Standards of Practice Practice Guideline for Adult Antibiotic Prophylaxis during Vascular and Interventional Radiology Procedures Aradhana M. Venkatesan, MD, Sanjoy Kundu, MD, David Sacks, MD, Michael J. Wallace, MD, Joan C. Wojak, MD, Steven C. Rose, MD, Timothy W.I. Clark, MD, MSc, B. Janne d’Othee, MD, MPH, Maxim Itkin, MD, Robert S. Jones, DO, MSc, FACP, Donald L. Miller, MD, Charles A. Owens, MD, Dheeraj K. Rajan, MD, LeAnn S. Stokes, MD, Timothy L. Swan, MD, Richard B. Towbin, MD, and John F. Cardella, MD J Vasc Interv Radiol 2010; 21:1611–1630 Abbreviations: AHA ϭ American Heart Association, GI ϭ gastrointestinal, GU ϭ genitourinary, IE ϭ infective endocarditis, IR ϭ interventional radiology, IV ϭ intravenous, IVC ϭ inferior vena cava, RF ϭ radiofrequency, SIR ϭ Society of Interventional Radiology, TIPS ϭ transjugular intrahepatic portosystemic shunt, UAE ϭ uterine artery embolization PREAMBLE complications from nosocomial infec- vide recommendations concerning only tion. This document summarizes the antibiotic prophylaxis, not treatment of There is a need for current, formal rec- findings from the available surgical and infectious complications. It is beyond ommendations in the interventional ra- IR literature on this topic. Anticipated the scope of this article to discuss the diology (IR) literature concerning the pathogens and corresponding antibiotic management of infectious complica- appropriate use of prophylactic antibi- coverage (dose and duration) are enu- tions sustained during vascular and in- otics for IR procedures. This is particu- merated for common vascular and non- terventional radiology procedures. larly important given the increasing in- vascular interventions in adults. Note The membership of the Society of In- cidence of antibiotic resistance and that this document is intended to pro- terventional Radiology (SIR) Standards of Practice Committee represents ex- perts in a broad spectrum of interven- tional procedures from the private and academic sectors of medicine. Gener- From the Center for Interventional Oncology, Radi- ventional Radiology (T.W.I.C.), New York Univer- ally, Standards of Practice Committee ology and Imaging Sciences (A.M.V.), National In- sity School of Medicine, NYU Medical Center, New members dedicate the vast majority of stitutes of Health Clinical Center; Department of York, New York; Departments of Radiology and Radiology and Radiologic Sciences (D.L.M.), Uni- Surgery (C.A.O.), University of Illinois Medical Cen- their professional time to performing in- formed Services University of the Health Sciences; ter, Chicago, Illinois; Department of Radiology and terventional procedures; as such, they Department of Radiology (D.L.M.), National Naval Radiological Sciences (L.S.S.), Vanderbilt University represent a valid broad expert constitu- Medical Center, Bethesda; Department of Radiol- Medical Center, Nashville, Tennessee; Department ency of the subject matter under consid- ogy, Division of Interventional Radiology (B.J.D.), of Radiology (T.L.S.), Marshfield Clinic, Marshfield, University of Maryland Medical Center, Baltimore, Wisconsin; and Department of Radiology (R.B.T.), eration for standards production. Maryland; Department of Medical Imaging (S.K.), Phoenix Children’s Hospital, Phoenix, Arizona. Re- Technical documents specifying Scarborough General Hospital; Division of Vascular ceived May 21, 2010; final revision received July 3, the exact consensus and literature re- and Interventional Radiology, Department of Med- 2010; accepted July 23, 2010. Address correspon- view methodologies as well as the ical Imaging (D.K.R.), University of Toronto, Uni- dence to A.M.V., c/o Debbie Katsarelis, 3975 Fair versity Health Network, Toronto, Ontario, Canada; Ridge Dr., Suite 400 N., Fairfax, VA 22033; E-mail: institutional affiliations and profes- Department of Interventional Radiology (D.S.) and [email protected] sional credentials of the authors of Section of Infectious Diseases (R.S.J.), Reading Hos- this document are available upon re- This document was written by the Standards of pital and Medical Center, West Reading; Depart- quest from SIR, 3975 Fair Ridge Dr., ment of Radiology, Division of Interventional Radi- Practice Committee for the Society of Interventional ology (M.I.), University of Pennsylvania Medical Radiology and endorsed by the Cardiovascular In- Suite 400 N., Fairfax, VA 22033. Center, Philadelphia; Department of Radiology terventional Radiological Society of Europe and Ca- (J.F.C.), Geisinger Health System, Danville, Pennsyl- nadian Interventional Radiology Association. vania; Department of Interventional Radiology None of the authors have identified a conflict of METHODOLOGY (M.J.W.), The University of Texas M.D. Anderson interest. Cancer Center, Houston, Texas; Department of Ra- SIR produces its Standards of diology (J.C.W.), Our Lady of Lourdes Medical Cen- ter, Lafayette, Louisiana; Department of Radiology © SIR, 2010 Practice documents using the follow- (S.C.R.), University of California San Diego Medical ing process. Standards documents of Center, San Diego, California; Department of Inter- DOI: 10.1016/j.jvir.2010.07.018 relevance and timeliness are concep- 1611 1612 • Guidelines for Adult Antibiotic Prophylaxis during IR Procedures November 2010 JVIR tualized by the Standards of Practice biotics are given when they should for antibiotic prophylaxis and of Committee members. A recognized not be given; and (iii) how often is making recommendations regarding expert is identified to serve as the antibiotic timing within recom- the use of drugs based on studies of principal author for the standard. mended guidelines. Although prac- suboptimal design. However, these Additional authors may be assigned ticing physicians should strive to difficulties are far outweighed by the dependent upon the magnitude of achieve perfect outcomes, in practice potential improvements in safety the project. all physicians will fall short of ideal and treatment efficacy that may be An in-depth literature search is outcomes to a variable extent. There- gained by implementing the key les- performed using electronic medical fore, in addition to quality improve- sons learned from the existing peer- literature databases. Then a critical ment case reviews conducted after reviewed scientific literature that has review of peer-reviewed articles is individual complications, outcome evaluated antibiotic prophylaxis performed with regard to the study measure thresholds should be used during surgical and IR procedures. methodology, results, and conclu- to assess treatment safety and effi- Given the limited scientific founda- sions. The qualitative weight of these cacy in ongoing quality improve- tion, most of the recommendations articles is assembled into an evi- ment programs. For the purpose of presented in this document are in- dence table, which is used to write these guidelines, a threshold is a spe- tended to guide clinical practice the document such that it contains cific level of an indicator that, when rather than to mandate the use of evidence-based data with respect to reached or exceeded, should prompt specific algorithms. The authors content, rates, and thresholds. a review of departmental policies fully anticipate that these guidelines When the evidence of literature is and procedures to determine causes will be appropriately revised when weak, conflicting, or contradictory, and to implement changes, if neces- future studies of greater scientific consensus for the parameter is sary. Thresholds may vary from rigor are available. Levels of evi- reached by a minimum of 12 Stan- those listed here; for example, pa- dence have been assigned to the cur- dards of Practice Committee mem- tient referral patterns and selection rent recommendations within this bers using a Modified Delphi Con- factors may dictate a different clinical practice guideline that ad- sensus Method (Appendix A) (1–3). threshold value for a particular indi- here to definitions created by the For the purposes of these documents, cator at a particular institution. American College of Cardiology and consensus is defined as 80% Delphi Therefore, setting universal thresh- American Heart Association (AHA) participant agreement on a value or olds is difficult, and each department Guidelines Task Force (4,5). A sum- parameter. is urged to adjust its thresholds as mary of these definitions are pro- The draft document is critically needed to meet its specific quality vided in Appendix B. reviewed by the Standards of Prac- improvement program situation. tice Committee members, either by SIR is committed to the basic prin- telephone conference calling or face- ciples of outcome-focused, evidence- INTRODUCTION to-face meeting. The finalized draft based medicine. Ideally, every Stan- from the Committee is sent to the SIR dards of Practice Committee During the past two decades, sev- membership for further input/criti- recommendation would be based on eral authors have reported on the use cism during a 30-day comment pe- evidence derived from multiple pro- of prophylactic antibiotics for IR pro- riod. These comments are discussed spective randomized trials of ade- cedures (6–9). Spies et al (6) were the by the Standards of Practice Com- quate statistical power. Unfortu- first to provide a critical review on mittee, and appropriate revisions nately, currently there are no antibiotic prophylaxis in IR. Their made to create the finished stan- published multicenter randomized study underscored the lack of ran- dards document.