- Prophylactic antibiotic therapy differs from presumptive and therapeutic antibiotic therapy in that the latter two involve treatment regimens for documented or presumed 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 (e.g., cefazolin) may require intraoperative redosing during long (>3 hours) procedures.
- 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 (e.g., 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 (e.g., methicillin-resistant Staphylococcus aureus) is documented or high enough to justify use.
On completion of the chapter, the reader will be able to:
Differentiate between prophylactic, presumptive, and therapeutic antibiotics in the perioperative patient.
Identify patient-specific risk factors for surgical site infections (SSIs).
Identify procedure-specific risk factors for SSIs.
List common pathogens responsible for SSIs.
Explain the importance of timing of antimicrobial prophylaxis for surgery.
Apply pharmacokinetic principles for antimicrobial prophylactic regimens for surgeries of different durations.
Choose an evidence-based prophylactic antimicrobial regimen for specific types of surgeries.
Individualize prophylactic antimicrobial regimens by considering the type of surgery, intrinsic patient risk factors, and knowledge of common pathogenic organisms.
Recommend an alternative prophylactic antimicrobial regimen for patients with life-threatening allergies to first-line therapies.
Identify clinical scenarios where multiple dose regimens of prophylactic antimicrobials are appropriate as compared to single dose regimens.
Discuss the role of preoperative mechanical bowel preparations in the setting of elective colorectal surgery.
Differentiate between traditional and minimally invasive surgeries and the relative risk of SSIs.
Debate the consequences of overzealous use of broad-spectrum antibiotics in the context of antimicrobial resistance and the changing epidemiology of pathogens responsible for SSIs.
List nonpharmacological interventions effective at reducing the risk of postoperative SSIs.
Formulate an appropriate monitoring plan for surgical patients at risk for SSIs.
According to the National Center for Health Statistics, some 46 million surgical procedures are performed annually in the United States, the majority of which are done in an outpatient setting.1 Infection is the most common complication of surgery.2 Surgical site infections (SSIs) occur in ˜3% to 6% of patients and prolong hospitalization by an average of 7 days at ...