ANTIBIOTIC RECOMMENDATIONS FOR PERI-OPERATIVE PROPHYLAXIS

ANTIBIOTIC RECOMMENDATIONS FOR PERI-OPERATIVE PROPHYLAXIS

This document provides guidance to clinicians for perioperative antibiotic prophylaxis at Boston Children's Hospital. Recommendations are based on national guidelines1, local antibiotic resistance data, and historical practice. These recommendations apply only to patients without active infection at time of surgery.

Pre-operative Timing Pre-operative doses for most antibiotics must be started no longer than 60 minutes before surgical incision and ideally should be complete prior to incision time. Agents with prolonged infusion (fluoroquinolones, vancomycin) must begin infusing no longer than 120 minutes prior to incision and ideally should be complete prior to incision time. For patients who are already on antibiotics prior to surgery, the standard pre-operative dose should still be administered UNLESS an antibiotic appropriate for surgical prophylaxis has been given within 1h (or 2h for drugs with prolonged infusion) prior to incision time.

Intra-operative Redosing Intra-operative redosing is needed for the following situations: o Duration of the procedure exceeds two half-lives of the antibiotic o Excessive blood loss (>25 mL/kg or >1500 mL for a 60kg adult) o Cardiac bypass

Post-operative Duration For non-cardiac procedures, antibiotic prophylaxis after the incision is closed is unnecessary and should be discontinued within 24 hours after the procedure For cardiac procedures, antibiotic prophylaxis should be discontinued no more than 48 hours after the procedure with the following exceptions: o Delayed sternal closure ? prophylaxis through chest closure o VAD placement ? 72 hours post-operatively Antibiotic prophylaxis should not be continued based on the presence of chest tubes, drains, or indwelling catheters.

Antibiotic Recommendations for Surgical Prophylaxis

MRSA Screening and Prophylaxis Patients with known MRSA colonization who are undergoing procedures with high risk for surgical site infection (cardiac cases, spinal procedures, and neurosurgical shunts) should have vancomycin ADDED to their usual surgical prophylaxis regimen as a one-time preoperative dose. Penicillin or cephalosporin-allergic patients who are receiving clindamycin should receive vancomycin IN PLACE of clindamycin if their MRSA is known to be resistant to clindamycin.

VRE Colonization Patients with known VRE colonization who are undergoing liver, multi-visceral, or lung transplant should have perioperative prophylaxis with activity against VRE1. The preferred agent is linezolid.

Dental Prophylaxis (not Oral Maxillofacial Surgery)2 Patients undergoing procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of oral mucosa should receive prophylaxis if they have a high-risk cardiac condition. These include: o Prosthetic cardiac valve (including prosthetic material used in valve repair) o Previous infective endocarditis o Unrepaired cyanotic congenital heart disease (CHD) o Repaired CHD with prosthetic material or device during the 6 months after the procedure o Repaired CHD with residual defects at or adjacent to the site with prosthetic material o Cardiac transplant recipients with cardiac valvulopathy Prophylaxis is also recommended for patients with venticuloatrial, ventriculocardiac, or ventriculovenous shunts. Prophylaxis may be considered on a case-by-case basis for patients with orthopedic hardware or immune-compromised status. Prophylaxis should be given as a single dose 30-60 minutes before the procedure. The recommended antibiotic agents are amoxicillin 50 mg/kg (max 2g) PO or ampicillin 50mg/kg (max 2g) IV given 30-60 minutes before the procedure. Penicillin allergic patients without anaphylaxis may receive cephalexin 50 mg/kg (max 2g) PO or cefazolin 50 mg/kg (max 2g) IV. Penicillin allergic patients with history of anaphylaxis or urticarial should receive clindamycin 20 mg/kg (max 600 mg) IV or PO.

1 Bratzler DW et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health-Syst Pharm 2013;70:195-283. 2 American Academy of Pediatric Dentistry. Guideline on antibiotic prophylaxis for dental patients at risk for infection. Updated 2014. Source: Clinical Practice Guidelines V37 (6): 292-297 Antibiotic Recommendations for Surgical Prophylaxis

ANTIBIOTIC RECOMMENDATIONS for Peri-operative Prophylaxis

General Procedures Clean procedures WITHOUT implantation of foreign material or high risk outcome Clean procedures with implantation of foreign material or high risk outcome Cardiac and Thoracic Procedures1 Primary or delayed closure Primary or delayed closure GT/colostomy

VAD Implantation

Pacemaker insertion (EP or sternotomy) Melody valve in Mitral position

Thoracic (non-cardiac, including VATS) GI / Abdominal Procedures Non-perforated appendectomy Perforated appendectomy (treatment) Upper GI and Biliary

Small intestine, NOT obstructed

Standard Prophylaxis

No prophylaxis

Cefazolin

Cefazolin Piperacillin-tazobactam Vancomycin + Piperacillin-tazobactam + Fluconazole Cefazolin Vancomycin + Piperacillin-tazobactam Cefazolin

Cefoxitin Piperacillin-tazobactam Cefazolin Cefazolin

Colorectal and obstructed small intestine

Cefoxitin

Esophageal Atresia Repair Esophageal Atresia Repair, Intubated and colonized Gynecology Diagonostic or exploratory laparatomy, laparoscopy, or hysteroscopy

Cefazolin + Metronidazole Targeted to colonizing organisms

No prophylaxis

IUD insertion

No prophylaxis

Hysterectomy

Cefazolin

Penicillin-allergic

No prophylaxis

Clindamycin

Vancomycin Vancomycin + Gentamicin Vancomycin + Ciprofloxacin + Fluconazole Vancomycin Vancomycin + Gentamicin Clindamycin

Ciprofloxacin + Metronidazole Neonates: Clindamycin + Gentamicin Clindamycin + Gentamicin Clindamycin + Gentamicin Ciprofloxacin + Metronidazole Neonates: Clindamycin + Gentamicin Clindamycin + Gentamicin Targeted to colonizing organisms

No prophylaxis

No prophylaxis Clindamycin + Gentamicin

Clean-contaminated, uro-genital, and mesh procedures Cefazolin

Clindamycin + Gentamicin

Antibiotic Recommendations for Surgical Prophylaxis

Head and Neck Procedures Tonsillectomy, Adenoidectomy, and FESS Typanostomy tube insertion Clean WITH insertion of prosthetic material Clean-contaminated Orthopedic Clean procedure or arthroscopy without implantation of foreign material Clean procedure or arthroscopy WITH implantation of foreign material

Open fracture (grade I or II)

Open fracture with extensive soft tissue damage and crushing (Grade III) High risk spinal fusion1

Spinal procedure without implantation or risk factors1

Plastic Surgery / Oral Maxillofacial Surgery Procedure with implant/graft/flap Clean-contaminated Urology

Cirumcision, Meatotomy, Hydrocele, Orchiopexy or Hernia repair (pre-pubertal)

Clean Procedure (no entry into GU tract) Clean-contaminated (entry into GU tract)

Myelomeningocele / Reconstructive or other cleancontaminated procedure

Artificial urinary sphincter repair or other implant Neurosurgery1 Clean procedures, CSF-shunting procedures, or intrathecal pump placement Solid Organ Transplant Heart Transplant

Antibiotic Recommendations for Surgical Prophylaxis

No prophylaxis No prophylaxis Cefazolin Ampicillin-sulbactam

Cefazolin or No prophylaxis2

Cefazolin Cefazolin Cefazolin + Gentamicin +/- Penicillin Cefazolin + Gentamicin Cefazolin

Cefazolin Ampicillin-sulbactam

No prophylaxis Cefazolin Cefazolin Cefoxitin or Targeted to colonizing urinary organisms Cefazolin + gentamicin

Cefazolin

Cefazolin

No prophylaxis No prophylaxis Clindamycin Clindamcyin

Clindamycin or No prophylaxis2 Clindamycin Clindamycin Clindamycin + Gentamicin Clindamycin + Gentamicin Clindamycin

Clindamycin Clindamycin +/- Gentamicin

No prophylaxis Clindamycin Clindamycin + Gentamicin Clindamycin + Gentamicin Vancomycin + Gentamicin

Clindamycin or Vancomycin

Vancomcycin

Heart Transplant GT/colostomy Heart Transplant with VAD or ECMO, no cannula infection/colonization Heart Transplant with VAD or ECMO AND cannula colonization/infection

Lung or Heart-lung Transplant

Liver Transplant

Piperacillin-tazobactam Cefazolin Tailored to skin flora + infecting organisms Tailored to skin flora + lung colonization Piperacillin-tazobactam

Liver / Small Bowel or Multivisceral Transplant

Piperacillin-tazobactam

Kidney Transplant

Bacteremia Prophylaxis for Oral Procedures

Dental: Manipulation of gingiva or root plus underlying at-risk condition (see cover page) Oral procedures (i.e. tonsillectomy) not otherwise requiring surgical prophylaxis plus underlying at-risk condition (see cover page)

Cefazolin Ampicillin or Amoxicillin Ampicillin or Amoxicillin

Vancomycin + Gentamicin Vancomcyin Tailored to skin flora + infecting organisms Tailored to skin flora + lung colonization Vancomycin + Ciprofloxacin Vancomycin + Aztreonam + Metronidazole Clindamycin

Clindamycin

Clindamycin

1If MRSA colonized, vancomycin should be ADDED to the prophylaxis regimen for cardiac cases, neurosurgical shunt placement, and spinal

procedures 2 In clean orthopedic procedures, such as knee, hand, and foot, and arthroscopy procedures that have no implantation of foreign materials, the

need for antimicrobial prophylaxis is not well established and may reflect surgeon preference.

Antibiotic Recommendations for Surgical Prophylaxis

 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download