## CHAPTER SUMMARY FROM THE PHARMACOTHERAPY HANDBOOK

For the chapter in the Wells Handbook, please go to Chapter 48. Surgical Prophylaxis.

## KEY CONCEPTS

KEY CONCEPTS

• Prophylactic antibiotic therapy differs from presumptive and therapeutic antibiotic therapy in that the latter two involve treatment regimens for presumed or documented infections, whereas the goal of prophylactic therapy is to prevent infections in high-risk patients or procedures.

• The risk of a surgical site infection (SSI) is determined from both the type of surgery and the patient-specific risk factors; however, most commonly used classification systems account for only procedure-related risk factors.

• The timing of antimicrobial prophylaxis is of paramount importance. Antibiotics should be administered within 1 hour before surgery to ensure adequate drug levels at the surgical site prior to the initial incision.

• Antimicrobial agents with short half-lives (eg, cefazolin) may require intraoperative redosing during procedures last more than 3 hours or 2.5 half-lives of the antimicrobial used.

• The type of surgery, intrinsic patient risk factors, most commonly identified pathogenic organisms, institutional antimicrobial resistance patterns, and cost must be considered when choosing an antimicrobial agent for prophylaxis.

• Single-dose prophylaxis is appropriate for many types of surgery. First-generation cephalosporins (eg, cefazolin) are the mainstay for prophylaxis in most surgical procedures because of their spectrum of activity, safety, and cost.

• Vancomycin as a prophylactic agent should be limited to patients with a documented history of life-threatening β-lactam hypersensitivity or those in whom the incidence of infections with organisms resistant to cefazolin (eg, methicillin-resistant Staphylococcus aureus) is documented or high enough to justify use.

According to the National Center for Health Statistics and the National Hospital Discharge Survey, nearly 57 million outpatient and 51 million in patient surgical procedures are performed annually in the United States.1,2 Infection is the most common complication of surgery.3 Surgical site infections (SSIs) occur in ~3% to 6% of patients and prolong hospitalization by an average of 7 days at a direct annual cost of $5 billion to$10 billion.4,5 SSIs are the third (14%-16%) most frequent cause of nosocomial infections among hospitalized patients and the primary (40%) cause of nosocomial infection in surgical patients.4 Prophylactic administration of antibiotics decreases the risk of infection after many surgical procedures and represents an important component of care for this population.

Antibiotics administered prior to the contamination of previously sterile tissues or fluids are called prophylactic antibiotics. The goal of prophylaxis is to prevent an infection from developing. Although eradication of distal (preexisting, unrelated to surgery) infections lowers the risk for subsequent postoperative infections, it does not per se constitute a prophylactic regimen. In fact, surgical prophylaxis should be prescribed concurrently under these circumstances because of important antimicrobial spectrum- and timing-related concerns. Both SSIs and hospital-acquired infections not directly related to the surgical site (eg, urinary tract infections and pneumonia) are termed nosocomial. Prevention of hospital-acquired ...

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