseudomonas.

2 Gastrointestinal LIKELY PATHOGENS ANTIMICROBIAL REGIMEN OR REDOSING COMMENTS GI:Cholecystectomy 3 GI: Upper Gastroduodenal 3 Escherichia coli and Klebsiella. Streptococci and staphylococci are occasionally isolated. Anaerobic bacteria are uncommon, but Clostridium is possible. Most common are nasopharyngeal commensals (streptococci, lactobacilli and diphtheroids) Cefazolin 1 g IV 4 pre-op Cefazolin 4 1 g IV pre-op Cefuroxime 1.5 g IV pre-op Bacteria isolated from bile during surgery are those most likely to be associated with wound infections. Prophylaxis indicated only for patients with increased ph from the use of H2 receptor blockers, proton pump inhibitors, with gastric obstruction or GI hemorrhage. GI: Colorectal 3 Enteric Gram-negative bacilli, anaerobes, with E. coli and Bacteroides fragilis the most common organisms. Bowel prep (day before surgery): Metoclopramide 10 mg PO 30 min. prior to GI lavage 1.5 L Q1H until clear (max. 4-6 L). When GI lavage is clear, start neomycin 1 g PO with erythromycin 1 g PO at 1300, 1400, and g-3 g IV pre-op Cefoxitin 1-2 g IV pre-op Ciprofloxacin 400 mg IV pre-op plus Metronidazole mg IV pre-op. Unasyn every 4 Ciprofloxacin: none Metronidazole every 6 Metronidazole 750 mg may be substituted for erythromycin in erythromycin-sensitive patients. NOTE: 50% of trials evaluated demonstrated <5% post-op infection rate and 90% of trials evaluated demonstrated <10% post-op infection rate with bowel prep alone. Systemic regimens reduce rate of infection beyond that seen with bowel prep as outlined above. If enterococcus is suspected or confirmed, vancomycin 1 g IV would be an alternative in the penicillinsensitive patient (this regimen would cover Enterococcus). Most primary prophylaxis regimens do not require coverage for Enterococcus or Pseudomonas. Clindamycin 900 mg IV plus gentamicin 1.7 mg/kg IV 30 pre-op GI: Appendectomy 3 Anaerobic organisms (especially B fragilis) and Gram-negative enteric organisms (predominantly E coli). Staphylococcus, Enterococcus and Pseudomonas species have also been reported. Uncomplicated: Cefoxitin 4 1 g IV pre-op Complicated (adult): g IV pre-op Complicated (children): Unasyn every 4 The incidence of infectious complications following appendectomy is dependent on the condition of the appendix at the time of surgery mg/kg pre-op

3 Gynecologic LIKELY PATHOGENS ANTIMICROBIAL REGIMEN OR REDOSING COMMENTS Lactobacillus sp. Staph aureus Corynebacterium sp. Gram-negative organisms Anaerobes Cefazolin 4 2 g IV Or Cefoxitin 4 2 g IV Or Clindamycin 900 mg Q8H IV plus gentamicin 1.7 mg/kg IV 30 min pre-op for penicillin-allergic patients Cardiothoracic LIKELY PATHOGENS ANTIMICROBIAL REGIMEN OR REDOSING COMMENTS General Cardiothoracic Coagulase-negative staph, Staph aureus, Corynebacterium, enteric Gram--negative bacilli. Cefuroxime 4,5 1.5 g IV pre-op AND/OR vancomycin 1 g IV (single dose) if implantation of prosthetic/valvular graft (Staphylococcus epidermidis), or if patient is MRSA-positive or at end of cardiopulmonary bypass. Vancomycin: none Cefuroxime has enhanced activity against coagulase-negative staphylococci Vancomycin 1 g IV, if penicillin allergic Left Ventricular Assist Device Rifampin 600 mg PO plus Ciprofloxacin 400 mg IV Fluconazole 400 mg IV Vancomycin 15 mg/kg (up to 1 g) IV Ciprofloxacin every 12 Fluconazole every 12 Vancomycin every 12 Lung transplant: Cystic Fibrosis patient Check Infectious Disease Recommendations

4 Vascular LIKELY PATHOGENS ANTIMICROBIAL REGIMEN OR REDOSING COMMENTS Abdominal aortic aneurysm: elective or ruptured Thoracoabdominal aneurysm Aortobifem/iliac bypass Renal or carotid endarterectomy Staph aureus (predominant), also Gram--negative bacilli, coagulase-negative staphylococci and enterococci Cefuroxime 4,5 1.5 g IV pre-op AND/OR vancomycin 1 g IV (single dose) if implantation of prosthetic/valvular graft (Staphylococcus epidermidis), or if patient is MRSA-positive Vancomycin 1 g IV, if penicillin allergic Vancomycin: none All preoperative antibiotics should be administered within 1 hour of incision Below/above knee amputations Lower extremity bypass (no warfarin) Transmetatarsal amputation Toe amputation 1st rib resection Neurosurgical LIKELY PATHOGENS ANTIMICROBIAL REGIMEN OR REDOSING COMMENTS Craniotomy Cerebrospinal fluid shunt Staphylococcus aureus, coagulase-negative staphylococci Staphylococci account for 75-80% of wound infections following shunt procedures; Gram--negative bacteria 1-20%. Cefazolin 4 1 g IV pre-op Cefuroxime 4,5 1.5 g IV pre-op Vancomycin 1 g IV as a single dose (IF incidence of infections with MRSA >10% in an institution, vancomycin is recommended, otherwise it is optional) Organisms listed represent >85% of post-op infections IF incidence of infections with MRSA >10% in an institution, vancomycin is recommended, otherwise it is optional

5 Orthopedics LIKELY PATHOGENS ANTIMICROBIAL REGIMEN OR REDOSING COMMENTS Total joint replacement Staphylococcus aureus and Staphylococcus epidermidis and various streptococci cause >66% of wound infections. Cefazolin 1,4 1 g IV preop Cefuroxime g IV pre-op Cefuroxime has enhanced activity against coagulase-negative staphylococci Use vancomycin only for severe penicillin allergy or if MRSA+. Some clinicians use clindamycin in penicillinallergic patients Vancomycin (15 mg/kg), up to 1 g IV pre-op if MRSA+ Hip fracture repair Staphylococci Cefazolin 1,4 1 g IV pre-op Cefuroxime g IV pre-op Vancomycin (15 mg/kg) up to 1 g IV if MRSA+ Use vancomycin only for severe penicillin allergy or MRSA+. Some clinicians use clindamycin in penicillin-allergic patients Clean orthopedic procedures (other) Staphylococci Minor procedures - None Major procedures Cefazolin 4 1 g IV preop, Use vancomycin only for severe penicillin allergy. Some clinicians use clindamycin in penicillin-allergic patients. Vancomycin 1 g IV preop if patient is MRSA-positive Genitourinary LIKELY PATHOGENS ANTIMICROBIAL REGIMEN OR REDOSING COMMENTS Transurethral Resection of Prostate 3 E coli as well as other Gram-- negative bacilli and enterococci Gentamicin 80 mg IV (single dose) plus Ampicillin 500 mg - 1 g IV (single dose) pre-op Ciprofloxacin 500 mg PO or 400 mg IV pre-op (single dose) None If urine is sterile the role of perioperative prophylaxis is probably of marginal benefit. Continuing antibiotic prophylaxis post TURP is strongly discouraged and will greatly increase the risk of nosocomial UTI with enterococci, resistant Gram-- negative bacilli, and candida.

6 Dirty Injury LIKELY PATHOGENS ANTIMICROBIAL REGIMEN OR REDOSING COMMENTS Ruptured viscus 3 Enteric Gram--negative bacilli, anaerobes (Bacteroides fragilis) and enterococci. Unasyn (ampicillin/sulbactam) 3 g IV pre-op Piperacillin/tazobactam 4.5 g IV pre-op Unasyn every 4 Pip/Tazo every 4 Gentamicin every 8 Use Unasyn for community-based peritonitis. Use piperacillin/tazobactam for peritonitis that develops secondarily in hospitalized patients or patients with prior antibiotic use at risk for resistant bacteria such as Enterococcus and Pseudomonas. Clindamycin 900 mg IV plus gentamicin 1.7 mg/kg IV pre-op for penicillin-allergic patients Traumatic wound Staphylococcus aureus, Group A streptococci, clostridia Cefazolin 4 1 g IV pre-op Cefuroxime 4,5 1.5 g IV plus or minus gentamicin 80 mg (or tobramycin 3.3 mg/kg) IV pre-op Add vancomycin 1g IV if MRSA+ Organisms may vary depending on source of injury. If wound has been massively contaminated by soil, manure or dirty water, a regimen with activity against P. aeruginosa, S. aureus, and other Gram--negative bacilli is recommended.

7 Footnotes: 1. This population is usually elderly and doses should be adjusted accordingly based on renal function. 2. Patients receiving vancomycin preoperatively may be given diphenhydramine 50 mg IV just before the vancomycin to reduce the risk of hypotension secondary to histamine release 3. Add endocarditis prophylaxis in patients at risk (ampicillin 2 g IV given 30 min prior to incision or vancomycin 1 g IV over 1 hour, completing infusion within 30 min of starting procedure). 4. Use clindamycin 600 mg 30 min pre-op for penicillin-allergic patients where the reaction is severe enough (i.e.: hives, angioedema, anaphylaxis) to warrant avoiding cephalosporins 5. Use cefazolin 1-2 g IV if cefuroxime is not available. References: 1. Clinical Infectious Diseases 2004;38: Arch Surg 1993; 128: Infect Control Hosp Epidemiol 1999; 20: Clin Pharm 1992; 11: Medical Letter 2004; 2: ASHP Therapeutic Guidelines on Antimicrobial Prophylaxis in Surgery April 21, 1999