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Source: Kanji S. Antimicrobial Prophylaxis in Surgery. In: DiPiro, JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM. Pharmacotherapy: A Pathophysiologic Approach. 8th ed. Accessed July 22, 2012.

  • Prophylactic administration of antibiotics to prevent development of surgical-site infection (SSI).
    • Presumptive antibiotic therapy administered when infection suspected but not yet proven.
  • SSIs by definition occur by postoperative day 30 except for those associated with prosthesis implantation, in which period extends to 1 year.
    • Classified as:
      • Incisional (e.g., cellulitis of incision site)
        • Superficial (skin or SC tissue)
        • Deep (fascial and muscle layers)
      • Involving organ or space (e.g., with meningitis).

  • SSIs occur in ~3–6% of patients and prolong hospitalization by average of 7 days.
    • Most common postoperative complication.
  • Third most frequent cause of nosocomial infections among hospitalized patients.
    • Primary cause (40%) of nosocomial infections in surgical patients.

  • Traditional classification system developed by National Research Council (NRC) stratifying surgical procedures by infection risk in Table 1.
    • NRC wound classification for specific procedure determined intraoperatively and is primary determinant of whether antibiotic prophylaxis warranted.
  • NRC classification system does not account for influence of:
    • Underlying patient risk factors including:
      • Comorbidities (e.g., diabetes)
      • Altered immune response (e.g., HIV, hepatitis C)
      • Nutritional status
    • Operation factors including:
      • Duration of surgical scrub and operation
      • Implantation of prosthetic materials
      • Surgical technique
  • Study on the Efficacy of Nosocomial Infection Control (SENIC) analyzed more than 100,000 surgery cases.
    • Identified risk factors associated with increased incidence of SSI:
      • Abdominal operations
      • Operations lasting >2 hours
      • Contaminated or dirty procedures
      • >3 underlying medical diagnoses
    • Stratification of NRC classification described in Table 1 by number of SENIC risk factors present resulted in variation of infection rates by as much as factor of 15 within same operative category.
  • SENIC risk assessment technique has been modified to include American Society of Anesthesiologists preoperative assessment score.
    • American Society of Anesthesiologists score ⩾3 was associated with increased SSI risk.

Table 1. National Research Council Wound Classification, Risk of Surgical-Site Infection (SSI), and Indication for Antibiotics

  • Bacteria involved in SSI acquired either from patient’s normal flora (endogenous) or contamination during surgical procedure (exogenous).
  • Loss of protective flora via antibiotics can upset balance and allow pathogenic bacteria to ...

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