1. Infections in Surgical Patients What about prophylaxis?
James Molton
Infectious Diseases Physician
Mater Hospital Brisbane

6. Retrospective audit, n=163
Sumi Britton, Diana Moore. Mater SAP Audit, April 2018

7. Sumi Britton, Diana Moore. Mater SAP Audit, April 2018

8. Indications for prophylaxis

9. Indications for prophylaxis
Wendy Munckhof. Aust Prescr 2005;28:38-401

10. Indications for prophylaxis
significant risk of postoperative infection (eg. colonic resection)
if an uncommon postoperative infection would have serious consequences (eg. prosthetic implant infection)
Note pre-existing prosthetic joint does not alter recommendations

11. Endocarditis prophylaxis
If indicated give amoxicillin 2g pre-procedure
eTG July 2018 edition

12. Choice of antibiotic

13. Choice of antibiotic
Most postoperative infections are caused by organisms that already colonise the patient
Consider bacterial flora most likely to cause SSI
Wendy Munckhof. Aust Prescr 2005;28:38-401

14. Choice of antibiotic Considerations: pre-existing infection
recent antimicrobial use
colonisation with MDROs – consider screening
prolonged hospitalisation
presence of prostheses
eTG July 2018 edition

15. ** If risk for MDROs (recent travel, antibiotics) contact ID **
Cephazolin 2g IV
To cover skin flora for clean-contaminated or contaminated procedures through intact skin
If ongoing procedure, repeat after 4 hours
Metronidazole 500mg IV
In addition to cephazolin for lower GI surgery or head and neck surgery via mucosa
Vancomycin 25mg/kg IV
Alternative to cephazolin if immediate hypersensitivity to penicillin. Note efficacy is reduced
In addition to cephazolin if MRSA colonised (consider decolonisation pre-procedure)
Gentamicin 2mg/kg IV
Give alone for TURP
In addition to cephazolin for urologic surgery
In addition to vancomycin for GI surgery in penicillin allergic patients
Ciprofloxacin 500mg PO
Give alone for trans-rectal prostate biopsy
** If risk for MDROs (recent travel, antibiotics) contact ID **

16. Timing – when to start?

17. Retrospective data
n=50 SSI post total hip arthroplasty
Suggested minutes pre-incision is best

18. RCT n=5580 general surgery inpatients Randomised to SAP
early (anaesthetic room)
vs late (operating room)
Early = median 42 mins before incision
Late = median 16 mins before incision

19. No difference between early and late SAP

20. New Swiss surveillance data suggests < 30 minutes is best
Prospective Swiss surveillance data from 172 institutions
n=121,645 adult patients undergoing cardiac surgery, orthopedic or abdominal surgery
Lowest risk of SSI with SAP 0-30min prior to incision
Andreas F. Widmer, ID Week 2018 Poster Abstract Session

21. Timing - when to stop?

22. Timing - when to stop? A single dose is sufficient for majority
Repeat intraoperative dose if procedure is prolonged
cephazolin – 4 hours
Postoperative doses (up to 24h) only required in defined circumstances
(eg some cardiac and vascular surgeries, lower limb amputation)
eTG July 2018 edition

23. Prophylaxis beyond 24h?
Odds Ratio
VA cohort study, n= 79,092 undergoing cardiac, orthopedic total joint, vascular, and colorectal procedures
Longer duration SAP did not lead to additional SSI reduction
Longer duration SAP increased risk of AKI and CDI
Judith M. Strymish, ID Week 2018 Oral Abstract Session

24. Timing - when to stop?
Prophylaxis should not extend beyond 24h, regardless of the procedure
No benefit
associated with an increased risk of adverse effects, including MDRO infection and C. difficile
Catheters or drains that remain in situ are not a justification to extend the duration of antibiotic prophylaxis
eTG July 2018 edition

25. Summary
Administer an antibiotic to cover bacterial flora likely to cause infection
Single dose minutes pre-procedure
Repeat cephazolin dose if procedure >4h
Consider screening and decolonisation for MRSA
Add vancomycin if remains positive
Contact ID if any queries

26. Accessory Slides
Mater Guidelines (based on eTG)