Surgical Prophylaxis -- antimicrobial use
  • Overview --Choice of agents (principles)
    • need not eradicate every potential pathogen
    • Effective agent example -- cefazolin (Ancef, Defzol)
      • long serum half-life
    •  Methicillin (Staphcillin)-resistant Staphylococcus aureus or methicillin (Staphcillin)-resistant coagulase-negative staphylococci -- vancomycin (Vancocin)
      •  routine use of vancomycin (Vancocin) for prophylaxis-- discouraged since it promotes vancomycin (Vancocin)-resistant strains
    • Colorectal surgery & appendectomy: cefoxitin (Mefoxin) or cefotetan (Cefotan) preferred due to enhanced activity relative to cefazolin (Ancef, Defzol) against anaerobes (bowel), e.g. Bacteriodes fragilis
    •  Agents not recommended
      •  Third-generation cephalosporins (cefotaxime (Claforan), ceftriaxone (Rocephin), cefoperazone (Cefobid), ceftazidime (Fortax, Taxidime, Tazicef), or ceftizoxime (Cefizox)
      •  Fourth-generation cephalosporins: e.g. cefepime (Maxipime)
      •  Rationale:
        •   expense, some are less activin cefazolin (Ancef, Defzol) (against staphylococci)
        •   non-optimal spectrum of action (includes activity against organisms not commonly encountered in elected surgery
        •   widespread for prophylaxis encourages emergence of resistance
  •  Cardiac Surgery
    •  Prosthetic valve, coronary bypass, other open-heart procedures, pacemaker/defibrillator implantation
      •  Probable pathogen: -- Staphylococcus epidermidis, Staphylococcus aureus,Corynebacterium, enteric gram-negative bacilli
      •  Antibacterial drug:
        •  cefazolin (Ancef, Defzol), cefuroxime (Zinacef, Ceftin)-- IV
        • Vancomycin, IV(Vancocin) (if above agents are ineffective or contraindicated)
      •  Antibacterial drug pre-treatment reduces infection incidence after cardiac surgery;
        • Significant reduction in the infection incidence associated with permanent pacemaker implantation
  •  Gastrointestinal diseases
    •  Esophageal/gastroduodenal
      • Probable pathogens:enteric gram-negative bacilli, gram-positive cocci
      • Treatment (high-risk only, i.e. esophageal obstruction, decreased gastric acidity/gastrointestinal motility, morbid obesity)
        • cefazolin (Ancef, Defzol) (IV)
    •  Biliary tract
      • Probable pathogens: enteric gram-negative bacilli, enterococci, clostridia
      • Treatment (high-risk only,i.e. age > 70, acute cholecystitis, non-functioning gallbladder, obstructive jaundice or common duct stones)
        • cefazolin (Ancef, Defzol) (IV)
    •  Colorectal
      • Probable pathogens: enteric gram-negative bacilli, anaerobes, enterococci
      • Treatment:
        • Oral --neomycin + erythromycin base
        • Parenteral -- cefoxitin (Mefoxin) or cefotetan (Cefotan) Or
        • Parenteral-- cefazolin (Ancef, Defzol) + metronidazole (Flagyl)
    •  Appendectomy, non-perforated
      •  Probable pathogens: enteric gram-negative bacilli, anaerobes, enterococci
      •  Treatment: cefoxitin (Mefoxin) Lorcet (hydrocodone/acetaminophen) fatigue and (IV)
    • Antibiotic prophylaxis:
      •   recommended for esophageal surgery with obstruction -- obstruction increases infection risk
      •  factors that promote high infection risk after gastroduodenal surgery:
        •   reduced gastric acidity and gastrointestinal motility -- reduction may occur because of:
          • obstruction
          • hemorrhage
          • gastric ulcer
          • malignancy
          • treatment with H2 blocker {ranitidine (Zantac)} or proton pump, inhibitors {e.g. omeprazole (Prilosec)}
          • morbid obesity
    •  Antibiotic prophylaxis not indicated for:
      •  routine gastroesophageal endoscopy (may be used for high-risk patients undergoing esophageal dilatation or sclerotherapy of varicies)
  • Gynecologic & Obstetric
    •  Vaginal or abdominal hysterectomy
      •  Probable pathogens: Enteric gram-negatives, anaerobes, enterococci, Group B strep
      •  Treatment: cefazolin (Ancef, Defzol) or cefotetan (Cefotan) or cefoxitin (Mefoxin)(IV)
    •  Cesarean section
      •  Probable pathogens: Enteric gram-negatives, anaerobes, enterococci, Group B strep
      •  Treatment: high-risk {active labor or premature membrane rupture};cefazolin (Ancef, Defzol) -- IV after cord clamping
    •  Abortion
      •  Probable pathogens: Enteric gram-negatives, anaerobes, enterococci, Group B strep
      •  Treatment: first trimester, high-risk {patients with previous pelvic inflammatory disease, previous gonorrhea or multiple sex partners) -- aqueous penicillin V (Pen-Vee K, Veetids) or doxycycline (Vibramycin, Doryx)
    •  Antibacterial prophylaxis:
      •  reduces infection incidence following vaginal hysterectomy & abdominal hysterectomy (probably)
      •  Perioperative/preoperative antibiotics: prevention of infection when given:
        •  following cord clamping in emergency cesarean section
        • high-risk situations {active Labor, premature membrane rupture,after mid-trimester abortion}
          • Possibly substantial protective effect of perioperative antibiotics in all women undergoing therapeutic abortions
  • Genitourinary
    •  Probable pathogens: enteric gram-negative bacilli, enterococci
    •  Treatment: high-risk only (urinate culture positive/unavailable; preoperative catheter, transrectal prostatic biopsy) --ciprofloxacin (Cipro) {PO or IV}
  • Head & Neck Surgery
    •  Incision through oral/pharyngeal mucosa.
    • Probable pathogens: Anaerobes, enteric gram-negative bacilli, Staphylococcus aureus
    • Treatment: clindamycin (Cleocin) + gentamicin (Garamycin)
      • reduce the high incidence of wound infection following head/neck operations which utilize incisions through oral or pharyngeal mucosal
  • Neurosurgery
    •  Craniotomy
    •  Probable pathogens: Staphylococcus aureus, Staphylococcus epidermidis
    •  Treatment: cefazolin (Ancef, Defzol) or vancomycin (Vancocin) (IV)
    • Antibacterial prophylaxis
      •  cerebrospinal fluid shunt: conflicting research results
      • Craniotomy: antistaphylococcal antibiotic -- reduced infection incidence
      •  Spinal surgery: antibiotics not effective in reducing the already low postoperative infection rate following conventional lumbar discectomy.
      •  Questionable effectiveness (not yet demonstrated in controlled clinical trials) for spinal fusion, prolonged spine surgery, or insertion of foreign material
  • Ophthalmic
    •  Probable pathogens: Staphylococcus epidermidis, Staphylococcus aureus, streptococci, enteric gram-negative bacilli, Pseudomonas
    •  Treatment: gentamicin (Garamycin), tobramycin (Nebcin), ciprofloxacin (Cipro), ofloxacin (Floxin), or neomycin-gramicidin-polymixin B; cefazolin (Ancef, Defzol)
    •  Most ophthalmologist use antibiotic eyedrops for prophylaxis in view of the potential for extremely serious postoperative endophthalmitis.{limited data to support effectiveness of prophylactic antimicrobials}
      • No evidence for the rational basis for use of prophylactic antibiotics when procedures do not invade the globe
  • Orthopedic
    •  Total joint replacement, internal fracture fixation
    •  Probable pathogens: Staphylococcus aureus, Staphylococcus epidermidis
    •  Treatment: cefazolin (Ancef, Defzol) or vancomycin (Vancocin) (IV)
    •  Rationale for Prophylaxis:
      •  antistaphylococcal agents decrease incidence of early & late infection following joint replacement
      •  decrease infection rate in compound/open fractures and when hip & other fractures are managed with internal fixation using nails, plates, screws, or wires
      •  For diagnostic & operative arthroscopic surgery -- antibody prophylaxis is not justified
  • Thoracic (noncardiac)
    •  Probable pathogens: Staphylococcus aureus, Staphylococcus epidermidis, streptococci, enteric gram-negative bacilli
    •  Treatment: cefazolin (Ancef, Defzol) or cefuroxime (Zinacef, Ceftin) or vancomycin (Vancocin)
    •  Rationale for Prophylaxis:
      •  commonly used for routine pulmonary surgery; limited research support
      •  insertion of chest tubes following closed-tube thoracostomy following chest trauma: cephalosporin (multiple doses) can prevent infection
      •  single preoperative cefazolin (Ancef, Defzol) dose (pulmonary resection): decrease in the incidence of wound infection -- no decrease in incidence of pneumonia or empyema
  • Vascular
    •  Arterial surgery (involving: a prosthesis, abdominal aorta, or groin incision)
      • Probable pathogen: Staphylococcus aureus, Staphylococcus epidermidis, enteric gram-negative bacilli
      • Treatment: cefazolin (Ancef, Defzol) or vancomycin (Vancocin)
    •  A lower extremity amputation for ischemia
      • Probable pathogen: Staphylococcus aureus, Staphylococcus epidermidis, enteric gram-negative bacilli, clostridia
      • Treatment: cefazolin (Ancef, Defzol)--or cefoxitin (Mefoxin) for better anaerobic coverage--or vancomycin (Vancocin)
    •  Rationale for prophylaxis:
      •  Cephalosporin: reduced likelihood of postoperative infection incidences following arterial reconstructive surgery on the abdominal aorta, vascular limb operations involving groin incisions, and lower extremity amputation for ischemia
      •  Recommended: for any vascular prosthetic material implantation (e.g. grafts supporting hemodialysis)
      •  Not indicated: carotid endarterectomy or brachial artery repair (assuming no prosthetic material involved)
The Medical Letter on Drugs and Therapeutics, "Antimicrobial Prophylaxis in Surgery", vol. 41 (issue 1060), August 27, 1999