Surgical Decolonization and Prophylaxis

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Surgical Decolonization and Prophylaxis SurgicalSurgical Decolonization Decolonization and Prophylaxis and Prophylaxis DECOLONIZATION DECOLONIZATION Nasal Screening Result Recommended Intervention Nasal Screening Result Recommended Intervention MRSA Negative • No decolonization required MSSAMRSA NegativeNegative • No decolonization required MSSA PositiveNegative • Intranasal mupirocin twice daily x 5 days MSSA Positive • Intranasal mupirocin twice daily x 5 days MRSA Positive • Intranasal mupirocin twice daily x 5 days, MRSA Positive AND• Intranasal mupirocin twice daily x 5 days, •ANDChlorhexidine bathing one day prior to surgery

ANTIMICROBIAL• ChlorhexidinePROPHYLAXISbathing one day prior to surgery ANTIMICROBIAL PROPHYLAXIS CLINICAL CONSIDERATIONS • Preoperative dose-timing CLINICAL CONSIDERATIONS • PreoperativeWithin 60 minutesdose-timing of surgical incision WithinExceptions: 60 minutes vancomycin of surgicaland fluoroquinolones incision within 120 minutes of surgical incisionExceptions: vancomycin and fluoroquinolones within 120 minutes of surgical • Weightincision-based dosing • WeightCefazolin-based: 2 gm dosingfor patients <120 kg, and 3 gm for patients ≥120 kg Vancomycin:Cefazolin: 2 gm usefor ABW patients <120 kg, and 3 gm for patients ≥120 kg Gentamicin:Vancomycin: use use ABW ABW unless ABW is >120% of their IBW, in which case use AdjBWGentamicin:(see below use ABW for equation)unless ABW is >120% of their IBW, in which case use • DurationAdjBW of(see prophylaxis below for equation) • DurationA single of dose, prophylaxis or continuation for <24 hours is recommended A single dose, or continuationI NTRAfor <24-OPERATIVE hours isREDOSING recommended • Required if the duration of procedureINTRA-OPERATIVE exceeds twoREDOSING half-lives of the drug or if there • isRequired extensive if theblood duration loss during of procedure the procedure exceeds (>1500 two half mL)-livesŦ of the drug or if there • Recommendation:is extensive blood lossuse duringthe same the antibiotic procedure dose (>1500 and mL)measureŦ the redosing interval • fromRecommendation: the time of administration use the same of antibiotic the preoperative dose and dose, measure not the redosingtime of incision interval ABW=from actual the body timeweight; of AdjBW administration= adjusted body weight; of the IBW preoperative= ideal body weight; dose, MRSA= Methicillinnot the- resistanttime of Staphylococcus incision aureus; MSSA= Methicillin-susceptible Staphylococcus aureus ABW= actual body weight; AdjBW= adjusted body weight; IBW= ideal body weight; MRSA= Methicillin-resistant Staphylococcus Ŧaureus Redosing; MSSA may= Methicillinnot be necessary-susceptible for patients Staphylococcus with poor aureus renal function (CrCl <30mL/min)

Ŧ Redosing may not be necessary for patients with poor renal function (CrCl <30mL/min) IBW Calculation: AdjBW Calculation: Male = 50 kg + [2.3 kg for each inch over 5 feet] AdjBW = 0.4 (ABW-IBW) + IBW IBW Calculation: AdjBW Calculation: Female = 45 kg + [2.3 kg for each inch over 5 feet] Male = 50 kg + [2.3 kg for each inch over 5 feet] AdjBW = 0.4 (ABW-IBW) + IBW Female = 45 kg + [2.3 kg for each inch over 5 feet]

References: 1. Schweuzer ML, Chiang H, Septimus E, Moody J, Braun B, Hafner J, et al. Association of a Bundled Intervention with Surgical Site Infections References:Among Patients Undergoing Cardiac, Hip, or Knee Surgery (STOP SSI – Study to Optimally Prevent SSI in Select Cardiac and Orthopedic 1. Procedures).Schweuzer ML, JAMA Chiang2015; H, 313(21):Septimus 2162E, Moody-2171. J, Braun B, Hafner J, et al. Association of a Bundled Intervention with Surgical Site Infections 2. ChenAmong AF, Patients Wessel UndergoingCB, Rao N. Staphylococcus Cardiac, Hip, or aureus Knee SurgeryScreening (STOP and SSI Decolonization – Study to Optimally in Orthopaedic PreventSurgery SSI in Select and Reduction Cardiac and of OrthopeSurgical dicSite Infections.Procedures). Clin JAMAOrthop2015;Relat 313(21):Res 2013; 2162 471:-2171. 2383-2399. 3.2. BratzlerChen AF,DW, Wessel Dellinger CB, Rao EP,N. Olsen Staphylococcus KM, Perl TM, aureus AuwaerterScreeningPG, Bolonand DecolonizationMK, et al. Clinical in Orthopaedic practice guidelinesSurgery forand antimicrobial Reduction of prophylaxis Surgical Site in surgery.Infections. Am Clin J HealthOrthop SystRelatPharmRes 2013; 70:195471: 2383-283.-2399. 3. Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm 2013; 70:195-283. PAGE 26 Antimicrobial Surgical Prophylaxis

AntimicrobialAntimicrobial Surgical REDOSINGSurgical ProphylaxisRECOMMENDATIONS Prophylaxis

Antibiotic REDOSINGHalf-life R(hours)ECOMMENDATIONS Redosing Interval (hours)

Ampicillin/sulbactamAntibiotic 0.8-1.3 Half-life (hours) 2 Redosing Interval (hours)

CefazolinAmpicillin/sulbactam 1.20.8-2.21.3 42

CefoxitinCefazolin 0.71.2-1.12.2 24 CiprofloxacinCefoxitin 30.7-7-1.1 Not2 necessary ClindamycinCiprofloxacin 23-47 6Not necessary GentamicinClindamycin 2-34 Not6 necessary MetronidazoleGentamicin 62-83 Not necessary VancomycinMetronidazole 46-8 Not necessary SURGICAL ALTERNATIVES FOR PATIENTS WITH BETA-LACTAM Vancomycin RECOMMENDED4-8 AGENTS Not necessary PROCEDURE ALLERGY SURGICAL ALTERNATIVES FOR PATIENTS WITH BETA-LACTAM Laparoscopic, NoneRECOMMENDED AGENTS None PROCEDURE ALLERGY low-risk Laparoscopic, CefazolinNone , cefoxitin, ClindamycinNone or vancomycin + aminoglycoside highlow--riskrisk cefotetan, ceftriaxone, or aztreonam or fluoroquinolone Laparoscopic, ampicillin/Cefazolin, cefoxitinsulbactam, Clindamycin or vancomycin + aminoglycoside high-risk cefotetan, ceftriaxone, or aztreonam or fluoroquinolone Small intestine, ampicillin/Cefazolin sulbactam Clindamycin + aminoglycoside or nonobstructed aztreonam or fluroquinolone Small intestine, Cefazolin Clindamycin + aminoglycoside or Smallnonobstructed intestine, Cefazolin + metronidazole, Metronidazoleaztreonam or fluroquinolone+ aminoglycoside or obstructed cefoxitin, cefotetan fluoroquinolone Small intestine, Cefazolin + metronidazole, Metronidazole + aminoglycoside or Herniaobstructed repair Cefazolincefoxitin, cefotetan Clindamycinfluoroquinolone, vancomycin

ColorectalHernia repair Cefazolin + metronidazole, Clindamycin,+ vancomycin aminoglycoside or cefoxitin, cefotetan, aztreonam or fluroquinolone; Colorectal ampicillin/sulbactamCefazolin + metronidazole, , MetronidazoleClindamycin + aminoglycoside+ aminoglycoside or or ceftriaxonecefoxitin, cefotetan+ , fluoroquinoloneaztreonam or fluroquinolone; metronidazoleampicillin/sulbactam, ertapenem, Metronidazole + aminoglycoside or ceftriaxone + fluoroquinolone Head and neck, Nonemetronidazole, ertapenem None Jen - thisclean page is too Head and neck, None None long. You’llHeadclean haveand neck, to Cefazolin, cefuroxime Clindamycin shorten placementit somehow. of prostheticHead and neck, Cefazolin, cefuroxime Clindamycin placement of Cleanprosthetic- Cefazolin + metronidazole, Clindamycin contaminated cefuroxime + cancerClean- surgery metronidazoleCefazolin + metronidazole, , Clindamycin contaminated ampicillin/sulbactamcefuroxime + cancer surgery metronidazole, ampicillin/sulbactam

References: 1. Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm 2013; 70:195-283. References: 1. Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm 2013; 70:195-283. PAGE 27 Antimicrobial Surgical Prophylaxis

AntimicrobialAntimicrobial Surgical Surgical Prophylaxis Prophylaxis ALTERNATIVES FOR PATIENTS WITH SURGICAL PROCEDURE RECOMMENDED AGENTS BETA-LACTAM ALLERGY ALTERNATIVES FOR PATIENTS WITH SURGICAL PROCEDURE RECOMMENDED AGENTS Ortho: clean hand, None None BETA-LACTAM ALLERGY knee, or foot not Ortho: clean hand, None None involving implantation knee, or foot not of foreign materials involving implantation ofOrtho: foreign implantation materials of Cefazolin Clindamycin, vancomycin foreign material and/or Ortho: implantation of Cefazolin Clindamycin, vancomycin total joints foreign material and/or totalUrologic jointswith risk Fluoroquinolone, Aminoglycoside +/- clindamycin factors for infection TMP/SMX, cefazolin Urologic with risk Fluoroquinolone, Aminoglycoside +/- clindamycin factorsUrologic, for clean infection without TMP/SMXCefazolin*, cefazolin Clindamycin, vancomycin entry into urinary tract Urologic, clean without Cefazolin* Clindamycin, vancomycin entryUrologic into involving urinary tract Cefazolin ± Clindamycin ± aminoglycoside or implanted prosthesis aminoglycoside, aztreonam, vancomycin ± Urologic involving Cefazolin ± Clindamycin ± aminoglycoside or cefazolin ± aztreonam, aminoglycoside or aztreonam implanted prosthesis aminoglycoside, aztreonam, vancomycin ± ampicillin/sulbactam cefazolin ± aztreonam, aminoglycoside or aztreonam Urologic, clean with ampicillin/sulbactamCefazolin* Fluoroquinolone, aminoglycoside ± entry into urinary tract clindamycin Urologic, clean with Cefazolin* Fluoroquinolone, aminoglycoside ± entryUrologic, into clean urinary- tract Cefazolin + clindamycinFluoroquinolone, aminoglycoside + contaminated metronidazole, cefoxitin metronidazole or clindamycin Urologic, clean- Cefazolin + Fluoroquinolone, aminoglycoside + TMP/SMX=contaminated trimethoprim/sulfamethoxazolemetronidazole, cefoxitin metronidazole or clindamycin

TMP/SMX=*Addition of trimethoprim/ a single dose sulfamethoxazoleof an aminoglycoside may be recommended for placement of prosthetic material (e.g. penile prosthesis) *Addition of a single dose of an aminoglycoside may be recommended for placement of prosthetic material (e.g. penile prosthesis)