Antimicrobial prophylaxis in surgery

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Antibiotic Prophylaxis in SurgeryAn Adapted Clinical Practice GuidelineFirst Edition 2013Presented ByDr. Tarek Altokhais,Consultant, Pedia Surgery & Head of Surgery CPG Subcommittee, Surgery DepartmentDr. Yasser Amer,CPG General Coordinator, CPG Committee, QMD09 JAN 20141Antibiotic Prophylaxis in Surgery

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Evidence-to-PracticeClinical Care GAP

Current Practice

Best Practice

CPGsDecrease Practice variation Informed clinical decision makingImplementation ScienceKnowledgeTranslationQuality/ Performance Improvement Patient Safety/ Care & Satisfaction09 JAN 20144Antibiotic Prophylaxis in Surgery

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Clinical Practice Guidelines (CPGs) Program of King Saud University Hospitals/ Medical CityKSUHs Taskforce Responsible Staff from:Clinical Practice Guidelines Committee;Quality Management Department;Clinical Departments (CPGs subcommittees);Shaikh Abdullah Bahamdan Research Chair for Evidence-Based Health Care and Knowledge Translation;Top Management & Leadership of College of Medicine and University Hospitals (Future KSU Medical City)09 JAN 20145Antibiotic Prophylaxis in Surgery

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18 CPGs Subcommittees - - ->> 21Department of Pediatrics [12+1]Department of Critical Care [2+1]Department of Psychiatry [2]Department of Community & Family Medicine (Family Medicine Unit) FMC [1+6]Department of Pharmacy [3+16]Department of Emergency Medicine [+11] Department of Medicine [8]Department of Orthopedic Surgery [1+1]Department of Otorhinolaryngology [1]Department of Ophthalmology [1]Department of Cardiac Sciences (Cardiology Cardiac Surgery) KFCC [3]Department of Surgery [2] Department of Obstetrics & Gynecology [1+3]Department of Dermatology [1]Department of Anesthesiology [1]Department of Laboratory Medicine & Pathology [+15]Department of Radiology [+3]Department of Nursing [1]NewDepartment of Occupational Health & Safety [2]Department of Rehabilitation Medicine [+1]Health Education Center [+3]

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Adapted from Source CPGs

CPG for Antimicrobial Prophylaxis in SurgeryDeveloped byAmerican Society of Health System Pharmacists, Infectious Diseases Society of America, Society for Healthcare Epidemiology of America and Surgical Infection Society. 1999 (updated 2013)09 JAN 2014Antibiotic Prophylaxis in Surgery7

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Hospital-Wide Policy & Procedure for Hospital CPGs AdaptationSEPT 2013NEW

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CPG objective

To provide practitioners with a standardized approach to the rational, safe, and effective use of antimicrobial agents for the prevention of surgical-site infections (SSIs) based on currently available clinical evidence and emerging issues


CPG Authorship group (CPG Champions)Adaptation working groupReview group

Dr. Danny Rabah, Consultant UrologyDr. Badr Aljabri, Consultant Vascular SurgDr. Wassim Hajar, Consultant Thoracic SurgDr. Mohammad Qattan, Consultant, Plastic SurgDr. Yaser Alfakey, Consultant OphthalmologyDr. Khalid Alsaleh, Consultant Orthopedic Surg/Spine, Head Ortho CPGDr. Neama Meriki, Consultant OBGYN, MFM, Head OBGYN CPG

09 JAN 2014Antibiotic Prophylaxis in Surgery11Dr. Tariq Altokhais, Head CPG Surg SubC, Consult. Pedia SurgDr. Abdelmonim El-Tarifi, Consult. UrologyDr. Khalid Alawi, Consult. SurgDr. Yasser Amer, CPGC, QMDSupport group: Dorothy Villena, CPGCSheila Rivera, CPGC

Search and Selection of source CPGs

09 JAN 201412Antibiotic Prophylaxis in Surgery8 CPGs internet databases searched27 source CPGs retrieved25 CPGs excluded based on HQ and selection criteria & 2 CPGs included for further appraisal by AGREE II Instrument.

Health Questions (PIPOH)

P: Patient/target population:Adult (age 19 years or older) and pediatric(age 118 years) patients undergoing surgery.Disease/Condition:Postoperative infections (i.e., initial infection following surgical procedures) without any other co-morbidities

Note: These CPGs do not specifically address newborn (premature and full-term) infants.While the CPGs do not address all concerns for patients with renal or hepatic dysfunction, antimicrobial prophylaxis often does not need to be modified for these patients when given as a single preoperative dose before surgical incision.


PIPOHI: Intervention and practices considered and CPG Category: Assessment of Therapeutic Effectiveness and Prevention.Primary antimicrobial prophylaxis (i.e., prevention of an initial infection) for surgical procedures, including antibiotic choice, dose, and dosage regimen.


P: Professionals and Intended Users (target users/ stakeholders) and Clinical Specialty:Physicians, Nurses, Allied Health Personnel and Clinical Pharmacists in Departments of Surgery and all Surgical subspecialties (Colon and Rectal Surgery, Gastroenterology, Plastic Surgery, Urology, Thoracic Surgery, Vascular Surgery and Neurological Surgery), Obstetrics and Gynecology, Orthopedic Surgery, Ophthalmology and Pharmacology.

09 JAN 201415Antibiotic Prophylaxis in SurgeryPIPOH

O: Major Outcomes Considered Postoperative infection rates Postoperative Morbidity and Mortality rates Duration and cost of health careAdverse effects


King Saud University Hospitals (KKUH/ KAUH) or KSU Medical City Tertiary/ Governmental/ University Hospital Departments and clinics (mentioned in the clinical specialty)


Note: These CPGs reflect recommendations for peri-operative antibiotic prophylaxis to prevent SSIs and do not apply for prevention of opportunistic infections in immunosuppressed transplantation patients (e.g. for antifungal or antiviral medications).


Inclusion / Exclusion source CPGs Selection Criteria

1) Methods of Development; Evidence-Based CPGs: (Detailed Methodology of Development Documented; link Recommendations with Evidence; link to Systematic Reviews) rather than Consensus-based CPGs (Expert opinion)2) Author(s) Organization (CPG development group) from CPGs Database & Specialized Society (clinical specialty) NOT single authors.3) Country: international NOT national CPGs.4) Date of Publication: range of year of publications: last 3 years(2011 2013) NOT older.5) Language: English CPGs only6) Status: only Original source CPG (de novo developed) NOT adapted CPGs


AGREE II Domain Scores for the 2 source CPGs ASHP 2013 & ICSI 2012

09 JAN 201420Antibiotic Prophylaxis in SurgeryAGREE II DOMAINSASHP 2013 CPG (%)ICSI 2012 CPG (%)D1: Scope & Purpose80 72 D2: Stakeholder Involvement94 61 D3: Rigour of Development86 69 D4: Clarity & Presentation94 69D5: Applicability42 52D6: Editorial Independence83 79Overall AssessmentYesNoThis table uses the AGREE II Domain Score Colour Coding proposed by Dr. Lubna Alansary(< 40% red - > 41 70% yellow - > 71 % green)

Evidence-Based Recommendations09 JAN 2014Antibiotic Prophylaxis in Surgery21

Accreditation Canada International


Current ROP

09 JAN 201423Antibiotic Prophylaxis in SurgeryWhen to START ?When to STOP ?2 Questions !!

Preoperative-dose Timing

Optimal time for administration of pre-operative antibiotics first dose is within 60 minutes before surgical incision (within 120 minutes for Vancomycin or Fluoroquinolones due to prolonged infusion times).


Dosing & Re-dosingSingle dose prophylaxis is usually sufficient, the duration of prophylaxis for most procedures should be less than 24 hours.The shortest effective duration of antimicrobial administration for preventing SSI is unknown; however, evidence is mounting that postoperative antimicrobial administration is not necessary for most procedures.Re-dosing may be required if surgery duration is 2 half lives of chosen antimicrobial or if blood loss is excessive.


Dosing & Re-dosing (contd)If an agent with a short half-life is used:-(e.g. cefazolin, cefoxitin) it should be re-administered if the procedure duration exceeds the recommended redosing interval.Re-administration:- warranted If prolonged or excessive bleeding or if other factors shorten the half-life of the prophylactic agent (e.g. extensive burns).Not be warranted for patients in whom the half-life of the agent may be prolonged (e.g. renal insufficiency or failure).


Route of administrationIV route typically preferred due to rapid, reliable, and predictable tissue and serum concentrations


Select Antimicrobial based onAgent active against most common pathogens for given procedure but with as narrow spectrum as possible.Safety profile of drug.Patient allergies and co-morbidities.


Rating Scheme for the Strength/ Levels of the Evidence

09 JAN 2014Antibiotic Prophylaxis in Surgery29Level of EvidenceType of StudyLevel IEvidence from large, well conducted, randomized, controlled clinical trials or a meta-analysisLevel IIEvidence from small, well conducted, randomized, controlled clinical trialsLevel IIIEvidence from well conducted cohort studiesLevel IVEvidence from well conducted casecontrol studiesLevel VEvidence from uncontrolled studies that were not well conductedLevel VIConflicting evidence that tends to favor the recommendationLevel VIIExpert opinion or data extrapolated from evidence for general principles and other procedures

Rating Scheme for the Strength/ Levels of RecommendationsGrade of R. (GoR)Level of E. (LoE)Category ALevels I-IIICategory BLevels IV-VICategory CLevel VII

EVIDENCE-BASED RECOMMENDATIONSThoracic Procedures

09 JAN 201430Antibiotic Prophylaxis in SurgeryRecommended Agents & DosageCefazolin 2 g*Ampicillin-sulbactam 3 g**Alternative agents in Patients with B-Lactam AllergyClindamycin 900 mgVancomycin 15 mg/kgStrength of Evidence (accord. To procedure)A, C

Gatsrodudenal Procedures

09 JAN 201431Antibiotic Prophylaxis in SurgeryRecommended Agents & DosageCefazolin 2 gAlternative agents in Patients with B-Lactam AllergyClindamycin 900 mg orVancomycin 15 mg/kg + aminoglycoside orAztreonam 2 g orFluoroquinoloneStrength of Evidence (accord. To procedure)A

Biliary tract - Open Procedure

09 JAN 201432Antibiotic Prophylaxis in SurgeryRecommended Agents & DosageCefazolin 2 g*Cefoxitin 2 gCefotetan 2 gCeftriaxone 2 gAmpicillin-sulbactam 3 g**Alternative agents in Patients with B-Lactam AllergyClindamycin 900 mg orVancomycin 15 mg/kg + aminoglycoside*** or Aztreonam 2 g or fluoroquinolone****Metronidazole 500 mg + aminoglycoside*** or fluoroquinolone****Strength of Evidence (accord. To procedure)A

Biliary tract - laparoscopic procedure

09 JAN 201433Antibiotic Prophylaxis in SurgeryRecommended Agents & DosageElective, low-risk: noneElective, high-risk:Cefazolin 2 g*Cefoxitin 2 gCefotetan 2 gCeftriaxone 2 gAmpicillin-sulbactam 3 g**Alternative agents in Patients with B-Lactam AllergyElective, low-risk: noneElective, high-risk:Clindamycin 900 mg or Vancomycin 15 mg/kg + aminoglycoside*** or Aztreonam 2 g or fluoroquinolone****Metronidazole 500 mg + aminoglycoside*** or fluoroquinolone****Strength of Evidence (accord. To procedure)A

Appendectomy for uncomplicated appendicitis

09 JAN 201434Antibiotic Prophylaxis in SurgeryRecommended Agents & DosageCefoxitin 2 gCefotetan 2 gCefazolin 2 g* + metronidazole Alternative agents in Patients with B-Lactam AllergyClindamycin 900 mg or vancomycin + aminoglycoside*** or aztreonam 2 g or fluoroquinolone****Metronidazole 500 mg + aminoglycoside*** or fluoroquinolone****Strength of Evidence (accord. To procedure)A

Appendectomy for uncomplicated appendicitis

09 JAN 201435Antibiotic Prophylaxis in SurgeryRecommended Agents & DosageCefoxitin 2 gCefotetan 2 gCefazolin 2 g* + metronidazole Alternative agents in Patients with B-Lactam AllergyClindamycin 900 mg or vancomycin + aminoglycoside*** or aztreonam 2 g or fluoroquinolone****Metronidazole 500 mg + aminoglycoside*** or fluoroquinolone****Strength of Evidence (accord. To procedure)A

Vascular Procedures

09 JAN 201436Antibiotic Prophylaxis in SurgeryRecommended Agents & DosageCefazolin 2 g*Alternative agents in Patients with B-Lactam AllergyClindamycin 900 mgVancomycin 15 mg/kgStrength of Evidence (accord. To procedure)A

Urologic procedure

09 JAN 201437Antibiotic Prophylaxis in SurgeryRecommended Agents & DosageLower tract instrumentation with risk factors for infection:-Fluoroquinolone (e.g. ciprofloxacin 400mg)Trimethoprim-sulfamethoxazoleCefazolin 2 g*Clean without entry into urinary tract:-Cefazolin 2 g*; addition of single dose of aminoglycoside may be recommended for placement of prosthetic materialIf involving implanted prosthesis:Cefazolin 2 g* with or without aminoglycosideCefazolin as dosed above with or without aztreonam 2gAmpicillin-sulbactam 3 g**Clean with entry into urinary tract:-Cefazolin 2 g*; addition of single dose of aminoglycoside may be recommended for placement of prosthetic materialClean-contaminated:-Cefazolin 2 g*+ metronidazole 500 mgCefoxitin 2 gLoEA

Urologic procedures

09 JAN 201438Antibiotic Prophylaxis in SurgeryAlternative agents in Patients with B-Lactam AllergyLower tract instrumentation with risk factors for infection:Aminoglycoside*** with or without clindamycin 900 mgClean without entry into urinary tract:Clindamycin 900 mgVancomycin 15 mg/kgIf involving implanted prosthesis, consider adding aminoglycoside*** or aztreonam 2 g to either regimenClean with entry into urinary tract:Fluoroquinolone****Aminoglycoside*** with or without clindamycin 900 mgClean-contaminated:Fluoroquinolone****Aminoglycoside*** + metronidazole 500 mg or clindamycin 900 mgLoEA

Orthopedic procedures

09 JAN 201439Antibiotic Prophylaxis in SurgeryRecommended Agents & DosageClean operations involving hand, knee, or foot and not involving implantation of foreign materials:-None.

Spinal procedures with and without instrumentation, hip fracture repair, implantation of internal fixation devices, total joint replacement: Cefazolin 2 g*LoEC, A

Orthopedic procedures

09 JAN 201440Antibiotic Prophylaxis in SurgeryAlternative agents in Patients with B-Lactam AllergyClean operations involving hand, knee, or foot and not involving implantation of foreign materials:NoneSpinal procedures with and without instrumentation, hip fracture repair, implantation of internal fixation devices, total joint replacement:Clindamycin 900 mgVancomycin 15 mg/kgLoEA

Plastic surgery -Clean with risk factors or clean-contaminated

09 JAN 201441Antibiotic Prophylaxis in SurgeryRecommended Agents & DosageCefazolin 2 g*Ampicillin-sulbactam 3 g**Alternative agents in Patients with B-Lactam AllergyClindamycin 900 mgVancomycin 15 mg/kgStrength of Evidence (accord. To procedure)C

Excluded recommendationsThe panel decided to exclude the recommendations related to:-Cardiac Surgery Procedures (Separate CPG)Organ Transplantation Procedures (not currently practiced in KSUMC)09 JAN 2014Antibiotic Prophylaxis in Surgery42

Implementation Strategies & ToolsTOOLS/ Resources:

STRATEGIESQuick Reference Guides (Key Recommendations)ProtocolStanding Orders: Paper OR CPOE: Integration into New HIS (e-SIHI) as CPOE (Power Plans or Power Charts)Patient Education Guide (in Ar/ Eng)Clinical Audit tools/ Performance measuresDissemination Process (print/ e-/website)Local Clinical Champions.Awareness raising/ training activities.Networking and linking with existing projects.Patients as champions for change.Regular M & E.09 JAN 2014Antibiotic Prophylaxis in Surgery43

Thank YOU all for listening 09 JAN 2014Antibiotic Prophylaxis in Surgery44

Antimicrobial prophylaxis in surgery

Health & Medicine

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