- Overview --Choice
of agents (principles)
- need not eradicate every
potential pathogen
- Effective
agent example -- cefazolin (Ancef,
Defzol)
- 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)
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