Timing of First Dose

For prevention of SSIs, correct timing of antimicrobial administration is imperative so as to allow the persistence of therapeutic concentrations in the blood and wound tissues during the entire course of the operation. The National Surgical Infection Prevention Project recommends infusing antimicrobials for surgical prophylaxis within 60 minutes of the first incision. Exceptions to this rule are fluoroquinolones and vancomycin, which can be infused 120 minutes prior to avoid infusion-related reactions. 1 No consensus has been reached on whether the infusion should be complete prior to the first incision. However, if a proximal tourniquet is used, antimicrobial administration should be complete prior to inflation.

Administration of the antimicrobial should begin as close to the first incision as possible. This is important for antimicrobials with short half-lives so that therapeutic concentrations are maintained during the operation and reduce the need for redosing. Beginning the antimicrobial infusion after the first incision is of little value in pre venting SSI. Administration of the antimicrobial after the first incision had SSI rates

similar to patients who did not receive prophylaxis. Dosing and Redosing

® The goal of antimicrobial dosing for surgical prophylaxis is to optimize the phar-macodynamic parameter of the selected agent against the suspected organism for the duration of the operation. Dosing recommendations can vary between institutions and guidelines. Clinical judgment should be exercised regarding dose modifications for renal function, age, and especially weight. Obese patients often require higher doses than do nonobese patients.1 Morbidly obese patients (body mass index greater than 40) who received 2 g of cefazolin had a lower incidence of SSI compared to patients receiving 1 g.31 An advisory statement from the National Surgical Infection Prevention Project suggested that for patients less than 80 kg, cefazolin should be dosed at 1 g; patients that are 80 kg or greater should receive 2 g of cefazolin for adequate pro-phylaxis.1

If an operation exceeds two half-lives of the selected antimicrobial, then another dose should be administered.1 Repeat dosing reduces rates of SSI. For example, cefazolin has a half-life of about 2 hours, thus another dose should be given if the operation exceeds 4 hours. The clinician should have extra doses of antimicrobial ready in case an operation lasts longer than planned.

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