Antimicrobial Prophylaxis in Specific Surgical Procedures

Gynecologic and Obstetric

Enteric gram-negative bacilli, anaerobes, group B streptococci, and enterococci are all possible pathogens that may be encountered in gynecologic or obstetric surgeries.

For patients undergoing hysterectomy, cefoxitin or cefotetan are appropriate therapies (Table 85-3). Cefazolin or ampicillin/sulbactam may be used. In the case of ft-lactam allergy, the following regimens are appropriate: clindamycin combined with gentamicin, aztreonam, or ciprofloxacin; metronidazole combined with gentamicin or ciprofloxacin, or clindamycin monotherapy. Metronidazole monotherapy is also indicated but is less effective than other regimens.1

Table 85-3 Recommended Regimens for Antimicrobial Prophylaxis of Specific Surgical Procedures"

Typ* of Operation

HIMLO iimitnJfd Pr&phytjml s H*-gimt rt Art* mdn fa^j


WwijiufjHy Heid ^ nivk

Cewiean wclio<i Hysterectomy

CciazoJin I -2 g IV every 8. hours- lot a tolal

Of OM I'iiniMiirH' l.i 1J JV y l.lliCJI

iii) rng every 4 houis tor a tptal flf ¡4 hours (i I ? lj IV i "Vi "i y IhOui^ (or J [-aof 2*h0wi

CflfiKlin I J g IV I'vfl y 3 four', for a total tl


Qfaptn 1-2 g IV x 1 Cefoielan 1 g IV x l.cefajolln l-?g IV* 1, c^ctftir» I -2 g IV k I

fissi loduorleml |h*|tv1 fit onrty: Otoitrutli&i. dtkf HjppfhSiiA morbid obrtly. himorrha^e, malignancy ftflarynaci (hHih-ii<,k nofy aye greater than 7ELacule ihdfctytfilH, ObllruCTiuO JaUKfce, duct slones, nonfunc timing gjUblacfck«} Coksrectil

Appendectomy Oihopedk

Caidioihoiaclc that neom/cih I g plus erythromycin tww 1 g (give 19. 16. and 9 hours prior to PKeduvj JV tefuwiLin 1-2 y k ' Cefoxitin 1 -Jg tv x l.retotefan ig IV k I

Cefardtri i-2 g N every & hours (or a total of 1* how

Cefaiolii 1-2 9IV mery S hours (or a total of ifl iwurswcfifurwiirW l.Sy IVeviry 17 hours tin a iccal of IS houi s

Cllndam^in 600-900 mg (Vcvc<y 6 hours lof a total of tKxit Of vancomycin 1 9 IVevtryg-13 l*Xiri fb1 a total of 74 hours VjriiOffiy^ irt 1 Lj IV CvCry 8 1 ? IsOui^ for J Kfl Jl Cf hams

Cllnctsmicin 60D "AO rili| IVi-.*4y fi hOuit fiji .1 [ of U hours (Ipioflctiiiin 40(1 ring IV x 1 5ee hysteretlomy

ArKHnaemlilc agent ImelcomdaToleO.i-l g IV x I or (lirxlamytin 600-900 mg IV x I combined wiflh c|ent^irilcin 1 ,J nikylii) IV v I, 1 1 cf W x I, or ciprofloxacin -100 mg fV x I Amp«: illrVtalbatlam ^ q IV x 1 OpofknaOn 400 mg IV * 1

Opoflwcin 4QC mg IV x 1

("efarolin I-i g IV plus metronldimte 0.5-1 glYx 1 or hjrateiFclwny legimens

Erlapenctn 1 y x I

Mel londarole 0.5-1 g IVpfa tjentamkm I.S mgifctj rvy 1

Vancomycin 1 g IVewry 12 hours or clindamycin 600-900 mgtvqth

Vancomycin 1 c| IV every 12 hours (or a total of tnjuii ortlirniamyiln WO-WO iltgl/Mlgf S lYsi's

Oiiing i«i>mrneiHLaiiC<ii Jii iitisod un coifirticiiclinkdl (fOK^ftX adult patient; with normal n?ii3l fusion'; tlOiiiKi tCf individual oaiienti and institutions may vary.

lOral leglmnn. should be used in coijuii; Ikvi with IV piophyfadls FiomBefs lr9tlS.

Cesarean sections are stratified into low- and high-risk groups. Patients who undergo emergency operations or have cesarean sections after the rupture of membranes and/or onset of labor are considered high risk. Prophylactic antimicrobials are most beneficial for high-risk patients but are used in both groups. Antimicrobial regimens similar to those for hysterectomy are appropriate. Antimicrobials should not be administered until after the first incision and the umbilical cord has been clamped. This practice prevents potentially harmful antimicrobial concentrations from reaching the newborn.

Orthopedic Surgery

Orthopedic operations are generally clean and are done under controlled conditions. Likely pathogens include grampositive cocci, mostly staphylococci. In the case of total joint (knee and hip) arthroplasty, cefazolin is the antimicrobial of choice. Patients with a ^-lactam allergy should receive either clindamycin or vancomycin. Antimicrobial prophylaxis should not exceed 24 hours and does not need to be continued until all drains and catheters have been removed. Antimicrobial-impregnated bone cement can be useful in lowering infection rates in orthopedic surgery but has not been approved for prophylaxis.

Cardiothoracic and Vascular Surgery

Cefazolin or cefuroxime are appropriate for prophylaxis in cardiothoracic and vascular surgeries. In the case of ^-lactam allergy, vancomycin or clindamycin are advised. Debate exists on the duration of antimicrobial prophylaxis. SSIs are rare after cardio-thoracic operations, but the potentially devastating consequences lead some clinicians to support longer periods of prophylaxis. The National Surgical Infection Prevention Project cites data that extending prophylaxis beyond 24 hours does not decrease SSI rates and may increase bacterial resistance.1 However, the Society of Thoracic Surgeons issued practice guidelines in 2006 to extend the duration of antibiotics to 48

hours following cardiac surgeries. Duration of therapy should be based on patient factors and risk of development of an SSI.

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