What about prophylaxis James Molton Infectious Diseases Physician Mater Hospital Brisbane Sumi Britton Diana Moore Mater SAP Audit April 2018 Retrospective audit n163 Sumi Britton Diana Moore Mater ID: 1012313
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1. Infections in Surgical PatientsWhat about prophylaxis?James MoltonInfectious Diseases PhysicianMater Hospital Brisbane
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6. Sumi Britton, Diana Moore. Mater SAP Audit, April 2018Retrospective audit, n=163
7. Sumi Britton, Diana Moore. Mater SAP Audit, April 2018
8. Indications for prophylaxis
9. Indications for prophylaxisWendy Munckhof. Aust Prescr 2005;28:38-401
10. Indications for prophylaxissignificant risk of postoperative infection (eg. colonic resection)if an uncommon postoperative infection would have serious consequences (eg. prosthetic implant infection) Note pre-existing prosthetic joint does not alter recommendations
11. Endocarditis prophylaxiseTG July 2018 editionIf indicated give amoxicillin 2g pre-procedure
12. Choice of antibiotic
13. Choice of antibioticMost postoperative infections are caused by organisms that already colonise the patientConsider bacterial flora most likely to cause SSIWendy Munckhof. Aust Prescr 2005;28:38-401
14. Choice of antibioticConsiderations:pre-existing infectionrecent antimicrobial use colonisation with MDROs – consider screeningprolonged hospitalisationpresence of prostheseseTG July 2018 edition
15. Cephazolin 2g IVTo cover skin flora for clean-contaminated or contaminated procedures through intact skinIf ongoing procedure, repeat after 4 hoursMetronidazole 500mg IVIn addition to cephazolin for lower GI surgery or head and neck surgery via mucosaVancomycin 25mg/kg IVAlternative to cephazolin if immediate hypersensitivity to penicillin. Note efficacy is reducedIn addition to cephazolin if MRSA colonised (consider decolonisation pre-procedure)Gentamicin 2mg/kg IVGive alone for TURPIn addition to cephazolin for urologic surgeryIn addition to vancomycin for GI surgery in penicillin allergic patientsCiprofloxacin 500mg POGive alone for trans-rectal prostate biopsy** If risk for MDROs (recent travel, antibiotics) contact ID **
16. Timing – when to start?
17. Retrospective datan=50 SSI post total hip arthroplastySuggested 30-60 minutes pre-incision is best
18. RCT n=5580 general surgery inpatientsRandomised to SAP early (anaesthetic room) vs late (operating room) Early = median 42 mins before incisionLate = median 16 mins before incision
19. No difference between early and late SAP
20. Andreas F. Widmer, ID Week 2018 Poster Abstract Session https://idsa.confex.com/idsa/2017/webprogram/Paper64509.html Prospective Swiss surveillance data from 172 institutionsn=121,645 adult patients undergoing cardiac surgery, orthopedic or abdominal surgeryLowest risk of SSI with SAP 0-30min prior to incisionNew Swiss surveillance data suggests < 30 minutes is best
21. Timing - when to stop?
22. Timing - when to stop?A single dose is sufficient for majority Repeat intraoperative dose if procedure is prolongedcephazolin – 4 hoursPostoperative doses (up to 24h) only required in defined circumstances (eg some cardiac and vascular surgeries, lower limb amputation)eTG July 2018 edition
23. VA cohort study, n= 79,092 undergoing cardiac, orthopedic total joint, vascular, and colorectal proceduresLonger duration SAP did not lead to additional SSI reductionLonger duration SAP increased risk of AKI and CDIOdds RatioJudith M. Strymish, ID Week 2018 Oral Abstract Session https://idsa.confex.com/idsa/2018/webprogram/Paper73284.html Prophylaxis beyond 24h?
24. Timing - when to stop?Prophylaxis should not extend beyond 24h, regardless of the procedure No benefitassociated with an increased risk of adverse effects, including MDRO infection and C. difficileCatheters or drains that remain in situ are not a justification to extend the duration of antibiotic prophylaxiseTG July 2018 edition
25. SummaryAdminister an antibiotic to cover bacterial flora likely to cause infectionSingle dose 15-30 minutes pre-procedureRepeat cephazolin dose if procedure >4hConsider screening and decolonisation for MRSAAdd vancomycin if remains positiveContact ID if any queries
26. Accessory SlidesMater Guidelines (based on eTG)
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