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Pathology that adds value




Wound infection is the second most common nosocomial infection. The direct costs
related to these infections in the USA are estimated at 1 billion dollars per year.
Approximately 17% of all hospitalized patients receive prophylactic antibiotics,
primarily for surgical procedures.

prior to the start of surgery and if their use is restricted to less than 24 hours
Toxic or allergic reactions can occur. Using safe agents for short periods of time can
minimize these.

A) Principles of surgical prophylaxis

Timing of antibiotic administration
Animal studies in the 1950s (1) showed that administration of antibiotics just before,
during, and up to 3 hours after surgery effectively prevented infections in wounds,
experimentally inoculated with bacteria.
Antibiotic must be given so that good tissue levels are present for the duration of the
procedure and for the first 3-4 hours after surgical incision.
Recent reviews (2) suggest administering parenteral antibiotics ideally 30-60
minutes before the surgical incision is made (with the induction of anesthesia) and
certainly within 2 hours of surgical incision.
Duration of prophylaxis
Controversial. There is little evidence to support prophylactic administration of
antibiotics past the period of operation and recovery of normal physiology following
anesthesia (3).
For most surgical procedures a single dose of antibiotic given just before the
procedure provides adequate tissue levels (4). Most experts agree that prophylaxis
should be discontinued within 24 hours of the operative procedure.
If a procedure lasts for several hours (longer than 3 hours) repeat doses of the
antibiotic may be necessary intra-operatively to maintain adequate levels.
Re-administration of the drug is indicated at intervals of 1 or 2 times the half-life of
the drug.
When a prosthetic device is inserted, prophylaxis is often given for at least 24 hours
(5). Most authors favour a three-dose regimen, depending on the drug being used.
Organisms involved
Most surgical infections are acquired from the patient's own microbial flora. The
remainder is acquired from the staff in the operating room during surgery

Cost: use the least expensive effective agent for the shortest period possible. Cost of
antibiotics is negligible compared with cost of prolonged hospitalization due to
Potential for a false sense of security: meticulous surgery and careful preoperative
and postoperative care are essential in minimizing wound infection.
Which agent?
Cephalosporins are widely favoured.
Reasons include: adequate spectrum of activity, few side effects and a low incidence
of allergic reactions.
First generation agents are more active against S aureus, are less expensive than the
newer agents and have a narrow spectrum of activity (therefore less likely to select
resistant organisms). They are the preferred agents for most surgical prophylaxis (6).
Cefazolin also has a moderately long serum half-life, which is ideal for prophylaxis
(1.8 hours). Data suggest that this agent should be used at a dosage of 2 gram for
an adult patient due to the pharmacokinetics of cefazolin (7).
For colorectal surgery cefoxitin is preferred because of activity against bowel
Third generation agents should preferably not be used for prophylaxis due to their
limited staphylococcal cover.
B) Which procedures benefit from prophylaxis
Gynaecological surgery
Hysterectomy: Indicated in vaginal hysterectomy, possibly in abdominal
hysterectomy. First generation cephalosporins appear to be as effective as second
or third generation drugs. In the cephalosporin allergic patient clindamycin is an

S aureus is the major pathogen in wound infections after clean surgery.

Cesarean section: Prophylaxis is indicated in patients with premature rupture of

membranes and emergency surgery. First generation cephalosporin is indicated
after the cord is clamped.

Gram negative bacteria cause wound infection especially when surgery of the
colon, gynaecological organs or genitourinary tract is undertaken.

Abortion: 1st trimester, pen G 2mU or doxycycline 300 mg po, 2nd trimester,
cefazolin 1 gram ivi.

Potential for resistant organisms is different in each hospital. The prevalence of a

specific organism may influence antibiotic selection.

Simple open fracture: First generation cephalosporin is recommended for
18-24 hours

Potential disadvantages of prophylaxis

Super infection with a resistant organism (e.g. Vancomycin Resistant Enterococcus
or VRE) is a potential risk. The risk is minimal if antibiotics are not initiated until just

Complex open fracture: As above or some authors recommend

ceftriaxone to ensure adequate activity against community acquired Gram negative
bacilli which can contaminate such a wound.

May 2010

Pathology that adds value




Open reduction of closed fracture with internal fixation:
Ceftriaxone 2 gm IV or IMI for one dose.
Joint replacement: Consequence of infection is serious. In a report of 1688 total
hip replacements the incidence of deep infections in those patients who received
systemic antibiotics versus gentamycin bone cement was not significantly different
(1.6% vs. 1.1%) (8). Value of using both techniques over either alone has not been
Cefazolin 2 gram iv pre-op ( 2nd dose) or vancomycin 15 mg/kg iv pre-op if
previous prosthetic surgery failed due to infection with MRSA / MRSE
Most patients with indwelling prosthetic joints generally do not require antimicrobial
prophylaxis when undergoing dental, gastrointestinal or genitourinary procedures.
Gastrointestinal surgery
Elective colorectal surgery: The most common practice in the USA is oral
antibiotics along with mechanical bowel cleansing the evening before surgery and
parenteral antibiotics pre-operatively. A limited study suggested that cefoxitin was
superior to cefazolin in this setting. A combination of ceftriaxone and metronidazole
is also effective, however third generation cephalosporins are generally not
recommended for prophylaxis.
Non-elective colorectal surgery: cefoxitin 1-2 gram IV is the agent of choice.
Cefazolin 2 gram IV plus metronidazole 0.5 gram iv can also be used. If a bowel
perforation is present a therapeutic course of antibiotics is indicated (cefoxitin or
clindamycin plus gentamycin for 5 days)
Gastro-duodenal surgery: cefazolin, cefoxitin or cefuroxime indicated for high
risk patients (i.e. morbid obesity, obstruction, diminished gastric motility or acidity)
Appendectomy: cefoxitin is the preferred agent. If perforated appendix, use
therapeutic regimen. For patients allergic to beta-lactam antibiotics use
metronidazole. The pathologic state of the appendix is the most important predictor
of postoperative infection (9).
Biliary tract surgery: Indicated for the high risk group i.e. patients older than 70
years, with obstructive jaundice, with acute cholecystitis or cholangitis, with
common duct stones or a non-functioning gall bladder. Prophylaxis is the same as
for gastro-duodenal surgery.
Urologic procedures
If the urine is infected it is preferable to sterilize it before surgery to the genitourinary
tract. Cefazolin 1 gram q8h for 1-3 doses perioperatively is indicated. If the urine is
sterile the use of prophylaxis is generally discouraged
Transrectal prostate biopsy: Ciprofloxacin 500 mg po 12 hrs prior to biopsy,
repeated 12 hrs after biopsy reduced bacteremia from 37% to 7% (10).
Head and neck surgery
Prophylaxis decreases the incidence of wound infection after head and neck surgery
involving an incision through the oral or pharyngeal mucosa by approximately
50%. Cefazolin 2 gram IV or clindamycin 600-900 mg iv single dose plus
gentamicin 1.5 mg/kg single dose is indicated.
Prophylaxis in neurosurgery unsettled (4).
It is reasonable to use prophylaxis in shunt surgery where the endemic rate of
infection is higher than 3% - 5%. Cefazolin or vancomycin is indicated.

Anti-staphylococcal antibiotics may decrease the incidence of wound infection after

craniotomies. No prophylaxis is indicated in patients with a closed scull fracture with
or without CSF leakage.
Cardiovascular surgery
Prophylaxis indicated for valvular procedures, coronary artery bypass
grafting, reconstruction of abdominal aorta, procedures on the leg that involve a
groin incision and any vascular procedure that inserts prosthesis. Single dose of
cefazolin 2 gram IV appears to be effective, although some authorities recommend
3x/d for 1-2 days. Vancomycin is an alternative at 15mg/kg iv or 2x/d for 1-2 days.
In patients who are nasal carriers with S aureus consider intranasal mupirocin the
evening before, day of surgery, and b.d. for 5 days post surgery.
Thoracic surgery
Indicated for pulmonary resection. Cefazolin caused a decrease in wound infection
but no decrease in pneumonia and empyema.
Cefuroxime continued for 48 hours after resection was particularly effective in
preventing empyema.
Abdominal: If no injury to hollow viscus use a single dose of cefoxitin. If
perforation of hollow viscus is present then a full course of antibiotics is advised.
Chest: Even in penetrating thoracic trauma the effectivity of prophylaxis is unclear.
Dirty surgery
In such cases (e.g. bowel perforation, complex fracture) antibiotics should be used
therapeutically for full courses.
Animal or human bites also deserve therapeutic courses.
1. Burke JF. The effective period of preventative antibiotic action in experimental
incisions and dermal lesions. Surgery 1961;50:161
2. Classen DC et al. The timing of prophylactic administration of antibiotics and
the risk of surgical wound infection. N Engl J Med 1992;326:281
3. Stone HH et al. Prophylactic and preventative antibiotic therapy: Timing,
duration and economics. Ann Surg 1979;189:691
4. Medical letter. Antimicrobial prophylaxis in surgery. Med Lett Drugs Ther
5. Norden C, Gillespie WJ, Nade S. Infections in Total Joint Replacements. In
Infections in Bones and Joints. Boston: Blackwell Scientific, 1994. Pp 291-319.
6. Dellinger EP et al. Quality standard for antimicrobial prophylaxis in surgical
procedures. Clin Inf Dis 1994;18:422
7. Kernodle DS, Kaiser AB. Postoperative Infection and Antimicrobial Prophylaxis.
In GL Mandell, JE Bennett and R Dolin, Principles and Practice of Infectious
Diseases (4th ed). New York: Churchill Livingstone, 1995. Pp 2742-2756
8. Joseffson G, Kolmert L. Prophylaxis with systemic antibiotics versus gentamicin
bone cement in total hip arthroplasty: A 10 year survey of 1688 hips. Clin
Orthoped Res 1993;292:210
9. Bauer T, Vennits BO, Holm B et al. Antibiotic prophylaxis in acute
nonperforated appendicitis. Ann Surg 1989,209:307-311
10. Gilbert DN, Moellering RC, Sande MA. Surgical Antibiotic Prophylaxis. In The
Sanford Guide to Antimicrobial Therapy (31st ed). Jeb C Sanford, 2001. Pp
Dr M Senekal
Microbiologist: Pathcare
Tel: 021-9379111

May 2010