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Antibiotic Prophylaxis to Prevent Surgical Site Infections ALAN R

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Antibiotic Prophylaxis to Prevent Surgical Site Infections ALAN R Antibiotic Prophylaxis to Prevent Surgical Site Infections ALAN R. SALKIND, MD, and KAVITHA C. RAO, MD, University of Missouri–Kansas City School of Medicine Surgical site infections are the most common nosocomial infections in surgical patients, accounting for approxi- mately 500,000 infections annually. Surgical site infections also account for nearly 4 million excess hospital days annually, and nearly $2 billion in increased health care costs. To reduce the burden of these infections, a partner- ship of national organizations, including the Centers for Medicare and Medicaid Services and the Centers for Dis- ease Control and Prevention, created the Surgical Care Improvement Project and developed six infection prevention measures. Of these, three core measures contain recommendations regarding selection of prophylactic antibiotic, timing of administration, and duration of therapy. For most patients undergoing clean-contaminated surgeries (e.g., cardiothoracic, gastrointestinal, orthopedic, vascular, gynecologic), a cephalosporin is the recommended prophylac- tic antibiotic. Hospital compliance with infection prevention measures is publically reported. Because primary care physicians participate in the pre- and postoperative care of patients, they should be familiar with the Surgical Care Improvement Project recommendations. (Am Fam Physician. 2011;83(5):585-590. Copyright © 2011 American Acad- emy of Family Physicians.) surgical site infection is defined performance measures for the appropriate This clinical content con- as an infection that occurs at or selection, administration, and termina- forms to AAFP criteria for near a surgical incision within tion of prophylactic antibiotics for patients evidence-based continu- 30 days of the procedure or undergoing clean-contaminated surgeries. ing medical education Awithin one year if an implant is left in In 2003, the CDC, CMS, and 10 additional (EB CME). See CME Quiz 1,2 on page 537. place. The Centers for Disease Control and national organizations developed the Sur- Prevention (CDC) estimates that approxi- gical Care Improvement Project (SCIP).7 mately 500,000 surgical site infections occur The Surgical Infection Prevention Proj- annually in the United States.3 They are the ect measures were subsequently incorpo- leading cause of nosocomial infections after rated into the SCIP, which has been widely surgery, accounting for nearly 40 percent of disseminated.7-9 nosocomial infections in surgical patients.2 Publicly reported SCIP performance The cost of care for patients with surgi- measures targeted at reducing postoperative cal site infections is nearly threefold higher surgical site infections include the following than that for surgical patients without the (the first three comprise the core infection infections during the first eight weeks after prevention measures)10: hospital discharge.3 These infections reduce • Prophylactic antibiotics should be ini- patients’ quality of life4 and account for tiated within one hour before surgical inci- 3.7 million excess hospital days and more sion, or within two hours if the patient is than $1.6 billion in excess costs annually.5 receiving vancomycin or fluoroquinolones. Furthermore, patients who develop surgical • Patients should receive prophylactic site infections are five times more likely to be antibiotics appropriate for their specific readmitted to the hospital, 60 percent more procedure. likely to spend time in the intensive care unit, • Prophylactic antibiotics should be dis- and twice as likely to die compared with sur- continued within 24 hours of surgery com- gical patients without the infections.6 pletion (within 48 hours for cardiothoracic In 2002, the Centers for Medicare and surgery). Medicaid Services (CMS), collaborating • Postoperative 6 a.m. blood glucose with the CDC, developed and implemented levels should be controlled (200 mg per dL the Surgical Infection Prevention Proj- [11.10 mmol per L] or less) in patients under- ect. Its goal was to provide evidence-based going cardiac surgery. Downloaded from the American Family Physician Web site at www.aafp.org/afp. Copyright © 2011 American Academy of Family Physicians. For the private, noncommer- March 1,cial 2011 use of◆ Volumeone individual 83, Numberuser of the 5Web site. All other rights reserved.www.aafp.org/afp Contact [email protected] for copyright questionsAmerican and/or permission Family Physician requests. 585 Surgical Site Infections which antibiotic is appropriate, and when SORT: KEY RECOMMENDATIONS FOR PRACTICE the antibiotic should be administered and Evidence discontinued. Clinical recommendation rating References Core Infection Prevention Measures: To help prevent surgical site infection, the A 7, 9, 11, Evidence Summary perioperative antibiotic should be infused 12, 18 within one hour before incision. Prophylactic antibiotic administration Perioperative antibiotic prophylaxis should be C 7, 8 should be initiated within one hour before consistent with published guidelines. the surgical incision, or within two hours Perioperative antibiotic prophylaxis should C 7, 8 if the patient is receiving vancomycin or generally be discontinued within 24 hours fluoroquinolones. after surgery completion. The goal of antibiotic prophylaxis is to ensure effective serum and tissue levels of the A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited- quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual drug for the duration of the surgery. Analysis practice, expert opinion, or case series. For information about the SORT evidence of data from 2,847 patients undergoing clean rating system, go to http://www.aafp.org/afpsort.xml. or clean-contaminated surgical procedures showed that those receiving antibiotic pro- phylaxis within two hours before incision had • Surgical site hair removal should be a surgical site infection rate of 0.6 percent. In appropriate for the location and procedure contrast, patients receiving prophylactic anti- (e.g., clippers, depilation, no hair removal). biotics more than three hours after surgical • Patients undergoing colorectal surgery incision had a twofold increase in surgical should be normothermic (96.8˚F [36˚C] or site infection, and those receiving antibiot- greater) within the first 15 minutes after ics more than two hours before incision had leaving the operating room. approximately a sixfold increase in risk.11 Despite demonstrated reductions in the Another study demonstrated that the risk incidence of surgical site infections follow- of surgical site infection following total hip ing implementation of these measures,11-14 arthroplasty was lowest when the appropri- a recent survey of U.S. hospitals found that ate antibiotic was administered within one the recommendations are not routinely fol- hour before incision.12 A recent multicenter lowed. Only 55.7 percent of surgical patients study of 29 hospitals in the United States also received prophylactic antibiotics within one supported administration within one hour hour of incision, and the antibiotic was dis- before incision and showed that adminis- continued within the 24 hours after surgery tration within 30 minutes before incision in only 40.7 percent of patients.15 Other stud- may reduce the risk even further.13 A meta- ies show that approximately 80 to 90 percent analysis of randomized controlled trials of surgical patients received antibiotic pro- showed that antibiotic administration just phylaxis, but the choice of regimen, timing before or at the time of anesthesia resulted in of administration, or duration of prophy- significantly lower infection rates in patients laxis were inappropriate in approximately undergoing spinal surgery.18 25 to 50 percent of patients.14 As an incen- If vancomycin or fluoroquinolones are tive to reduce rates of surgical site infections, used, infusion should be started within CMS reduced reimbursement to hospitals one to two hours before incision to account for some of these infections.16 for longer infusion times. Infusion of pro- Because primary care physicians are phylactic antibiotics should be completed involved in pre- and postoperative care before tourniquet inflation.8,9 and some perform or assist in surgical pro- When Is Repeat Antibiotic Infusion Con- cedures,17 they have the opportunity to sidered? Most authorities and study results impact the incidence of surgical site infec- support a single dose of antibiotic given tions by understanding which surgeries call within one hour before incision.8,9,19,20 How- for prophylactic antibiotic administration, ever, the antibiotic infusion may be repeated 586 American Family Physician www.aafp.org/afp Volume 83, Number 5 ◆ March 1, 2011 Surgical Site Infections intraoperatively for procedures lasting more vancomycin for surgical site infection pro- than four hours and when substantial blood phylaxis is not recommended for any type loss (more than 1,500 mL) occurs.9,21 The of surgery.2,8 However, vancomycin may be antibiotic should be redosed at one to two considered for patients with a beta-lactam times the half-life of the drug.9 A retrospec- allergy and in institutions with high rates tive analysis of patients who underwent car- of methicillin-resistant S. aureus (MRSA) or diac surgery showed that in patients with an increase in surgical site infections caused surgeries lasting more than four hours, the by MRSA or coagulase-negative staphylo- risk of surgical site infection was reduced cocci, particularly following prosthetic
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