Antibiotic Prophylaxis Update

Choosing Surgical Antimicrobial Prophylaxis

Peri-Procedural Administration

Surgical Prophylaxis and AMS at Epworth HealthCare

Mr Glenn Valoppi

Dr Trisha Peel

Dr Joseph Doyle

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Choosing Surgical Antimicrobial Prophylaxis (SAP)

Right Drug Right Dose

Glenn Valoppi

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Therapeutic Guidelines: Antibiotic

Who are the authors of the guidelines?

What are the guidelines, and how are they produced?

What the guidelines are not designed to be?

Role as a reference against which appropriateness is judged

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Therapeutic Guidelines: Antibiotic

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Therapeutic Guidelines: Antibiotic

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Therapeutic Guidelines: Antibiotic

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Therapeutic Guidelines: Antibiotic

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When SAP is indicated

Consider prophylaxis if there is a significant risk of postoperative infection (e.g. colonic resection) or if postoperative infection would have serious consequences (e.g. infection associated with a prosthetic implant), even when such infection is uncommon.

Use of SAP reduces risk of infections, but also carries a risk of harms. These may include

- Allergic reactions

- Adverse drug reactions

- Selection of resistant organisms (C. difficile)

- Promotion of antimicrobial resistance

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Selection of agent

The prophylactic antibiotic regimen should be directed against the organism(s) most likely to cause postoperative infection.

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Most clean procedures: Clean-contaminated procedures:

Skin flora with which patient is colonized

As for clean procedures, plus

Staphylococcus aureus Gram-negative rods

Coagulase-negative staphylococci

Enterococci

Selection of agent

For most procedures, cephazolin is the drug of choice for prophylaxis because it is

- the most widely studied antimicrobial agent, with proven efficacy

- it has a desirable duration of action,

- spectrum of activity against organisms commonly encountered in surgery,

- reasonable safety

- low cost

Vancomycin is not as effective as cephazolin for preventing postoperative infections caused by MSSA.

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Bratzler DW, Dellinger EP, Olsen KM, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health-Syst Pharm. 2013; 70:195–283

Immediate beta-lactam hypersensitivity

When all penicillins and cephalosporins are to be avoided

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Usual substitute Other possibilities

Gram-positive organisms

vancomycin teicoplaninclindamycin

Gram-negative organisms

gentamicin ciprofloxacinaztreonam

Selection of dose (in adults)

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Selection of dose (in adults)

Drug Dose

Cephazolin 2g

Consider 3g If weight >120kg

Vancomycin 15mg/kg Use actual body weight

Teicoplanin* 400mg-800mg

Gentamicin 2mg/kgTo cover procedure only

Use adjusted body weight if actual body weight >20% higher than ideal body weight5mg/kg

For extended duration coverage

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Adapted from Therapeutic Guidelines: Antibiotic Version 15, and Bratzler DW, Dellinger EP, Olsen KM, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health-Syst Pharm. 2013; 70:195–283

Insertion of urinary catheters

It is not appropriate to administer an antibiotic (e.g. gentamicin) at the time of catheter insertion; this practice is not supported by evidence and may cause adverse effects.

Standard SAP - using cephazolin - provides adequate coverage against most bacteria that are implicated in peri-operative urinary tract infections.

If using vancomycin as a substitute for SAP (eg in beta-lactam allergy), consider inclusion agent with coverage of urinary pathogens

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Bacteriuria and risk of PJI

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Bacteriuria and risk of PJI

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Special CasesWhen the guidelines don’t apply.

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Cardiac conditions associated with risk for infective endocarditis

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International guidelines for using SAP for prevention of IE have been progressively reducing the list of indications for prophylaxis.

2008 NICE guidelines in UK had recommended that antibiotic prophylaxis is not required for any person before dental or other procedures.

2014 review published in Lancet, showed increase in the incidence of infective endocarditis in the UK – unclear if due to adherence to new guidance

Cardiac conditions associated with risk for infective endocarditis

Cardiac Risk Factors

prosthetic cardiac valve or prosthetic material used for cardiac valve repair

previous infective endocarditis

congenital heart disease but only if it involves: a) unrepaired cyanotic defects, b) completely repaired defects with prosthetic material or devices, during the first 6 months after the procedure c) repaired defects with residual defects at or adjacent to the site of a prosthetic patch or device (which inhibit endothelialisation)

rheumatic heart disease in high-risk patients

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Procedures associated with risk for infective endocarditis

Dental Procedures (examples) Other Procedures and conditions

extraction suspected or confirmed genitourinary tract or intra-abdominal infection

periodontal procedures including surgery, subgingival scaling and root planing

genitourinary or gastrointestinal tract procedure where surgical antibiotic prophylaxis is routinely indicated

replanting avulsed teeth

other surgical procedures (eg apicoectomy)

SAP should include coverage of enterococci (ampicillin / vancomycin)

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Colonisation with MROs

MDR Gram negative organisms

Consider screening patients undergoing complex GI surgery, or trans-rectal biopsy of prostate, if increased likelihood of faecal carriage of MDR GN;

- Previous colonisation

- International travel (esp. with healthcare contact)

Selection of SAP is determined by results of susceptibility testing

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Questions?

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