Antibiotic Prophylaxis for Surgical Procedures

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Antibiotic Prophylaxis for Surgical Procedures Bill Salzer University of Missouri-Columbia 9/29/07 salzerw@health.missouri.edu

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Preventing Surgical Infections Antibiotic prophylaxis Drugs- which when, how many doses? Non antibiotic measures- evidence based Hair removal Normothermia Oxygen supplementation Normoglycemia

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0 4 8 1 2 Alexander JW et al. Arch Surg. 1983;118:347–352. Hair-Removal Techniques and SSIs Infection, % Discharge 30-Day Follow-up 5.2% (14/271) 8.8% (23/260) 6.4% (17/266) 10% (26/260) 4% (10/250) 7.5% (18/241) 1.8% (4/226) 3.2% (7/216) PM AM PM AM Razor Razor Clipper Clipper

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Perioperative Normothermia 200 CRS patients Control: Routine intraoperative thermal care (mean temperature 34.7°C) Treatment: Active warming (mean temperature 36.6°C) Incidence of SSI Control 19% (18/96) Treatment 6% (6/104); P=0.009 Kurz A et al. N Engl J Med. 1996;334:1209–1215.

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Supplemental Oxygen 500 CRS patients 80% or 30% inspired oxygen during operation and for 2 hours post surgery All patients received prophylactic antibiotics Results Arterial and subcutaneous PO2 higher in 80% oxygen group Lower incidence of SSIs with higher supplemental oxygen (5.2% vs 11.2%; P=0.01) Greif et al. N Engl J Med. 2000;342:161–167.

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1,000 cardiothoracic surgery patients with preoperative hemoglobin A1c (HbA1c) levels measured 300 known diabetic patients 42 with undiagnosed diabetes Incidence of SSI Diabetes (known and undiagnosed) 5.8% (20/342) Without diabetes 1.5% (10/658) Diabetes with HbA1c =8% 7.9% (10/126) Diabetes with HbA1c <8% 4.0% (7/174) Latham R et al. Infect Control Hosp Epidemiol. 2001;22:607–612. SSIs and Glucose Levels (cont)

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SSIs and Glucose Levels 0 1 2 3 4 5 6 7 8 100–150 150–200 200–250 250–300 Day 1 Blood Glucose (mg/dL) Deep Infection Rate, % Zerr KJ et al. Glucose control lowers the risk of wound infection in diabetics after open heart operations, page 360. Reprinted from The Annals of Thoracic Surgeons, Vol. 63. Copyright 1997, with permission from the Society of Thoracic Surgeons. All rights reserved. 1.3% 1.6% 2.5% 6.7% P=0.002

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Preoperative Strategies to Limit SSIs: Skin Surface Preparations Antiseptic showers Reduced bacterial counts by 3.5 log10 from baseline1 No evidence that they affect SSIs2 Skin preparation in the operating room (OR) Usually iodophors, alcohol-containing products, or chlorhexidine gluconate2 1. Seal LA et al. Am J Infect Control. 2004;32:57–62. 2. Mangram AJ et al. Am J Infect Control. 1999;27:97–134.

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Antimicrobial Prophylaxis Antimicrobial agent to prevent or reduce infection Ideally Targeted antibiotic Narrow spectrum agent Targeting few pathogens Short term

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Surgical Prophylaxis- Principles Its not the tool it’s the craftsman You can’t kill everything Surgical wound and deeper infections Focus on likely pathogens-what are you cutting? Narrow spectrum, long half life drugs Dose timing- pre-incision, close Single pre-op dose adequate for most Good vs bad effects Effect of prior hospitalization, antibiotics

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Antibiotic Prophylaxis-Caveats You can’t kill everything Adverse drug effects Select resistant pathogens C diff colitis Select more virulent pathogens Avoid drugs/classes that are used for therapy

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Evidence Based? A-I GI tract, oropharynx, vascular, craniotomy, ortho-implants, cardiac, hysterectomy, C-section, B-I- clean Breast, hernia B-III Implant prosthetic, low risk gastric or biliary, open GU C-III Minimally invasive- laparoscopic procedures ? ERCP

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0% 5% 10% 15% 20% Infections, % Staphylococcus aureus Coagulase-negative Staphylococcus Enterococcus spp. Escherichia coli Pseudomonas aeruginosa Enterobacter spp. Major Pathogens in SSI NNIS Report. Am J Infect Control. 1996;24:380–388.

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Beta-lactams for Surgical Prophylaxis Cefazolin- “Ancef” or “Kefzol” Ideal properties- cost, 1/2 life-2 hr, spectrum 1-2 gr pre-op, repeat q4-6h if long job, bleeder Post-op doses? Probably not needed Cefotetan or cefoxitin- colon, anaerobes, GYN Cefotetan- t1/2 3.5 h, cefoxitin- 1 hr Ertapenem Colon surgery, t1/2 -4 hr

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Failure of Prophylaxis at 4 Weeks Posttreatment (Evaluable Population) C diff colitis 1.7% 0.6%

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Penicillin Allergic? What type? Anaphylactoid or rash? Allergic to cephalosporins? Prior surgeries? Truly allergic Vancomycin Clindamycin Colon- clindamycin or metronidazole combos

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Vancomycin for Surgical Prophylaxis Serious beta-lactam allergy ? Excess MRSA, MRSE in ortho, CT surgery Will CA-MRSA emerge? Vancomycin I gr IV Start 1 hr pre-op, don’t give fast, 1 hour infusion

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Perioperative Prophylactic Antibiotics: Timing of Administration Infections, % Hours From Incision 14/369 5/699 5/1,009 2/180 1/61 1/41 1/47 15/441 0 1 2 3 4 =–3 >–2 >–1 0 1 2 3 4 =5 Classen DC et al. N Engl J Med. 1992;326:281–286. Copyright © 1992 Massachusetts Medical Society. All rights reserved.

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Surgical Prophylaxis- One Dose? Single Preop dose Evidence based, 0ne better than none, ?post-op Cost, toxicity, etc Preop + 24 hours No evidence it’s better than 1 preop Cost Toxicity Superinfection with resistant organisms More C diff

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Impact of Prolonged Antibiotic Prophylaxis 2,641 patients undergoing CABG Group 1 <48 hours of antibiotics Group 2 >48 hours of antibiotics SSI rates Group 1 9% (131/1,502) Group 2 9% (100/1,139) Odds ratio 1.0 (95% CI: 0.8–1.3) Increased antibiotic resistant pathogens – Group 2 Odds ratio 1.6 (95% CI: 1.1–2.6) CABG = coronary artery bypass grafting; CI = confidence interval. Harbarth S et al. Circulation. 2000;101:2916–2921.

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Website Resource www.surgicalinfectionprevention.org

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SIP Program Quality Indicators Quality Indicator No. 1 Proportion of patients who receive antibiotics within 1 hour before surgical incision Quality Indicator No. 2 Proportion of patients who receive prophylactic antibiotics consistent with current recommendations Quality Indicator No. 3 Proportion of patients whose prophylactic antibiotics were discontinued within 24 hours of surgery end time Bratzler DW. Available at: http://www.medqic.org/scip/pdf/spkrnotesSIP_to_SCIP_101205.ppt. Accessed May 26, 2006.

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Preventing Surgical Infections Patient safety Education- QA/QI issues Cost of Post-op and nosocomial infections Big brother is watching How? Evidence-based approach Appropriate perioperative antibiotics Appropriate perioperative nonantibiotic measures

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