Surgical Prophylaxis

Surgical Prophylaxis

Clinical Considerations

These guidelines are for patients without pre-existing infectious process

  • Continue to treat the infection. If the current antibiotic spectrum does not cover the usual organisms covered by routine prophylaxis for procedure, add the recommended prophylactic antibiotic.
  • Ensure dose is given at appropriate time to achieve maximal tissue levels at time of incision. Administer an extra dose within 60 minutes before surgical incision.

Administer antibiotics within 60 minutes of incision time (within 120 minutes for vancomycin and fluoroquinolones)

Decisions to follow these recommendations must be based on the judgement of the clinician and individual patient circumstances

  • According to available literature and specialty society guidelines, routine use of antimicrobial prophylaxis may be omitted in procedures with low risk of infection.
  • These procedures include but are not limited to: D&C for non-pregnancy indications,² hysteroscopy,² dermatologic procedures without breech of oral mucosa,³ tonsillectomy,⁴ clean-contaminated head and neck surgery,⁴ laparoscopic cholecystectomy in patients without increased risk for infectious complications.¹
  • Factors that indicate a high risk of infectious complications in laparoscopic cholecystectomy include: emergency procedures, diabetes, procedure duration anticipated to exceed 120 minutes, intraoperative gallbladder rupture, age of greater than 70 years, conversion from laparoscopic to open cholecystectomy, American Society of Anesthesiologists classification of 3 or greater, episode of biliary colic within 30 days before the procedure, reintervention in less than one month for noninfectious complication of prior biliary operation, acute cholecystitis, anticipated bile spillage, jaundice, pregnancy, nonfunctioning gallbladder, immunosuppression, and insertion of prosthetic device.
  • Because a number of these risk factors are not possible to determine before surgical intervention, it may be reasonable to give a single dose of antimicrobial prophylaxis to all patients undergoing laparoscopic cholecystectomy.¹
  • Refer to specialty guidelines for more detailed lists of procedures and prophylactic regimen recommendations.

The 4 Rights of Surgical Prophylaxis

  • Antibiotic recommendations per 2013 ASHP/IDSA/SIS/SHEA consensus guidelines are based on the most common surgical site pathogens for procedure type and penetration to surgical site
  • Penicillin allergy: Patients with reported penicillin allergy had significantly increased odds of surgical site infection (SSI) likely due to receipt of second-line prophylactic agents
  • Get an accurate history: what drug, details of reaction, other antibiotics received

Non-Severe - May Re-Challenge

  • Maculopapular rash without hives, wheezing, anaphylaxis
  • Non-allergic reaction such as GI intolerance

Severe - Do Not Re-Challenge

  • Immediate type hypersensitivity: Hives, angioedema, wheezing, anaphylaxis
  • Late reactions: Hemolytic anemia, thrombocytopenia, serum sickness, drug reaction with eosinophilia, Stevens Johnson syndrome (SJS)/Toxic epidermal necrolysis (TEN)

MRSA Colonization

  • Consider adding vancomycin to standard prophylaxis
  • CMHS’s most recent outpatient antibiogram reports MRSA susceptibility to clindamycin at only 72%

Standardized doses recommended in the 2013 consensus guideline are appropriate for most adult patients to achieve adequate antibiotic levels above the minimal inhibitory concentration (MIC) of pathogens at the surgical site.

  • Obese, especially morbidly obese, patients have significantly decreased tissue and serum antibiotic concentrations with standard doses. Increasing cefazolin and cefoxitin from 2 g to 3 g is justified in patients greater than or equal to 120 kg to reach levels higher than bacterial MIC.
  • For patients weighing <40 kg, pediatric weight-based doses may be considered.

Successful prophylaxis requires that the antibiotic achieve goal serum and tissue concentrations at the time of incision. Administration of antibiotics too early before or too late after the time of incision will result in suboptimal tissue levels and increase the risk for post-operative wound infection.

  • Antibiotic infusion should begin within 60 minutes prior to incision. Antibiotics with longer infusion times like vancomycin or fluoroquinolones should be initiated within 120 minutes prior to incision.
  • Prophylactic agents should maintain adequate levels of drug in serum and tissue for the interval during which the surgical site is open.
  • Intraoperative redosing is needed if the duration of the procedure exceeds two half-lives of the antibiotic or there is excessive blood loss (>1500 mL).
  • Redosing may not be warranted in patients whom the half-life of the drug is prolonged such as patients with renal insufficiency.
  • Unless there is known infection, prophylactic antibiotics should be discontinued within 24 hours for most procedures. Single dose prophylaxis is usually sufficient.
  • Prompt discontinuation of prophylaxis does not appear to impact the risk of developing SSI but continuation increases risk for antibiotic related problems such as resistance and C. difficile associated diarrhea.