1. PRESENTED AT KOA CONFERENCE 2016 OKELLO S.O MOI UNIVERSITY SCHOOL OF MEDICINE Guidelines for Antimicrobial Prophylaxis for Surgical Site Infections: A review of literature

2. Introduction Surgical Site infections (SSI) are associated with significant burden to patients and the healthcare system. Infection rates following clean orthopedic operations fall in the range of less than 5% but following open fractures can be as high as 20%. Use of antibiotic prophylaxis is one of the key strategies for prevention of SSI However, perioperative antibiotic use in Kenya is largely surgeon dependent and not standardized

3. Problem Statement and Justification There are inadequate national guidelines on perioperative antibiotic prophylaxis This is coupled with lack of SSI surveillance in most centers conducting orthopedic surgeries Perioperative antibiotic use remains largely surgeon dependent and based on what is available There is need for standard guidelines to ensure quality of care even in newer centers

4. Objectives To find out the optimal timing of the first dose of antibiotic prophylaxis To determine the duration of antibiotic prophylaxis To review guidelines on the choice of antibiotic for prophylaxis in the peri-operative period.

5. Methodology A total of thirty-two relevant published original scientific research papers on surgical site infections were reviewed and analyzed with emphasis on the timing of the first dose of antibiotic prophylaxis, the duration of antibiotic prophylaxis and the choice of antibiotic. Findings were analyzed along the set objectives

6. RESULTS

7. Timing of 1 st dose of antibiotic Optimal timing of the first dose of antibiotic prophylaxis should be within 60 minutes before the initial surgical incision should be repeated after 3 hours if the surgery lasts longer.

8. Duration of antibiotic prophylaxis Antibiotic prophylaxis after wound closure is generally unnecessary should not be continued beyond 24 hours. Rates of SSI similar among short term and prolonged group Prolonged use associated with emergence of resistance

9. Choice of Antibiotic for prophylaxis Should be based on local susceptibility patterns: National surveillance necessary Generally beta-lactams adequate (single antibiotic). Target gram positive cocci Cefazolin or Cefuroxime generally ok. Vancomycin or Clindamycin for patients with beta- lactam allergy; should be preserved

10. Discussion Available literature consistent on giving first dose before surgical incision (60 minutes) Some articles recognize need for repeat after 3 hours but no need after wound closure Most studies of good quality and are in different contexts Little controversy on this aspect

11. Discussion Most authors agreed that antibiotic prophylaxis should not be continued beyond 24 hours after wound closure This was true in different settings including Kenya Choice of antibiotic dependent on local susceptibility patterns Studies were mainly designed as RCT with good quality Can be replicated in many settings

12. Conclusion Surgical site infections in orthopedics can be adequately prevented by the use of optimally chosen antibiotics given within 60 minutes before the initial incision and not continued beyond 24 hours after surgery. Choice of antibiotic should vary from site to site based on local susceptibility patterns but should target gram positive cocci.

13. Reccomendations Sites/ Country should develop guidelines on use of antibiotic prophylaxis which should include  Initiation of 1 st dose within 60 minutes before incision  Repeat every 3 hours if surgery lasts long  Discontinue antibiotic within 24 hours  Antibiotic choice guided by local suscptibility patterns. Consider Cefazolin or Cefuroxime There should be a robust national surveillance of SSI involving all operating sites

14. REFERENCES Aiken AM, Wanyoro AK, Mwangi J, Juma F, Mugoya IK, et al. (2013) Correction: Changing Use of Surgical Antibiotic Prophylaxis in Thika Hospital, Kenya: A Quality Improvement Intervention with an Interrupted Time Series Design. PLoS ONE 8(12) Bowater, R.J., Stirling, S.A., Lilford, R.J. (2009). Is Antibiotic Prophylaxis in Surgery a Generally Effective Intervention: Testing a Generic Hypothesis Over a Set of Meta-Analyses. Annals of Surgery. 249(4): 551-556 Classen, D.C., Evan, R.S., Pestonik, S.L., Horn, S.D., Menlove, R.L., Bukke, J.P. (1992). The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection. New England Journal of Medicine. 326:281-6 Dale, W.B., Houck, M.P., (2003). Antimicrobial Prophylaxis for Surgery: An Advisory Statement from the National Surgical Infection Prevention Project. Clinical Infectious Diseases. 38(2):1706- 1715 Dipiro, J.T., Cheung, R.P., Bowden, T.A., Mansberger, J.A. (1986). Single dose systemic antibiotic prophylaxis of surgical wound infections. The American Journal of Surgery. 152(5):552-559 Harbarth, S., Samore, M.H., Lichtenberg, D., Carmeli, Y. (2008). Prolonged Antibiotic Prophylaxis After Cardiovascular Surgery and Its Effect on Surgical Site Infections and Antimicrobial Resistance. Circulation Korol E, Johnston K, Waser N, Sifakis F, Jafri HS, Lo M, et al. (2013) A Systematic Review of Risk Factors Associated with Surgical Site Infections among Surgical Patients. PLoS ONE 8(12): e83743. doi:10.1371/journal.pone.0083743 Nelson, C.L., Green, T.G., Porter, R.A., Warren, R.D. (1983). One Day versus Seven Days of Preventive Antibiotic Therapy in Orthopedic Surgery. Clinical Orthopaedics & Related Research. 176 Norden, C.W. (2003). A Critical Review of Antibiotic Prophylaxis in Orthopedic Surgery. Clinical Infectious Diseases. 5(5):928-932 van Walraven C, Musselman R (2013) The Surgical Site Infection Risk Score (SSIRS): A Model to Predict the Risk of Surgical Site Infections. PLoS ONE 8(6): e67167. doi:10.1371/journal.pone.0067167 Wildemann, B., Haas, N.P., Raschke, M. (2006). Prophylaxis and treatment of implant-related infections by antibiotic-coated implants: a review. Injury. 37(2): S105-S112