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Assessment of the risk of infection is based on patient and procedure
Surgical antibiotic prophylaxis is indicated for patients at high risk of
infection or in those at high risk of complications from postoperative
The choice of agent is based on the most likely pathogen associated with
surgicalsite infection. Institutional patterns of pathogens, their
resistance profiles, and antibiotic cost impact agent selection.
To maximize the benefit of prophylaxis, antibiotic administration should
be completed within 1 hour before incision to achieve adequate drug
Intravenous administration is most commonly used. Coadministration of
an oral regimen is recommended in colorectalsurgery.
Antimicrobials with shorter half-lives may require administration of an
additional intraoperative dose in prolonged surgical cases.
Single-dose preoperative prophylaxis is sufficient for most surgical
Continuation of postoperative prophylaxis for up to 24 hours in cardiac
surgery has been recommended by some professional organizations.
Continuation of prophylaxis beyond these time frames is not associated
with improved outcomes and increases the risk of superinfections,
emergence of resistance, adverse effects, and cost.
Surgicalsite infections are classified as superficial or deep incisional and
usually occur within 30 days after the surgical procedure. Deep organ
or space infections can occur up to several months after surgery and up
to a year after implantation of prosthetic material.
Continuous quality improvement is critical in the prevention of surgical Case 63-9 (Question 1)
infection and should be overseen by a multidisciplinary team.
Surgical site infection (SSI) occurs when a pathogenic organism multiplies in a
surgical wound, leading to local and sometimes systemic signs and symptoms.
Infections complicate surgical procedures in about 2% to 5% of cases but can be as
high as 20%, depending on the surgical procedure and the patient.
infections are the most common health-care associated infections.
at risk of death, increase morbidity, extend the duration of hospitalization,
associated with an annual cost of $3.5 billion to $10 billion in the United States.
Prophylactic antibiotics are widely used in surgical procedures and account for
substantial antibiotic use in many hospitals.
7 The purpose of surgical antibiotic
prophylaxis is to reduce the prevalence of postoperative wound infection.
Appropriate use of prophylactic antimicrobial agents results in decreased patient
morbidity and hospitalization costs for many surgical procedures.
benefits of prophylaxis are questionable for surgical procedures at low risk of
infection (e.g., urologic operations in patients with sterile urine).
inappropriate or indiscriminate use of prophylactic antibiotics can expose the patient
to unnecessary risk of drug toxicity and superinfections, promotes the selection of
resistant organisms, and increases cost.
operation, which is about 1 to 2 hours. What is the risk of infection following surgery for her?
The likelihood for development of postoperative site infection is related to the
degree of bacterial contamination during surgery, the virulence of the infecting
organism, and host defenses. Risk factors for postoperative site infection can be
classified according to procedure-specific factors and patient characteristics.
Bacterial contamination can occur from exogenous sources (e.g., the operative team,
instruments, airborne organisms) or from endogenous sources (e.g., the patient’s
microflora of the skin, respiratory, genitourinary, or gastrointestinal [GI] tract).
Procedure-specific factors such as the surgeon’s experience and technique, the
duration of the procedure, and the operating room environment have important
influence on SSI rates. Infection control procedures to minimize all sources of
bacterial contamination, including patient and surgical team preparation, operative
technique, and incision care, are compiled in Centers for Disease Control and
Prevention guidelines for surgical site infection.
The risk of postoperative wound infection is influenced by host factors, such as
extremes of age, obesity, tobacco use, malnutrition, and comorbid states, including
diabetes mellitus, glycemic control in diabetic patients, remote infection, ischemia,
oxygenation and body temperature during the procedure, colonization with
microorganisms, immune status, and immunosuppressive therapy.
Measuring and predicting risk of infection determines which patients should
receive antibiotic prophylaxis. The Centers for Disease Control and Prevention
Study on the Efficacy of Nosocomial Infection Control (SENIC) developed an index
that included the level of wound contamination and three other criteria based on
procedure-related and patient-related factors.
18 Modification of this tool has led to
the National Nosocomial Infection Surveillance (NNIS) System risk index that takes
into account the patient’s preoperative assessment (American Society of
Anesthesiologists Assessment),
the level of contamination of the procedure, the
duration of the procedure, and the use of a laparoscope.
added because of the associated decreased incidence of infection with the
introduction of laparoscopic procedures. Indexes like these are particularly useful for
comparison of performance among institutions and public reporting.
Based on these risk factors for infection, the decision whether a given patient
should receive antimicrobial prophylaxis depends on a number of factors.
Antimicrobial prophylaxis should be given for surgical procedures (a) with a high
rate of infection (i.e., clean-contaminated or contaminated procedures), or (b)
involving the implantation of prosthetic materials, or (c) in which an infection would
have catastrophic consequences.
9 A widely used surgical wound classification
system to assist in this decision-making process follows.
C.P. is at relatively low risk of infection. There is only one point as attributed to
the NNIS score because she will undergo a clean surgery within the average time
frame. Her American Society of Anesthesiologists score is 2, being known with mild
systemic disease (obese, rheumatoid arthritis, age over 60).
CLASSIFICATION OF SURGICAL SITE
From 1960 to 1964, the National Academy of Sciences National Research Council
conducted a landmark study of surgical site infections and formulated a widely used
standard classification based on the risk of intraoperative bacterial contamination
20 Current recommendations for surgical prophylaxis pertain to clean
surgeries at high risk of complications and/or involving implantation of prosthetic
material, clean-contaminated surgeries, and select contaminated wounds.
Antimicrobial therapy for dirty surgeries in which infection already is established is
considered treatment instead of prophylaxis and is not discussed further in this
chapter. Table 63-2 lists suspected pathogens and recommendations for site-specific
prophylactic antimicrobial regimens; a detailed examination of clinical trials
supporting these recommendations is presented elsewhere.
National Research Council Wound Classification
Clean No acute inflammation or entry into
GI, respiratory, GU, or biliary tracts;
no break in aseptic technique occurs;
Elective, controlled opening of GI,
respiratory, biliary, or GU tracts
without significant spillage; clean
wounds with major break in sterile
Contaminated Penetrating trauma (<4 hours old);
major technique break or major
spillage from GI tract; acute,
Dirty Penetrating trauma (>4 hours old);
infectious process); preoperative
30–100 Therapeutic antibiotics
GI, gastrointestinal; GU, genitourinary.
operating room and of various other factors. Ann Surg. 1964;160(Suppl 2):1.
Suggested Prophylactic Antimicrobial Regimens for Surgical Procedures
Neurosurgery Staphylococcus aureus, Cefazolin Clindamycin, vancomycin
S. aureus, S. epidermidis Cefazolin Cefuroxime, clindamycin,
Thoracic S. aureus, S. epidermidis,
Cefazolin Ampicillin–sulbactam,
Cefazolin Clindamycin, vancomycin
S. aureus, S. epidermidis Cefazolin Clindamycin, vancomycin
Cefazolin + metronidazole Ampicillin–sulbactam,
Cefoxitin Cefazolin + metronidazole,
Biliary tract (only for highrisk procedures)
Cefazolin Cefoxitin, ampicillin–
Colorectal Gram-negative enterics,
Cefazolin + metronidazole Ampicillin–sulbactam,
Cesarean section Group B streptococci,
Hysterectomy Group B streptococci,
Fluoroquinolone Aminoglycoside +
PRINCIPLES OF SURGICAL ANTIMICROBIAL
Decision to Use Antimicrobial Prophylaxis
biliary tract surgery (cholecystectomy). Why is antimicrobial prophylaxis warranted for M.R.?
Biliary tract surgery is considered a clean-contaminated procedure and, therefore,
carries a risk of surgical wound infection approaching 10% (Tables 63-1 and 63-2).
Prophylaxis for biliary tract surgery is limited to high-risk categories, which include
obesity, age older than 70 years, diabetes mellitus, acute cholecystitis, obstructive
jaundice, common duct stones, emergency procedures, pregnancy,
immunosuppression, nonfunctioning gallbladder, or insertion of prosthetic device.
Prophylaxis is not recommended for low-risk procedures such as elective
laparoscopic cholecystectomy. Thus, prophylaxis is warranted in M.R., who falls
into at least two high-risk categories (age older than 70 years and acute
written for M.R. Why is this an appropriate (or inappropriate) antibiotic selection?
The selected prophylactic agent should be directed against likely infecting
organisms (Table 63-2) but need not eradicate
every potential pathogen. In general, pathogens associated with infection originate
from the skin or the associated structures contiguous to the regions involved in the
surgical procedure. Cefazolin has been proved effective for most surgical
procedures, including biliary tract surgery, given that the goal of prophylaxis is to
prophylaxis because they are no more effective than cefazolin and may alter
microbial flora, increasing the emergence of microbial resistance to these otherwise
valuable agents. The 2 g cefazolin dose is appropriate for all adults weighing less
than 120 kg and should be 3 g for patients over 120 kg.
Timing of Antimicrobial Administration
CASE 63-2, QUESTION 3: Why is the administration time for this antimicrobial appropriate (or
Classic animal studies conducted by Burke
need for therapeutic antibiotic concentrations in the bloodstream and in vulnerable
tissue at the time of wound contamination. Bacteria were most likely to enter the
tissue beginning with the initial surgical incision and continuing until the wound was
closed; antibiotics administered more than 3 hours after bacterial contamination were
ineffective in decreasing the rate of wound infection.
after the surgical incision was deemed the “effective” or “decisive” period for
prophylaxis, when the animal’s wound was most susceptible to the beneficial effects
of the antibiotic. This decisive period for administration of prophylactic antibiotics
has been confirmed in humans to be somewhere within 2 hours before incision as
compared to earlier administration or anytime after incision.
for optimal outcomes is still being investigated.
For maximal efficacy, an antibiotic should be present in therapeutic concentrations
at the incision site as early as possible during the decisive period and continuing
until the wound is closed. Because an antibiotic administered postoperatively cannot
achieve therapeutic concentrations during the decisive period, postoperative
administration does not prevent postoperative wound infections, and infection rates
are similar to those in patients who receive no antibiotics.
Consequently, prophylactic antibiotics should be administered before the surgical
procedure in the operative suite.
9 Prophylactic antibiotics are most effective when
given within the 1-hour window before surgical incision; rates of infection increase
significantly if antibiotics are administered more than 1 hour before incision or
26 Administration of vancomycin and fluoroquinolones should
begin within 120 minutes before surgical incision because of the prolonged infusion
times required for these drugs. If a tourniquet is required to control blood flow to a
limb during surgery, the evidence is insufficient to recommend administering the dose
before or after inflation of the tourniquet.
The “on-call” prescribing practice for surgical prophylaxis, as with M.R., has
fallen into disfavor because the time between antibiotic administration and the actual
incision may exceed 1 hour. This delay may result in subtherapeutic antibiotic
concentrations during the decisive period.
29 M.R.’s cefazolin should be ordered
preoperatively and should be administered in the OR within 1 hour of the surgical
CASE 63-2, QUESTION 4: Will M.R. require a second dose of cefazolin during the surgical procedure?
The duration of the surgical procedure and the half-life of the administered
antibiotic should be considered when determining the need for an additional
intraoperative dose. The longer the duration of the surgical procedure, particularly
with short half-life antibacterials, the greater the incidence of postoperative
31 Cefazolin, with a half-life of approximately 1.8 hours, is effective in
a single preoperative dose for most surgical procedures. For prolonged procedures,
or those with major blood loss,
33 additional intraoperative doses should be
administered every 2 half-lives of the drug.
9 M.R. should require an additional
intraoperative cefazolin dose only if the surgical procedure is prolonged (>4 hours).
Laboratory data include the following:
Hemoglobin (Hgb), 10.4 g/dL (normal, 12.1–15.3 g/dL; SI units, 104 g/L)
Hematocrit (Hct), 29.7% (normal, 36%–45%; SI units, 0.297)
Prothrombin time (PT), 15 seconds (normal, 10–13 seconds)
diet; (b) mechanical bowel cleansing with polyethylene glycol-electrolyte lavage solution (CoLYTE,
the appropriateness of the oral route of administration of antibiotic prophylaxis for G.B.
In general, oral administration of surgical antimicrobial prophylaxis is not
recommended because of unreliable or poor absorption of oral agents in the
anesthetized bowel. Oral nonabsorbable agents, however, function effectively as GI
decontaminants because high intraluminal drug concentrations are sufficient to
34 The concentration of bacteria in the colon may approach
16 bacteria/µL, and colorectal procedures, such as the one G.B. will undergo, carry
a relatively high risk of postoperative infection. Antimicrobial regimens with activity
against aerobic and anaerobic bacterial fecal flora (Escherichia coli and other
Enterobacteriaceae and Bacteroides fragilis) are effective in preventing
postoperative wound infections.
A widely used oral antimicrobial regimen is 1 g each of the nonabsorbable
antibiotics neomycin sulfate (for gram-negative aerobes) and erythromycin base (for
anaerobes), given 1 day before surgery at the times indicated for G.B.
bowel cleansing, such as with polyethylene glycol-electrolyte or sodium phosphate
lavage solution, precede administration of this regimen; the purpose of bowel purging
is to evacuate the colonic contents as completely as possible to decrease colonic
bacterial counts. Effective oral alternatives to neomycin plus erythromycin include
metronidazole with or without neomycin or with kanamycin, or kanamycin plus
; however, clinical situations warranting the use of such alternatives
over the well-established neomycin–erythromycin regimen are practically
nonexistent. Thus, the regimen selected for G.B. is highly appropriate.
CASE 63-3, QUESTION 2: The surgical resident has canceled the oral neomycin–erythromycin bowel
effective and rational choice for G.B.?
Numerous parenteral regimens, specifically with agents that possess both aerobic
and anaerobic activity, are effective as surgical prophylaxis in colorectal
procedures. The second-generation cephalosporins with significant anaerobic
activity (e.g., cefoxitin) are superior to first-generation cephalosporins, which lack
sufficient anaerobic activity.
38 Mechanical bowel preparation with the combination
of oral and intravenous antibiotics is superior to oral or intravenous agents alone.
Also, the cefoxitin order for G.B. would be unacceptable if the surgery lasts longer
than 3.5 hours (the relatively short half-life of cefoxitin could be associated with
inadequate antibacterial levels and predispose her to infection).
procedures (>3 hours) such as anticipated for G.B., an alternative agent with a longer
half-life, such as ertapenem, or a second dose of cefoxitin should be considered.
Ertapenem has been found to be superior to cefotetan in preventing infection after
40 This improved efficacy may be because of the long half-life or
broader antibacterial activity.
41 Whereas ertapenem may offer certain advantages as a
prophylactic antibiotic, its use in this indication is discouraged by most clinicians.
Although unproven, the potential impact of widespread ertapenem utilization on
subsequent carbapenem resistance is of hypothetical concern.
acquisition cost of ertapenem also needs to be considered. Thus, for G.B., the
importance of redosing intravenous regimens with short half-lives in prolonged
surgery should be stressed to the resident.
CASE 63-3, QUESTION 3: The surgical resident has reconsidered the cefoxitin order and decides to
the rate of postoperative wound infection compared with either regimen administered singly?
Coadministration of an oral regimen followed by a parenteral antibiotic prior to
incision is equivalent or superior to administration of either regimen alone in
43 Oral antibiotics, however, have only been evaluated in
combination with mechanical bowel preparation. The optimal agents and regimens as
prophylaxis in colorectal surgery remain to be adequately determined. For now,
combination of oral and parenteral antimicrobial prophylaxis with mechanical bowel
preparation is recommended for colorectal surgery.
Although the incidence of postoperative wound infection for cardiothoracic
procedures is low (<5%), the devastating consequences of a postoperative
endocarditis (after valve replacement) and mediastinitis or sternal osteomyelitis
(after sternotomy) warrant antimicrobial prophylaxis.
associated with cardiothoracic surgery include Staphylococcus aureus and
Staphylococcus epidermidis (particularly with hardware placement) (Table 63-2);
based on these potential pathogens, successful prophylactic regimens include
cefazolin and cefuroxime. When cefazolin has been compared with cefuroxime or
cefamandole, a statistical trend in favor of the second-generation cephalosporins has
been noted, and collective wound infection rates were slightly higher in the cefazolin
In contrast, a comparison of prophylactic cefazolin and cefuroxime in
patients having open heart surgery noted a significantly greater incidence of sternal
wound infection and mediastinitis in the cefuroxime group.
have not observed improved efficacy with cefuroxime compared with cefazolin.
In conclusion, cefazolin probably is at least as effective as second-generation
cephalosporins; therefore, the choice of agent should be based on an institution’s
antimicrobial susceptibility and cost data. Hospital-specific antimicrobial resistance
patterns are especially important in determining the incidence of methicillin-resistant
S. aureus (MRSA) or methicillin-resistant S. epidermidis (MRSE) surgical site
infection rates. Although vancomycin has not been determined to be superior to
cefazolin, vancomycin is the drug of choice for prophylaxis in patients colonized
53 Patients are at higher risk of MRSA carriage if they are frequently
hospitalized or have a prolonged hospital stay, are exposed to broad-spectrum
antibiotics, are known for comorbid conditions, or have severe underlying illness.
The population to be screened for MRSA carriage and undergo decolonization with
mupirocin is still being debated but is mostly considered for patients undergoing an
orthopedic or cardiac procedure. Surveillance of susceptibility of S. aureus isolated
from SSIs should be done if mupirocin is used for decolonization.
Meta-analyses reveal no differences between first- and second-generation
cephalosporins or between β-lactams and glycopeptides in the prevention of surgical
56 Thus, the cefazolin prophylaxis selected for L.G. is acceptable,
provided the patient is not colonized with MRSA or MRSE. Additional empiric
coverage with an aminoglycoside, a fluoroquinolone, or aztreonam may be
considered when gram-negative pathogens are a concern according to local
epidemiology and risk factors including hospital admission greater than 48 hours
before surgery, diabetes, and ventilator-dependency.
With regard to duration, the shortest effective prophylactic course of antibiotics
should be used (i.e., single dose preoperatively or not more than 24 hours
postoperatively for most procedures).
58 Postoperative doses after wound closure are
usually not required and may increase the risk of resistance. Single-dose prophylaxis,
a viable option for many surgical procedures (see Case 63-5, Question 1), is still
being evaluated for cardiac procedures.
In practice, cardiothoracic antimicrobial
prophylaxis often is continued up to 24 hours after surgery, as in L.G. No benefit is
seen to prolonging prophylaxis to more than 24 hours, and such use should be
discouraged. The duration of antimicrobial prophylaxis ordered for L.G. is
As noted previously, the shortest effective duration of prophylaxis should be used.
In the past, 1- to 5-day antimicrobial regimens were commonly used for cesarean
section, but single-dose regimens have been proven to be as effective as these longer
59 demonstrated that a single 2-g dose of cefazolin was superior
to either a single 1-g dose or a three-dose, 1-g prophylactic regimen. Others have
noted similar results (i.e., a single cefazolin dose administered after the umbilical
cord is clamped is sufficient in preventing postoperative wound infections in
60–63 Single-dose prophylaxis is less costly and minimizes the
development of bacterial resistance.
12 Antibiotic prophylaxis has traditionally been
administered after clamping of the umbilical cord to minimize infant drug exposure.
This early exposure could theoretically mask the signs of neonatal sepsis and favor
the acquisition of resistant organisms. However, administration before initial
incision and cord clamping decreases the incidence of maternal infections without
adverse consequences to the child.
63–65 Thus, G.J. should receive a single 2-g dose of
cefazolin before incision, without the three additional doses.
Single-dose prophylaxis has been found to be effective in a variety of GI tract,
orthopaedic, and gynecologic procedures.
30 A single dose of an antibiotic with a
short half-life, however, may provide insufficient antimicrobial coverage during a
prolonged surgical procedure. Repeated intraoperative dosing or selection of an
agent with a longer half-life is recommended when the duration of surgery is long to
maintain adequate tissue concentrations throughout the procedure.
Signs of Surgical Site Infection
for signs of site infection to manifest?
Most surgical site infections involve the incision site and are defined as either
superficial (involving the skin and subcutaneous fat) or deep incisional (involving
fascia and muscle). Typically, an infected incision site wound is red, warm, and
purulent and sometimes swollen, tender, or painful. Poor wound healing or
dehiscence (premature opening of the incision) is highly suggestive of infection. A
surgical site infection can also involve any part of the anatomy (e.g., organs or
spaces), other than the incision, which was opened or manipulated during an
16 The purulent drainage, if present, should be cultured to identify the
causative pathogen and direct antimicrobial therapy. Empiric therapy directed against
the most likely pathogens should be instituted while awaiting culture and sensitivity
test results. Although most incision site infections are diagnosed shortly after surgery
(within 30 days), some deep-seated infections present indolently during weeks to
months, for example, abscess formation.
Infection of surgically implanted prosthetic
hardware may take place up to a year after the surgical procedure.
Selection of an Antimicrobial Agent
QUESTION 1: L.T., a 46-year-old woman, has a recent history of abnormal uterine bleeding and vaginal
appropriate surgical prophylaxis antimicrobial regimen for L.T.?
The selection of a prophylactic regimen should be based on the spectrum of
activity of the agents and the most likely pathogens associated with the given surgical
procedure (Table 63-2), pharmacokinetic characteristics (e.g., half-life), adverse
event profile, impact on bacterial resistance selection, and cost.
The usefulness of antimicrobial prophylaxis in vaginal hysterectomies is well
66 The mosteffective, yet most narrow-spectrum agent should be selected considering that the
goal of prophylaxis is not to eradicate every potential pathogen but to reduce
bacterial counts below a critical level necessary to cause infection. Cefazolin has
been proven to be as effective a prophylactic agent as ceftriaxone for vaginal
67 This finding reinforces the fact that a more broad-spectrum agent
(e.g., a third-generation cephalosporin) is unwarranted.
Similar to vaginal hysterectomy, cefazolin and numerous agents (cefotetan,
cefoxitin, ampicillin–sulbactam, etc.) decrease the incidence of postoperative
surgical infection when the abdominal approach is used.
hysterectomy, most trials have not revealed significant differences between first- and
second-generation cephalosporins.
significantly higher incidence of major postoperative surgical infections in patients
and has a relatively long half-life (~1.8 hours), and a single dose has proven
Obstetricians and Gynecologists.
70 Although it has a broader spectrum of coverage, a
single dose of cefoxitin would also be an appropriate choice for this patient.
fragilis, it is being considered as an alternative to cefazolin prophylaxis for L.T. Comment on the
appropriateness of this proposed change in prophylaxis.
The second- and third-generation cephalosporins and ampicillin–sulbactam
generally are not more effective than the first-generation cephalosporins for surgical
prophylaxis in vaginal hysterectomy or in gastroduodenal, biliary, and clean surgical
9 One exception to these findings is in the prevention of infection after
colorectal procedures and perhaps hysterectomy. Several investigations have
documented the failure of first-generation agents when used as prophylaxis in
colorectal procedures, probably a consequence of their weak anaerobic coverage.
As stated previously, second- and third-generation agents and ampicillin–sulbactam
generally are no more efficacious than cefazolin and should not be used for surgical
prophylaxis in most procedures. Cefoxitin, however, would be a reasonable choice
in colorectal surgery or hysterectomy. Considering that this patient is having a
hysterectomy, either cefazolin or cefoxitin is appropriate.
does this allergy history impact on the selection of surgical prophylaxis for S.N.?
Cefazolin is the preferred prophylactic agent for most clean procedures, including
cardiac, vascular, and orthopedic procedures
(Table 63-2). Although the risk of cefazolin cross-allergenicity to penicillin is
relatively low, S.N. experienced a serious, accelerated reaction (hives, SOB) with
penicillin; consequently, she should not receive cefazolin. The organisms most likely
to cause postoperative infection after total hip replacement are S. aureus and S.
epidermidis (Table 63-2). Nafcillin, cefazolin, and vancomycin possess excellent
activity against S. aureus; however, the β-lactams have only marginal activity against
S. epidermidis. Regardless, nafcillin (and cefazolin) should be avoided because of
the penicillin allergy, and the preferred agent for S.N. is vancomycin.
Preoperative vancomycin 15 mg/kg should be administered IV slowly, during at
least 60 minutes. This slow rate of infusion is necessary to reduce the risk of
scheduled. What surgical antimicrobial prophylaxis should be ordered for B.K.?
As with colorectal surgery, the most likely infecting organisms in appendectomy
a r e Bacteroides species and gram-negative enterics (Table 63-2). On surgical
inspection, if the appendix appears normal (not inflamed, without perforation), then
antimicrobial prophylaxis is unnecessary.
If the appendix is inflamed without
perforation, a single preoperative antibiotic dose is necessary. If the appendix is
perforated or gangrenous (complicated), infection is already established and
postoperative treatment is warranted. The status of the appendix, however, cannot be
determined before surgery; therefore, all patients should receive at least one
preoperative dose of an appropriate antibiotic.
74 After surgical inspection of the
appendix, the need for postoperative antibiotic therapy can be determined.
Based on the pathogens likely to be encountered, an antimicrobial agent with both
aerobic and anaerobic activity should be used. Consequently, cefoxitin is an
acceptable choice for prophylaxis.
Risks of Indiscriminate Antimicrobial Use
indiscriminate use of antimicrobials for surgical prophylaxis?
The risks of indiscriminate use of antimicrobials include the potential for adverse
effects and superinfection. The administration of any β-lactam agent poses the risk of
a hypersensitivity reaction, and many antibiotics, including cefoxitin, as is being used
in B.K., predispose patients to Clostridium difficile–associated disease. The risk of
developing this superinfection increases with duration of antibiotic exposure.
Avoiding unnecessary initial and prolonged exposure reduces the risk of this
superinfection and its associated complications.
antimicrobials increases the selection of resistant organisms in a given patient that
could be nosocomially spread to other hospitalized patients.
OPTIMIZING SURGICAL ANTIMICROBIAL
institution guidelines. Which criteria would you want to measure antibiotic prophylaxis prescription
performance? What interventions could improve how antibiotics are used in prophylaxis?
Antibiotic control strategies have improved the appropriate use of antimicrobial
agents for surgical prophylaxis. Numerous factors including individual knowledge,
attitudes, beliefs, and practice; team communication and allocation of
responsibilities; and institutional support for promoting and monitoring practice
influence antibiotic prophylaxis measures.
Interventions for improvement are
focused on education of practitioners, standardization of the ordering, the delivery
and the administration processes, and providing feedback on performance as
measured by infection rates and compliance with improvements. The Surgical Care
Improvement Project (SCIP), a national multidisciplinary initiative developed by the
Centers for Medicare and Medicaid Services, aims at improving surgical care.
Reducing surgical site infections is among one of the targeted goals of this
79 Prophylactic antimicrobial received within 1 hour before surgical
incision, prophylactic antimicrobial consistent with published guidelines, and
prophylactic antimicrobial discontinued within 24 hours of surgery end time are three
performance measures included in this quality improvement process. The first two,
antibiotic timing of administration and appropriate antibiotic selection, are
associated with a decrease in the surgical site infection rate.
Smaller scale projects have also been successful at improving antibiotic use and
decreasing infection rates. A multidisciplinary team generated electronic quick
orders allowing for a computer-enhanced decision-making process and developed an
antibiotic administration protocol. Appropriate selection of antibiotics increased
from 78% to 94%, timely administration improved from 51% to 98%, and clean
wound infection rate decreased from 2.7% to 1.4%.
In collaboration with other health care providers, pharmacists should be
responsible for optimizing the timing, choice, and duration of antimicrobial surgical
prophylaxis. Education of surgical, anesthesia, and nursing staff, supported by
hospital policy changes initiated by pharmacists, improved appropriate timing from
68% to 97% and resulted in significant cost avoidance.
81 Post-discharge surveillance
is also critical in reducing surgical site infections.
A full list of references for this chapter can be found at
http://thepoint.lww.com/AT11e. Below are the key references and websites for this
chapter, with the corresponding reference number in this chapter found in parentheses
Epidemiol. 2008;29(Suppl 1):S51. (17)
initiatives to improve outcomes for patients having surgery. Clin Infect Dis. 2006;43:322. (79)
N EnglJ Med. 1992;326:281. (26)
http://www.cdc.gov/HAI/ssi/ssi.html.
(HICPAC). General Guidelines. https://www.cdc.gov/infectioncontrol/guidelines/index.html.
http://www.cdc.gov/nhsn/datastat.html.
Safer Healthcare Now! Surgical Site Infection (SSI).
http://www.patientsafetyinstitute.ca/en/Topic/Pages/Surgical-Site-Infections-(SSI).aspx.
National Institute for Health and Clinical Excellence. Surgical Site Infection.
http://www.nice.org.uk/guidance/CG74.
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Adverse Effects: Immunization adverse effects are in part dependent
upon the type of vaccine preparation used. Adverse effects from live
attenuated vaccines mimic the disease but are less severe and occur 7
to 10 days postvaccination. Inactivated (killed whole virus) vaccination
adverse effects include soreness at the site of administration within 24
hours after vaccination. Vaccination adverse effects are significantly
less severe than the disease itself.
Immunization Schedules: Recommended immunization schedules are
designed to optimize immune response, standardize regimens, and
enhance immunization rates. Birth to 18 years and adult immunization
schedules are reviewed and updated annually.
Catch-up Immunization Schedules: To catch up within an
immunization series, it is not necessary to restart from the first dose of
the schedule. A delay in receiving subsequent doses does not interfere
with final immunity gained from the vaccination.
Hepatitis B: Hepatitis B vaccination is effective for both pre-exposure
and postexposure prophylaxis. To prevent vertical transmission to an
infant from a mother, it is key to provide vaccination within 12 hours of
birth along with hepatitis B immunoglobulin for those mothers who test
Hepatitis B: The highest incidence of hepatitis B infection occurs in
young adults. Hepatitis B vaccination is recommended for adults who
participate in high-risk behaviors and those in close contact with the
Hepatitis A: Hepatitis A immunization is targeted toward toddlers with
the aim of preventing transmission to adolescents and adults.
Diphtheria, tetanus, and acellular pertussis/Pertussis booster:
Waning immunity against pertussis has resulted in outbreaks of pertussis
in the United States. Adolescents and adults, particularly those with
close contact with young infants, should receive a single dose of
Haemophilus influenzae b: Immunization recommendations for
Haemophilus influenzae type b is age-dependent. The older an infant is
at presentation, the fewer doses needed to elicit a response. A single
vaccine dose may be considered in children and adults with underlying
diseases that place them a risk for infection.
Polio: Inactivated polio vaccine is recommended over the oral
attenuated vaccine for polio vaccination in the United States because
inactivated vaccine is associated with a lower incidence of vaccineassociated paralytic polio.
Polio: Routine vaccination of adults against polio with inactivated
poliovirus vaccine is not recommended unless individuals plan travel to
endemic areas. Oral polio vaccine may be considered only in unique
Meningococcal: Vaccination is recommended within populations at
increased for risk for contracting Neisseria meningitidis, including
travelers to endemic areas, patients with specific immunodeficiencies,
functional/anatomic asplenia, lab personnel dealing with meningococcus,
Human Papillomavirus: This three-dose vaccination series is
recommended for adolescent females for the prevention of cervical and
anogenital cancers, anogenital warts, and recurrent respiratory
papillomatosis. It is also recommended for males in the prevention of
Pneumococcus: Streptococcus pneumoniae mostly affects young
children and the elderly. The conjugate vaccines protect against 80%
(PCV 7) and 90% (PCV 13) of infectious strains that cause disease in
children younger than 6 years old.
Pneumococcus: The polysaccharide vaccine does not elicit immune
response in children younger than 2 years old, and protects against 23
strains of S. pneumoniae that typically cause adult disease.
Influenza: Vaccination is recommended for anyone older than 6 months
of age who does not have a current contraindication. The inactivated
vaccine is delivered intramuscularly or intradermally, whereas the live
attenuated vaccine is delivered as a nasalspray formulation.
Rotavirus: Infants vaccinated with the rotavirus vaccine shed the virus
in the feces after immunization; however, the risk of transmission to an
immunocompromised contact is relatively low with appropriate
Measles/Mumps/Rubella (MMR): Parents are fearful of the risk of
autism which has been falsely associated with the MMR vaccine.
Pharmacists must provide counseling to overcome parental fears and
ensure protection against measles.
Varicella: Postexposure vaccination with the varicella vaccine is
recommended within 5 days of exposure for those unvaccinated or who
have not received a second dose of vaccine.
Varicella: Herpes zoster vaccination is recommended in adults older
previously received the varicella zoster vaccine.
Vaccine Administration: Intramuscular vaccinations are administered
at a 90-degree angle into the muscle using a 1-inch needle.
Subcutaneous vaccinations are administered at a 45-degree angle into
the subcutaneous tissue by pinching this tissue up to prevent insertion
into the muscle. When multiple injections are given at the same site,
separate each injection by 1 inch.
Advocacy and Establishing Services: Pharmacists have an important
role as immunization advocates to positively increase immunization
rates. Pharmacist immunization training is widespread throughout the
United States, but pharmacists must adhere to guidelines and principles
established by their state pharmacy practice act when administering
The use of immunizations to control common infectious diseases is a major public
health achievement. Children, adolescents, and adults are now routinely immunized
against 17 infectious diseases.
Immunization rates are high overall and have
remained stable in the United States with more than 80% of children 3 years of age
receiving all the recommended vaccines.
influenza and pneumococcus range from 20-43%, with higher coverage for
individuals older than 65 years.
3 Unfortunately, despite overall high rates of
immunization coverage, disparities still exist in vaccination coverage for the
socioeconomically disadvantaged and by ethnicity.
improvement and an opportunity for all health professionals to have an impact.
The need for timely immunization administration is key to preventing disease
4 As the incidence of vaccine-preventable disease continues to decrease,
patients are becoming less aware of the significance and severity of the
diseases that could be prevented.
5–8 This, along with parental concerns regarding
vaccine safety, may jeopardize previous vaccination achievements.
providers play a vital role in clarifying misconceptions and educating parents and
other health professionals about the importance of proper and complete
7 Any contact with a patient represents an opportunity to promote
immunization, and thus every medication history should include a review of
immunization status to detect any deficiencies.
The principle of vaccination against disease is that the introduction of a small amount
of the pathogen to the body produces protective immunologic memory (active
immunity) and, if the pathogen is reintroduced at a later date, a greater immunologic
response is elicited but without inducing disease.
9 The ideal vaccine would present a
non-virulent form of a pathogen that produces a strong immunologic response once in
Current vaccine types include live attenuated, killed (inactivated) whole organism,
subcellular/subunit, and DNA-based vaccines.
(See Table 64-1 for a listing of
common vaccines and their formulation type.) Live attenuated vaccines contain
weakened or inactivated forms of the pathogen, which causes replication within the
host and ultimately elicits antibody and cell-mediated immunity within the body via
11 Live vaccine administration produces a mild,
typically asymptomatic infection at the time of vaccination followed by long-lived
immunity from a single immunization.
Killed whole organism and subcellular/subunit vaccines do not replicate within
the host, nor can they revert to pathogenicity, but they often require adjuvants and/or
multiple doses to increase the duration of immune response to the antigen.
the organisms in whole pathogen vaccines are inactivated (killed), their effectiveness
may be impaired by circulating antibodies, maternal antibodies (in infants), or
concomitant infections. Toxoids are a specific kind of inactivated vaccine formed by
modifying a biological toxin (e.g., diphtheria and tetanus), usually by mixing it with
Subunit vaccines contain either a protein or polysaccharide antigen within the
vaccine and elicit less reaction than whole pathogen vaccines, thus immune
responses are weaker and require multiple doses similar to inactivated vaccines.
Conjugated subunit vaccines, consisting of a polysaccharide-protein-conjugate where
component. Recombinant vaccines available include hepatitis B, human
papillomavirus (HPV), recombinant influenza, and live typhoid vaccine.
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