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Prophylactic Antibiotic Guidelines in Modern Interventional Radiology Practice

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Prophylactic Antibiotic Guidelines in Modern Interventional Radiology Practice View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by Lebanese American University Repository Prophylactic Antibiotic Guidelines in Modern Interventional Radiology Practice Eunice Moon, M.D.,1 Matthew D.B.S. Tam, B.M.B.Ch., M.R.C.S., F.R.C.R., M.A.(Oxon), M.Clin.Ed.,1 Raghid N. Kikano, M.D.,1 and Karunakaravel Karuppasamy, M.B.B.S., F.R.C.R.1 ABSTRACT Modern interventional radiology practice is continuously evolving. Developments include increases in the number of central venous catheter placements and tumor treat- ments (uterine fibroid therapy, radio- and chemoembolization of liver tumor, percutaneous radiofrequency and cryoablation), and new procedures such as abdominal aortic aneurysm stent-graft repair, vertebroplasty, kyphoplasty, and varicose vein therapies. There have also been recent advancements in standard biliary and urinary drainage procedures, percuta- neous gastrointestinal feeding tube placement, and transjugular intrahepatic portosystemic shunts. Prophylactic antibiotics have become the standard of care in many departments, with little clinical data to support its wide acceptance. The rise in antibiotic-resistant strains of organisms in all hospitals worldwide have forced every department to question the use of prophylactic antibiotics. The authors review the evidence behind use of prophylactic antibiotics in standard interventional radiology procedures, as well as in newer procedures that have only recently been incorporated into interventional radiology practice. KEYWORDS: Antibiotic, prophylactic, interventional radiology Objectives: Upon completion of this article, the reader should be able to (1) state the correct timing of prophylactic antibiotic; (2) determine which procedures benefit from prophylactic antibiotics; (3) explain the potential infectious complication for each procedure; and (4) identify which patient groups are at increased risk for postprocedural infection. Accreditation: Tufts University School of Medicine (TUSM) is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. Credit: Tufts University School of Medicine designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Prophylactic antibiotics (PR-ABXs) are widely The routine and widespread use of broad-spec- used in interventional radiology (IR), from simple trum antibiotics has been responsible in part for the tunneled central venous catheter placement, to more emergence of more virulent antibiotic-resistant bacteria complex tumor therapy-related embolization. Many in recent years,1 and the doubling of methicillin-resistant interventional radiologists routinely give PR-ABXs, Staphylococcus aureus (MRSA) infection rates in intensive though there is little evidence in the literature to care units over the past 10 years.2 Not surprisingly, there support this practice. is a direct MRSA infection rate with the prophylactic use 1Department of Vascular and Interventional Radiology, Cleveland Kondo, D.O. and Charles E. Ray, Jr., M.D. Clinic Foundation, Cleveland, Ohio. Semin Intervent Radiol 2010;27:327–337. Copyright # 2010 by Address for correspondence and reprint requests: Eunice K. Moon, Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY M.D., Staff, Department of Vascular and Interventional Radiology, 10001, USA. Tel: +1(212) 584-4662. Cleveland Clinic Foundation, 9500 Euclid Avenue HB-6, Cleveland, DOI: http://dx.doi.org/10.1055/s-0030-1267853. OH 44195 (e-mail: [email protected]). ISSN 0739-9529. Pharmacology in Interventional Radiology; Guest Editors, Kimi L. 327 328 SEMINARS IN INTERVENTIONAL RADIOLOGY/VOLUME 27, NUMBER 4 2010 of third-generation cephalosporins.3 Likewise, the promised. Catheter-related sepsis, or catheter-related percentage of enterococci resistant to vancomycin has bloodstream infection (CRBSI), is most commonly increased from 0.5% in 1989 to 25.9% in 1999.4 caused by coagulase-negative Staphylococci and Enter- From physicians to hospitals to governments, ococci. Fungal infections due to Candida are also relatively there has been more critical examination of PR-ABX common. useandmodificationinclinicalpracticepatterns.1,3,5 Infections are thought to be introduced through Multiday therapy has changed to single-dose PR- hub manipulation rather than related to colonization of ABX,6 and in some cases PR-ABX is altogether the line at insertion. The infection risk for all central eliminated.7 Critical examination of PR-ABX use in venous catheters in the intensive care unit (ICU) is IR must follow. estimated at 5.3 per 1000 catheter days.4 In the United Surgical wounds are classified into four catego- States, this results in 250,000 infections per year with a ries, each with a known infection risk. Clean wounds 12 to 25% mortality, at an average cost of $25,000 per (no gastrointestinal [GI], genitourinary [GU] or respi- infection. ratory tract access) carry an infection risk of <5%. There is no difference in infection rates between Clean-contaminated wounds (where the GI, biliary, catheters placed in the operating room or IR suite,17 GU, or respiratory tract is entered without sign of even in neutropenic patients.18 However, different in- infection and no break of aseptic technique) carry a fection rates are reported depending on the device. 10% infection risk. Contaminated wounds (presence of Totally implantable devices (ports) appear to have the infection or inflammation without pus) carry a 20% lowest infection rates (0.1–0.9 per 1000 catheter infection risk, whereas dirty wounds (clinically infected days).19,20 Ports are more resistant to infection as there biliary or GU system or involving an abscess) carry a is no external hub manipulation. In comparison, an 39% infection risk.8 Spies and McDermott suggested infection rate of 1.8 to 2.5 per 1000 days is seen with applying the wound classification to guide PR-ABX Hickman catheters.20 Dialysis catheters have an infec- use.8,9 PR-ABXuseinIRhasoftenbeenextrapolated tion rate of 4.2 per 1000 catheter days4 for cuffed from surgical data, which may overestimate the risk catheters and 7.1 per 1000 catheter days for noncuffed given smaller incisions with IR procedures.10 PR-ABX catheters. Peripherally inserted central catheters (PICC) use is generally accepted in clean-contaminated have the highest rates of infection (up to 8 per 1000 wounds, and in clean procedures where prosthetic catheters days in oncology patients).21 material is implanted or where infection would be a There is no evidence to support routine use of significant threat to the patient.11,12 Antibiotic use PR-ABX prior to central venous catheter placement in prior to contaminated or dirty procedures is essential adults. This is largely based on a meta-analysis of nine but would be more correctly categorized as therapeutic, trials with 588 patients.27 A recent article did not not prophylactic. Specific at-risk groups will differ for recommend routine antibiotic prophylaxis, but suggested each type of procedure.8,13 administering cefazolin (1 g IV) if placing a totally Timing of PR-ABX is critical. Longer infusion implantable device or if the patient is immunocompro- intravenous (IV) antibiotics may be given within mised.22 2hourspriortoincision,11 but short infusion IV anti- Despite the existence of any conclusive evidence biotic administration demonstrates greatest efficacy supporting the use of PR-ABX, use of PR-ABX appears when given within 30 minutes prior to incision.14 to be standard practice among members of the Society of PR-ABX given after the surgical incision is less bene- Cardiovascular and Interventional Radiology (now the ficial.10 Direct correlation exists between the duration Society of Interventional Radiology)23; cefazolin (1 g of surgery and the risk of infection.6,13,15 In cases IV) and vancomycin (1 g IV) have become standard of lasting greater than 4 hours, redosing of the antibiotic care in penicillin allergic patients. The Centers for that was correctly given prior to surgery reduces the risk Disease Control (CDC) discourages the use of prophy- of infection.14,16 lactic vancomycin for catheter placement due to its use Our goals are to identify the procedures that increasing the risk of acquiring a vancomycin-resistant would benefit from PR-ABX, identify the organisms Enterococci (VRE) infections.4 likely to be problematic for a specific procedure, identify There are higher rates of infections in certain special patient groups most likely to be at risk for subgroups, such as neutropenic and immunocompro- procedure-related sepsis, and recommend the antibiotic mised patients, but there is no robust evidence to support best suited for the procedure. antibiotic use in theses populations. For example, higher rates of infection were reported in HIV patients com- pared with non-HIV patients in a prospective study of TUNNELED CENTRAL VENOUS CATHETER 391 patients, where all patients received PR-ABX.24 Image-guided venous access procedures have low infec- Similar infection rates are seen in neutropenic patients tion rates, even among patients who are immunocom- as compared with those patients who are using their PROPHYLACTIC ANTIBIOTIC GUIDELINES/MOON ET AL 329 catheter for total parenteral nutrition (TPN)25 at the ARTERIOGRAPHY AND ENDOVASCULAR time of placement. STENT PLACEMENTS The main preventative strategy is therefore pa- Diagnostic angiography
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