The Guideline for Reducing Surgical Site Infection

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Table of Contents

Need for a guideline and benefits
Risk factor for surgical site infection
Benefits and risk of antibiotics
Administration of Surgical Antibiotic Prophylaxis
Surgical Antibiotic Prophylaxis Recommendations
Provision of Information and Support
Works Cited

Need for a guideline and benefits

This guideline provides recommendations to reduce inappropriate prophylactic antibiotic prescription in pre and post-surgery and consequently reduce surgical site infection (SSI). There is an ever-increasing need to use antibiotics intelligently, especially due to the prevalence of more resistant organisms. It further addresses risk factors for surgical site infection, benefits, and risks of antibiotic prophylaxis, indicators for surgical antibiotic prophylaxis and finally recommend a suitable administration of intravenous prophylactic antibodies. As such, this guideline gives some procedures used in surgical prophylaxis to prevent SSI by using antibiotics.

Risk factor for surgical site infection

Microorganisms cause surgical site infections (SSIs). Some of the most common germs include staphylococcus, Streptococcus, and Pseudomonas. These pathogens spread through contact with caregivers, contaminated surgical instruments, through airborne microorganisms, or sometimes organisms already in the patient’s body spreading to the surgical wound.

SSI risk factors can be broadly classified into, host characteristics, operation environmental factors and microbial factors. For patients’ state, factors that increase peril include poor nutritional state, obesity, extreme age, smoking, existing infections, diabetes, bacterial colonization, and the use of immunosuppressive drugs. On the other hand, operation factors include insufficient preoperative skin preparation, inadequate instrument sterilization, the presence of foreign material in surgical sites, poor surgical technique, prolonged operation, antimicrobial prophylaxis, and postoperative hypothermia among others (Johns Hopkins Medicine 1). Microbial factors include virulence, contaminated inoculum, and nasal or skin carriage. In this guideline, the American Society of Anesthesiologists (ASA) comorbidities score is used. The higher the score level the higher the risk.

Surveillance and prediction of SSI factors play a crucial role in managing SSI. As such, stakeholders in surgery and SSI management have suggested and used varied risk indicators to improve surveillance accuracy. This guideline uses NNIS, which is based on stratification of SSI risks.

The NNIS risk index starts from 0-3 (based on the American Society of Anesthesiologists) and the risk increases with increasing risk score. Using the risk index, surgeons comprehend how comorbidity, wound class and operation time contribute to the risk defined by types of operative wound. Further, this guideline identifies the operations for which routine prophylaxis is evidence supported (Musmar, Baba and Owais).

Nonetheless, the surgeon assessment of risks and benefits will primarily inform their decision. As such, a surgeon can administer prophylaxis to patients contrary to the provision given by a clinical guideline. However, the surgeon must first be convinced that the SSI risk is prevalent. Additionally, the guideline recommends that the surgeons record their justifications and criteria used for risk assessment.

Benefits and risk of antibiotics

The severity of post elective surgery SSI consequences states the value of surgical antibiotic prophylaxis. For instance, properly administered prophylaxis drastically reduces long-term postoperative morbidity in patients with anastomosis of the colon or total hip replacement surgery. Nonetheless, prophylaxis only decreases short-term morbidity in most surgical operations.

Further, prophylaxis has the potential to shorten hospital stay. Although the length of hospital stay depends on the type of surgery, SSI increases it. Therefore, to prevent SSI and consequently, reduce the hospital stay, the use of antibiotic is necessary. Additionally, antibiotic prophylaxis has been linked to faster returns to normal work after discharge from hospitals. Finally, the use of antibiotics reduces post-surgical costs by reducing the care intensity (Pear 56-64).

However, misuse of antibiotics has adverse effects on surgical patients. First, optimal management may be compromised if surgical patients are wrongfully attributed to a penicillin allergy. Penicillin is among the most commonly used antibiotic prophylaxis. Therefore, its allergic manifestation plays a key role in antibiotic prophylaxis. As such, a patient’s history, especially their reaction penicillin antibiotic, is integral to allergy evaluation.

Second, a couple of antibiotics are associated with diarrhea. Nevertheless, ways of reducing the incidence of antibiotic-associated diarrhea (AAD) remain difficult in many research cases. In children, a single randomized controlled trial has linked the yeast Saccharomyces boulardi to 23% to 8% relative to placebo. However, S. boulardi treatment may increase fungaemia risk especially in patients with compromised immunity. Therefore, thorough research should be considered before administering S. boulardi. In adults, the use of active Lactobacillus, particularly from yoghurt has posted positive results (Scottish Intercollegiate Guidelines Network).

Third, there are general surges of antibiotic resistance in hospitals. Studies have shown that the more patients use antibiotics, the higher the chances of developing resistance. For instance, uncontrolled studies revealed that subsequent antibiotic treatment is faced with high risks of resistance. Exposure to a single dose of antibiotics such as ciprofloxacin is linked to a substantial increase in resistance in the subsequent treatments.

Fourth, administering antibiotics to surgical patients exposes them to risks of Clostridium difficile infections (CDI). The risk is amplified if patients are in with diarrhea and multiple risk factors. It is therefore imperative to note that CDI has been linked to a considerable number of deaths.

Administration of Surgical Antibiotic Prophylaxis

While a wide range of microorganisms may be responsible for surgical site infection, SSI normally results from a significantly small number of microorganisms. Nevertheless, the choice of antibiotic is imperative in preventing SSI (Scottish Intercollegiate Guidelines Network 24).

Choice of Surgical Antibiotic

Antibiotic preferred should be effective against pathogens mostly related with wound infections after a given surgical procedure and against pathogens found in the part of the body for operation
The choice of a suitable antibiotic for a given patient should consider comparative efficacy as well as potential adverse effects and allergies
For a number of surgical procedures, both cefoxitin 2 g and cefazolin 1 g tend to be the most preferred antibiotic agents due to their long-lasting effects, effectiveness on pathogens common in operating environments, and their affordability
It is recommended that patients allergic to penicillin should receive vancomycin or clindamycin
- Patients not at risk for infection should receive clindamycin because of resistant-gram pathogens inferior to its more focused spectrum and generally fast infusion period
- Vancomycin is not recommended for routine usages
- Changes of surgical antibiotic prophylaxis regimen could be essential specifically in patients with pre-existing infections before surgery, fundamental length of hospital stay before surgery and past positive colonization
- For patients already on drugs before the surgery, it is normally not necessary to provide other drugs for surgical prophylaxis, particularly if the administered antibiotic is considered effective, appropriate for the type of surgery intended and the timing is optimized compared to surgical time
- It is necessary to consider the maximum doses for each patient, for instance, 2 g of cefazolin is recommended for patients weighing more than 80 kg

Dosage Selection

It is usually recognized as best practice that the needed dosage of antibiotic for prophylaxis is similar to that used for infection therapy. Only a single dose is considered adequate under most conditions.

Timing

Surgical antibiotic infusion for surgical prophylaxis should be introduced within one hour before the surgical procedure (cases of cesarean procedures and oral administration are however exempted)
For vancomycin, administration may start within two hours before the surgery because of extended periods of infusion and to ensure enough tissue levels at the period of the procedure
All antibiotics for administration should be finished before the surgery because some studies have established that provision ‘as near to the period of surgery as possible may not be the best approach. It is therefore recommended that antibiotic should be administered between 15 minutes to one hour (Scottish Intercollegiate Guidelines Network).

Dosing and Timing of Antibiotic Prophylaxis.

Antibiotic Agent	Pediatric Intravenous Dose (Adult Dose)	Infusion Time In Minutes	Timing of the First Dose	Redosing for Regular Renal Activities
Ampicillin/Sulbactam	50 mg/kg (1.5 ‐ 3 gm)	30	Start 60 min or less before incision	After every three hours
Cefazolin	25 mg/kg (max 1 gm; if more than 80 kg, use 2 gm)	30	Start 60 min or less before incision	After every four hours
Cefepime	50mg/kg (1‐2 gm)	30	Start 60 min or less before incision	After every four hours
Cefoxitin	40 mg/kg (1‐2 gm)	30	Start 60 min or less before incision	After every three hours
Clindamycin	10 mg/kg (600‐900 mg)	30	Start 60 min or less before incision	Every six hours
Gentamicin	2.5 mg/kg (120 mg if more than 80 kg)	30	Start 60 min or less before incision	After every eight hours
Metronidazole	10 mg/kg (500 mg)	30	Start 60 min or less before incision	After every six hours
Vancomycin	15 mg/kg (1 gm if greater than 50 kg)	60	Start 60 to 120 min before incision	After every 12 hours

Duration

The precise optimal time of perioperative prophylaxis has not been determined. In addition, it is improbable that patients would get further health benefits through more doses once the wound has healed and post-operative antibiotic prophylaxis is not required.
One prophylaxis dose with or without other intraoperative doses in extended surgical procedures is preferred. When prophylaxis is administered beyond the period of the procedure, then the use of antibiotics should cease within 24 hours unless clear indications are provided (NewYork-Presbyterian Hospital 1-8).
More intraoperative doses may be necessary in extended surgical procedures at a given interval, preferably twice the half-life of the antibiotic. That is, redosing should occur one interval less than the usual practice.
More intraoperative doses may not be necessary for surgical patients with prolonged cases of half-life of the drug, specifical patients with renal issues.
It is not recommended to continue with the antibiotic prophylaxis until the removal of all drains and catheters.

Multiresistance Carriage (MRSA)

MRSA carriage could be a critical risk factor for surgical site infection. SSI is generally responsible for adverse health outcomes, specifically for patients undergoing high-risk surgeries. Hence, patients recognized to have MRSA should also have an intervention therapy before the high-risk procedure (Rochester General Health System 1-4).

Guidelines.

Surgical Procedure	Pathogens	Primary Antibiotic Prophylaxis	Alternative	Duration
Cardiac
Coronary artery bypass and other open heart surgery	Staphylococcus aureus, S. epidermidis	Cefazolin 1-2 grams	Vancomycin 1 gram	Up to 24 hours
Prosthetic valve	Staphylococcus aureus, S. epidermidis	Cefazolin 1-2 grams and gentamicin 1.5 mg/kg	Vancomycin 1 gram + gentamicin 1.5 mg/kg	Up to 24 hours
Pacemaker, defibrillator placemen	Staphylococcus aureus, S. epidermidis	Cefazolin 1-2 grams	clindamycin 600 mg or vancomycin 1 g	Up to 48 hours maximum
Gastro-intestinal
PEG placement, PEG revision	Enteric gram-negative bacilli, gram-positive cocci	Cefazolin 1-2 grams or cefoxitin 2 grams	clindamycin 600 mg IV + gentamicin 1.5 mg/kg IV	1 Pre-operation Dose
Appendectomy, non-perforated	Enteric gram-negative bacilli, anaerobes, Enterococci	Cefoxitin 2 grams or cefazolin 1-2 grams IV + metronidazole 500 mg	clindamycin 600 mg IV + gentamicin 1.5 mg/kg IV	1 Pre-operation Dose
Genitourinary
Cystoscopy with manipulation – lithotripsy, ureteroscopy	Enteric gram-negative bacilli, enterococci	Ampicillin 2 grams IV and gentamicin 1.5 mg/kg IV or cefazolin 1-2 grams	clindamycin 600 mg IV and gentamicin 1.5 mg/kg	1 Pre-operation Dose
Transrectal prostate biopsy	Enteric gram-negative bacilli, enterococci	Cefoxitin 2 grams IV	clindamycin 600 mg IV + gentamicin 1.5 mg/kg IV	1 Pre-operation Dose
Gynecologic and Obstetric
Cesarean section	Enteric gram-negative bacilli, anaerobes, Group B strep, enterococci	Cefazolin 1 gram IV or cefoxitin 2 grams IV	Clindamycin 600 mg IV and gentamicin 1.5 mg/kg IV	1 Pre-op Dose or After Cord-clamping
Vaginal, abdominal, or laparoscopic, hysterectomy	Enteric gram-negative bacilli, anaerobes, Group B strep, enterococci	Cefazolin 1-2 grams IV or cefoxitin 2 grams IV	clindamycin 600 mg IV ± gentamicin 1.5 mg/kg IV	1 Pre-op Dose
Head and Neck
Incisions through oral or pharyngeal mucosa	Anaerobes, enteric gram negative bacilli, S. aureus	Cefazolin 1-2 grams IV	Clindamycin 600-900 mg IV + gentamicin 1.5 mg/kg IV	1 Pre-op Dose
Neuro-surgery
Craniotomy	S. aureus, S. epidermidis	Cefazolin 1-2 grams IV	Vancomycin 1 gram IV	1 Pre-op Dose
Ophthalmic
	S. epidermidis, S. aureus, streptococci, enteric gram-negative bacilli, Pseudomonas Aeruginosa	gentamicin, tobramycin, moxifloxacin, gatifloxacin or neomycin-gramicidin- polymyxin B; multiple drops topically over 2 to 24 hours		For up to 24 Hours
Orthopedic
Total joint replacement, internal fixation of fractures	S.aureus, S. epidermidis	Cefazolin 1-2 grams IV	Clindamycin 600 mg IV or vancomycin 1 gram IV	For up to 24 Hours
Thoracic (non-cardiac)
	S. aureus, S. epidermidis, streptococci, enteric gram-negative bacilli	Cefazolin 1-2 grams IV	Vancomycin 1 gram IV	1 Pre-op Dose
Transplants
Heart		Cefazolin 1-2 grams IV	Vancomycin 1 gram IV	1 Pre-op Dose
Pancreas or kidney		Ampicillin/sulbactam 3 grams and fluconazole 400 mg	Clindamycin 600 mg IV and aztreonam 1 g and fluconazole 400 mg	For up to 24 – 48 Hours
Kidney		Cefazolin 1-2 grams	Vancomycin 1 gram	1 Pre-op Dose
Lung		ampicillin/sulbactam 3 grams	Aztreonam 1 g and vancomycin 1 g IV	For up to 5 days
Vascular
Arterial surgery – prosthesis, the abdominal aorta, or a groin incision	S. aureus, S. epidermidis, enteric gram- negative bacilli	Cefazolin 1-2 grams IV	Vancomycin 1 gram IV	1 Pre-op Dose
Lower extremity amputation for Ischemia	S. aureus, S. epidermidis, enteric gram- negative bacilli	Cefazolin 1-2 grams IV	Vancomycin 1 gram IV	1 Pre-op Dose

Surgical Antibiotic Prophylaxis Recommendations

The recommendations for these drugs are based on evidence obtained from clinical experiments on effectiveness of antibiotic prophylaxis in controlling cases of surgical site infection (Scottish Intercollegiate Guidelines Network 28).

It is recommended that antibiotic prophylaxis should only be administered when clear evidence of benefits have been established. Conversely, they should never be considered when efficacy outcomes are not known. It is imperative to recognize that there is a paucity of evidence demonstrating the efficacy of antibiotic prophylaxis in children (from birth to 16 years old) (Scottish Intercollegiate Guidelines Network 29). Hence, general principles noted in antibiotic prophylaxis for adults have been applied to guide applications of drugs in children. On this note, recommendations have been provided for surgical antibiotic prophylaxis.

Antibiotic prophylaxis is effective in reducing cases morbidity, cost of hospitalization and is most likely to lessen the use of antibiotics
It is recommended that antibiotic prophylaxis should be used for all patients. Nevertheless, there are exceptions, particularly when the use of prophylaxis would increase costs of hospitalization and dependence on antibiotics. Specific reasons for restriction of prophylaxis to certain ‘high risk’ patients should be provided alongside justification. In addition, it is important to maintain continuous documentation of the infection rates to determine variations between patients who receive antibiotic prophylaxis and others who do not. These strategies are useful to determine clinical effectiveness of surgical antibiotic prophylaxis particularly when no evidence is available (Scottish Intercollegiate Guidelines Network 31). Trials may have not been performed or outcomes have been obtained from a rather small negligible sample.
It is not recommended to use surgical antibiotic prophylaxis when it has not been clinically proven effective, as well as when outcomes of infections are not deemed severe. This would reduce the use of antibiotic for minimal expected benefits.

Administration of antibiotic prophylaxis, notably administered by the parenteral intravenous route has traditionally proven reliable and efficient prophylaxis used to control surgical site infection in every type of surgery. It is important to administer surgical antibiotic prophylaxis intravenously. However, there are cases of oral administration. The rate of absorption may be used to determine the concentration of tissue and serum during oral administration. It is however important to note that little evidence is available to support the use of oral administration of antibiotic prophylaxis. In addition, it is difficult to determine the best time for administration because of the prevailing theater conditions.

It is not recommended to administer fluoroquinolones and cephalosporins because of potential to contribution to antibiotic resistance. Thus, patients identified as carrying MRSA should not receive these antibiotics because they may result in overgrowth of MRSA and increased rates of subsequent infections (Scottish Intercollegiate Guidelines Network 34). Minimal prophylactic antibiotic may be administered to control symptomatic risks of infections low.

Topical administration is used in high-risk surgeries particularly with gentamicin containing collagen fleeces after abdominal operations on rectal cancer to reduce possible wound infection after the procedure.

In some instances, for example, the administration of intranasal mupirocin to avert surgical site infections, are not consistent because of limited sample size, variations in clinical study designs, and different surgical groups. Such antibiotics may only be suitable for non-general surgical procedures such as orthopedic or cardiothoracic operations (Scottish Intercollegiate Guidelines Network 34).

Provision of Information and Support

It is generally important to provide information and support to patients, caregivers, families and the public on surgical antibiotic prophylaxis. This would ensure that they comprehend various approaches adopted to control infections or any other emerging issues. In addition, they would be more informed and take part in SSI control.

Works Cited

Johns Hopkins Medicine. Surgical Site Infections. n.d. Web.

Musmar, Samar MJ, Hiba Baba and Ala Owais. “Adherence to guidelines of antibiotic prophylactic use in surgery: a prospective cohort study in North West Bank, Palestine.” BMC Surgery 14 (2014): 69. Print.

NewYork-Presbyterian Hospital. Surgical Prophylaxis: Antibiotic Recommendations for Adult Patients. 2011. Web.

Pear, Suzanne M. Patient Risk Factors and Best Practice for Surgical Site Infection Prevention. 2007. Web.

Rochester General Health System. Surgical Prophylaxis Antibiotic Guidelines. 2012. Web.

Scottish Intercollegiate Guidelines Network. Antibiotic prophylaxis in surgery: A national clinical guideline. 2014. Web.

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