Prophylaxis (ICAN-ISC workshop)
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The document discusses guidelines for proper antibiotic prophylaxis administration to reduce surgical site infections. It recommends administering the first dose of antibiotics within 120 minutes before incision and optimally 30 minutes prior. The timing should be considered based on the antibiotic's properties like penetration and half-life as well as the surgery indication. Most studies have confirmed efficacy of administering antibiotics for 12 hours or less of prophylaxis.
![Andreas Voss
¤ Lichtenstein-procedure
40-75% inappropriateness in single hospitals
(open inguinal hernia repair with mesh):
¤ US (Everitt et al., Infect Control Hosp Epid 1990; Silver et al., Am J Surg 1996; -less SSI in patients with antibiotics
Gorecki et al.,World J Surg 1999). compared to placebo
¤ Canada (Girotti et al., CJS 1990; Zoutman et al., Can J Surg 1999) Taylor EW et al. Br J Surg. 2004
¤ UK (Griffiths et al., J Hosp Infect 1986) Yerdel MA et al. Ann Surg 2001
¤ France (Bailly et al, J Hosp Inf 2001)
Platt R et al. N Engl J Med 1990
¤ Italy (Mozillo et al., Eur J Epidemiol 1988; Motola et al., J Chemother 1998)
¤ Belgium (Sasse et al., J Antimicrob Chemother 1998)
¤ The Netherlands (Gyssens et al., J Antimicrob Chemother 1996) -no difference in SSI between patients with
¤ Switzerland (Parret et al., Schweiz med Wschr 1993) prophylaxis (1.6%) and placebo (1.8%).
¤ Israel (Finkelstein et al., Isr J Med Sci 1996)
¤ Australia (Johnston et al., Austr Clin Rev 1992) Aufenacker TJ et al. Ann Surg 2004
¤ Clean
² ElecKve,
non-‐traumaKc,
non-‐infected
Wound Cruse & Ford SENIC Olson & Lee Culver et al
classification (n=63000) (n=59000) (n=36500) (n=85000)
² Hip
replacement,
catheter/device
implantaKon
¤ Clean-‐contaminated
Clean 1,5 2,9 1,3 2,1
² Open
GI-‐tract,
urogenital-‐tract,
or
airways
Clean-
7,7 3,9 2,4 3,3
contaminated
² GI-‐surgery,
hysterectomy,
open
fracture,
CABG
¤ Contaminated
Contaminated 15,2 8,5 7,9 6,4
² TraumaKc
wound
<
6h,
leakage
from
GI
tract,
Dirty 40,0 12,6 - 7,1
infected
urine
or
bile
¤ Dirty/infected
² Infected,
pus,
fecal
contaminaKon,
necroKc
Kssue
Clean contaminated and contaminated,
Clean surgery NO risk of wound infection > 5-30 %
except - implant surgery
¤ Colorectal surgery [Baum, 1981]
- high intrinsic risk for SSI
¤ Appendectomy [Gorbach, 1991]
¤ Esophageal surgery
¤ Gastroduodenal surgery, high risk
Clean contaminated procedures YES
¤ Small bowel
Dirty surgery = needs THERAPY ¤ Biliary system, high risk
¤ Gynaecological surgery [Hemsell, 1991]
¤ Head and neck surgery [Shapiro, 1991]
www.sign.ac.uk/guidelines
3](https://image.slidesharecdn.com/prophylaxisican-iscworkshop-121119160948-phpapp01/85/Prophylaxis-ICAN-ISC-workshop-3-320.jpg)
Prophylaxis (ICAN-ISC workshop)
- 1. Andreas Voss Andreas Voss iPrevent UMCN & CWZ Nijmegen, The Netherlands To reduce preventable surgical morbidity and mortality by 25% by 2010 US national costs: $130-845 million/year à saving = $ 32.5 to 212.5 million/year Bratzler & Hunt, Clin Infect Dis 2006; 43:322-30.ccccc 1
- 2. Andreas Voss ¤ 80-‐year-‐old male receiving a knee prosthesis is brought to the OR at 10:00 am for pre-‐operaKve preparaKon and anaesthesia. ¤ Surgeons requested 1 g of cefotaxim to be given as prophylaxis. Prophylaxis was given by anaesthesiologist at 10:10 am. ¤ OR nurse immediately starts with “standard prepara4on” for knee surgery, starts disinfecKng the skin at 10:30 am and the first incision of the surgeons is set at 10:42 am. ¤ Due to unforeseen complicaKons the surgery takes longer than expected and the surgeon orders a second dose of the anKbioKc, that is given at 12:40 am. ¤ A9er the operaKon the surgeon orders 2 further deliveries of the anKbioKc for 7 pm of the same day and 7 am of the next day. ¤ 1g Cefotaxim ² dose? ² choice of ceph. ¤ Standard prep for knee surgery and AB-‐shot at 10:10h, first incision at 10:42h ¤ Second dose 12:42h ¤ A[er 2 extra doses 2
- 3. Andreas Voss ¤ Lichtenstein-procedure 40-75% inappropriateness in single hospitals (open inguinal hernia repair with mesh): ¤ US (Everitt et al., Infect Control Hosp Epid 1990; Silver et al., Am J Surg 1996; -less SSI in patients with antibiotics Gorecki et al.,World J Surg 1999). compared to placebo ¤ Canada (Girotti et al., CJS 1990; Zoutman et al., Can J Surg 1999) Taylor EW et al. Br J Surg. 2004 ¤ UK (Griffiths et al., J Hosp Infect 1986) Yerdel MA et al. Ann Surg 2001 ¤ France (Bailly et al, J Hosp Inf 2001) Platt R et al. N Engl J Med 1990 ¤ Italy (Mozillo et al., Eur J Epidemiol 1988; Motola et al., J Chemother 1998) ¤ Belgium (Sasse et al., J Antimicrob Chemother 1998) ¤ The Netherlands (Gyssens et al., J Antimicrob Chemother 1996) -no difference in SSI between patients with ¤ Switzerland (Parret et al., Schweiz med Wschr 1993) prophylaxis (1.6%) and placebo (1.8%). ¤ Israel (Finkelstein et al., Isr J Med Sci 1996) ¤ Australia (Johnston et al., Austr Clin Rev 1992) Aufenacker TJ et al. Ann Surg 2004 ¤ Clean ² ElecKve, non-‐traumaKc, non-‐infected Wound Cruse & Ford SENIC Olson & Lee Culver et al classification (n=63000) (n=59000) (n=36500) (n=85000) ² Hip replacement, catheter/device implantaKon ¤ Clean-‐contaminated Clean 1,5 2,9 1,3 2,1 ² Open GI-‐tract, urogenital-‐tract, or airways Clean- 7,7 3,9 2,4 3,3 contaminated ² GI-‐surgery, hysterectomy, open fracture, CABG ¤ Contaminated Contaminated 15,2 8,5 7,9 6,4 ² TraumaKc wound < 6h, leakage from GI tract, Dirty 40,0 12,6 - 7,1 infected urine or bile ¤ Dirty/infected ² Infected, pus, fecal contaminaKon, necroKc Kssue Clean contaminated and contaminated, Clean surgery NO risk of wound infection > 5-30 % except - implant surgery ¤ Colorectal surgery [Baum, 1981] - high intrinsic risk for SSI ¤ Appendectomy [Gorbach, 1991] ¤ Esophageal surgery ¤ Gastroduodenal surgery, high risk Clean contaminated procedures YES ¤ Small bowel Dirty surgery = needs THERAPY ¤ Biliary system, high risk ¤ Gynaecological surgery [Hemsell, 1991] ¤ Head and neck surgery [Shapiro, 1991] www.sign.ac.uk/guidelines 3
- 4. Andreas Voss Abd/thoracic Colo-rectal vaginal infected trauma appendectomy hysterectomy UT open # 1. First generation cephalosporins ¤ High efficacy 2. Second generation cephalosporins ¤ Low toxicity à “No” side effects 3. Third generation cephalosporins ¤ As narrow spectrum as possible 4. Glycopeptides ¤ On-‐Kme administraKon possible! 5. Penicillin and betalactamase inhibitor ¤ Low costs 6. Clindamycin (allergy?) ¤ Different from AB used for treatment ¤ Optimal dose is not exactly known ¤ For most drugs, therapeutic dose is used ¤ Half-life of the drug needs to be considered ¤ Increase the dose for obese patients Forse RA et al. Surgery 1989;106:750-6 Nightingale & Quintiliani, Pharmacotherapy 1991;11:6S-13S 4
- 5. Andreas Voss Surgery Type Antimicrobial recommendations Surgery Type Antimicrobial recommendations Hysterectomy " Cefotetan, cefazolin, cefoxitin, cefuroxime, or ampicillin- Hip or knee Preferred: Cefazolin or cefuroxime sulbactam arthroplasty If patient high risk for MRSA: Vancomycin* Beta-lactam allergy: " Clindamycin + gentamicin or fluoroquinolone* or aztreonam Beta-lactam allergy: " Metronidazole + gentamicin or fluoroquinolone* " Vancomycin or clindamycin " Clindamycin monotherapy Colorectal † Neomycin + erythromycin base; neomycin + metronidazole Cardiac or Preferred: Cefazolin or cefuroxime " " Cefotetan, cefoxitin, cefazolin + metronidazole, or ampicillin- vascular If patient high risk for MRSA: Vancomycin* sulbactam Beta-lactam allergy: Beta-lactam allergy: " Clindamycin + gentamicin or fluoroquinolone* or aztreonam " Vancomycin or clindamycin " Metronidazole + gentamicin or fluoroquinolone* Bratzler DW, Hunt DR. Clin Infect Dis. 2006 Bratzler DW, Hunt DR. Clin Infect Dis. 2006 NEJM 1992;326:281-6 3.8% 0.6% RR 6.7 RR 1.0 -24 to –2h = early - 2h = preop 1.4% 0 to +3h = peri-op >3h = post-op 3.3% RR 2.4 RR 5.8 SSI Administration < 120 minutes before: RR 0.5 Stone Ann Surg 1976;184:443-452 Administration 2 or more hours before: RR 5.3 5
- 6. Andreas Voss …optimal timing …is 30 minutes prior to incision… … administration of the first dose within one hour… ¤ Guideline: <120 minutes before ¤ Depends on: ² Could be -‐120 or -‐60 or -‐30 or -‐1 ² AnKbioKc choice (penetraKon, top concentraKon, HLT) ² Do you believe that all of the above is correct? ² IndicaKon (need to be present in Kssue, equilibrium between ¤ Need to agree on a range e.g. compartments) ² -‐45 to -‐15 or ² -‐90 to -‐30 90 to15 minutes before incision – or - stop of blood-flow Favors multiple dose Favors single dose McDonald Aust NZ J Surg 1998;68:388 6
- 7. Andreas Voss ¤ Most studies have confirmed efficacy of ≤12 hrs of prophylacKc anKbioKcs ¤ Many studies have shown efficacy of a single dose ¤ Whenever compared, the shorter course has been as effecKve as the longer course and results in less anKbioKc resistance ¤ ProporKon of paKents who have their anKbioKc ¤ Overview Status quo dose iniKated within 1 hour before surgical ¤ IndicaKon incision (2 hours for vancomycin or fluoroquinolones) ¤ Choice of anKbioKc ¤ ProporKon of paKents who receive prophylacKc anKbioKcs consistent with current ¤ Timing recommendaKons (published guidelines) ¤ DuraKon ¤ ProporKon of paKents whose prophylacKc ¤ Quality control anKbioKcs were disconKnued within 24 hours of surgery end Kme (48 hours for cardiac surgery) ¤ ProporKon of paKents who have their 12.44 13.09 anKbioKc dose iniKated within 1 hour before surgical incision* * Or any other time/time range your quality improvement team agreed on 7
- 8. Andreas Voss 00:57 Timing as agreed on ¤ Install quality improvement team 00:50 ² MDs, nurses and OR management, surgeon (chair), anesthesiologist, ward staff, QM, IC, pharmacist 00:43 00:36 ¤ Why is prophylaxis not given on Kme? 00:28 ² Process, structure, logisKcs, responsibiliKes 00:21 00:14 ¤ Consensus on how to do it 00:07 ² Agree on Kme range 00:00 ² Describe a realisKc process (SOP) ² Assign responsibiliKes Timing as agreed on v Antibiotic has to be in the tissue at time of 00:57 incision or stop of blood-flow 00:50 00:43 v Time period = end infusion until incision 00:36 v Could be start of infusion as long as extra time is 00:28 added and everyone in the hospital knows the rules 00:21 v 2nd shot after 2-3 halftimes (3-4 h) 00:14 00:07 v 2nd shot senseless during stop blood-flow 00:00 v No prophylaxis after 24 hours 8