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SURGICAL ANTIBIOTIC PROPHYLAXISSteve Johnson, PharmD, BCPSPrime Therapeutics, IncOBJECTIVES• Discuss antibiotic use as prophylaxis vspresumptive therapy vs treatment of infections.• Discuss risk factors for developing a surgical wound infection.– NRC wound classification and risk of infection• Discuss selection and administration of antibiotic therapy for surgical procedures.• Discuss duration of antibiotic therapy for prophylaxisINTRODUCTION• Approximately 23 million surgical procedures are performed per year in the United States.• Post operative infection rate = 6%• > 1 million surgical wound infections per year • 25% of all nosocomial infections are related to surgical wound infections– Several of these infections are probably preventableINTRODUCTION• Surgical wound infections increase health care costs by about 1.5 billion/year– Prolonged hospitalization stay– Increased morbidity/mortality• Prophylactic antibiotics have been shown to decrease the risk of infection for many procedures and represents an important component of optimal management of the surgical patient.– Surgical antibiotic prophylaxis is well established and common practice.INTRODUCTION• Controversies regarding prophylactic antibiotic use include:– Selection of antibiotic therapy– Duration of antibiotic therapy– Development of bacterial resistance– Role of newly developed antibiotics• Factors resulting in failure of prophylaxis– Inadequate timing of antibiotic – Failure to readminister antibiotic for prolonged proceduresDEFINITIONS• Prophylaxis:– Administration of an antibiotic prior to contamination of previously sterile tissues or fluids.• Presumptive therapy:– Administration of an antibiotic when there is a strong possibility but unproven established infection• Treatment:– Administration of an antibiotic when an established infection has been identified.DEFINITIONS• Surgical wound infections (SWI):– Incisional infections identified by purulent or culture positive drainage is isolated from any structure above the fascia in proximity to the initial wound– Deep infections are characterized by purulent drainage from subfascial drains, wound dehiscence, or abscess formation and involve adjacent sites manipulated during surgery.– Wound Dehiscence– Breakdown of the surgical woundWOUND CLASSIFICATION• Identifying patient risk– Even with adequate sterile techniques and potent antibiotics wound infections develop in 2-9% of all surgical procedures– Bacteria are found in 90% of surgical incisions despite all aseptic precautions.– The National Research Council stratifies infection risk by surgical procedure- Clean- Clean/contaminated- Contaminated- DirtyWOUND CLASSIFICATION• Clean– SWI risk (<2%)– Elective surgery– No acute inflammation or transection of gastrointestinal (GI) tract, oropharyngeal, genitourinary (GU), biliary or tracheobronchial tracts– No break in aseptic technique– Examples include:- Craniotomy, orthopedic surgery, cardiothoracic and vascular surgery– Antibiotic use is controversialWOUND CLASSIFICATION• Clean-contaminated– SWI risk (2-10%)– Urgent or emergent case that is otherwise clean, controlled opening of GI, GU, oropharyngeal, biliary, or tracheobronchialtracts,– Minimal spillage and/or minor aseptic technique break– Examples include:- Invasive head and neck surgery, cholecystectomy, urologic procedure, hysterectomy, orthopedic surgery with prosthesis– Antibiotics used for prophylaxisWOUND CLASSIFICATION• Contaminated– SWI risk (10-20%)– Any procedure in which there is gross soiling of the operative field during procedure, as well as surgery of open traumatic wounds (< 4 hours old).– Examples include:- Colorectal surgery with spillage, biliary or GU tract surgery in the presence of infected bile or urine and clean or clean/contaminated procedures marred by a major break in technique.– Antibiotics used for prophylaxisWOUND CLASSIFICATION• Dirty– SWI risk (>30%)– Purulence or abscess, preoperative perforation of GI, oropharyngeal, biliary, or tracheobronchialtracts, penetrating trauma > 4 hours old.– Examples include:- Perforated appendicitis with abscess formation– Antibiotics are utilized for treatment and not prophylaxisIDENTIFIED RISK FACTORS• Incidence of a SWI depends on numerous factors specific to either the procedure itself or the individual patient.– Type of surgical procedure and bacterial load encountered– Underlying medical condition of the patient– Surgical procedure- Technique - Duration- Patient preparation- Equipment preparationRISK FACTORS• Patient-related factors– Age > 60, sex (female), weight (obesity)– Presence of remote infections– Underlying disease states- Diabetes, congestive heart failure (CHF), liver disease, renal failure– Duration of preoperative stay- hospitalization > 72 hours, ICU stay– Immunosuppression– ASA (American Society of Anesthesiologists) physical status (3,4, or 5)ASA RISK FACTORSClass Description1 Normal healthy patient2 Mild systemic disease3 Severe systemic disease not incapacitating4 Incapacitating systemic disease that is aconstant threat to life5 Not expected to survive 24 hrs with/withoutoperationRISK FACTORS• Surgery-related factors– Type of procedure, site of surgery, emergent surgery– Duration of surgery (>60-120 min)– Previous surgery– Timing of antibiotic administration– Placement of foreign body- Hip/knee replacement, heart valve insertion, shunt insertion– Hypotension, hypoxia, dehydration, hypothermiaRISK FACTORS• Surgery related factors– Patient preparation- Shaving the operating site- Preparation of operating site- Draping the patient– Surgeon preparation- Handwashing- Skin antiseptics- GlovingRISK FACTORS• Wound-related factors– Magnitude of tissue trauma and devitalization– Blood loss, hematoma– Wound classification- Potential bacterial contamination– Presence of drains, packs, drapes– Ischemia– Wound leakageANTIBIOTICS USE58Hip Fracture Repair42Total Hip replacement3Head & Neck-ContaminatedNAHead & Neck-Clean5Colorectal Surgery14Open Heart SurgeryNNTProcedureANTIBIOTIC SELECTION• Characteristics of an optimal antibiotic for surgical prophylaxis– Effective against suspected pathogens– Does not induce bacterial resistance– Effective tissue penetration– Minimal toxicity– Minimal side effects– Long half-life– Cost effectiveANTIBIOTIC USE•


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U of M PHAR 6124 - SURGICAL ANTIBIOTIC PROPHYLAXIS

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