Re: Surgical Prophylaxis Done Right
From: Rafael Haciski (haciski@earthlink.net)
Tue Jul 28 10:52:09 2009
I have the same problem - hospital is after me because I make them
look bad when they are reviewed: they do not distinguish between
hysterectomy (generic term, presumably abdominal or vaginal) and
laparoscopic supracervical hysterectomy.
Does anyone have any supporting evidence for such prophylaxis?
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Rafael Haciski MD FACOG
Anchor Health Centers GYN
800 Goodlette Rd #360
239-643-8780 office
239-571-0292 cell
Naples, FL 34102
On Jul 28, 2009, at 10:49 AM, Richard Chudacoff MD FACOG wrote:
> Nothing here says we need antibiotics for a laparoscopic surgery
> that does not enter the vagina, yet if I don't use the antibiotic I
> get reprimanded by the hospital. There is no evidence for this
> stance, yet arguing makes me a disruptive physician. Go figure
>
> Richard Chudacoff, MD FACOG
> Las Vegas International Center for Advanced Gynecologic Care
>
> On Mon 27/07/09 21:16 , GIN11153@aol.com sent:
> thought this might interest you:
>
> Infection Prevention
> Surgical Prophylaxis Done Right
> Robert Manasse, PhD
>
> Despite well-publicized guidelines for choosing antibiotics for
> surgical prophylaxis, tens of thousands of surgical patients still
> aren't receiving the right antibiotic treatment. A recent Consumers
> Union analysis found that prophylactic antibiotics either weren't
> administered or weren't prescribed in accordance with the Surgical
> Care Improvement Project to about 100,000 surgical patients
> nationwide over a 1-year period. SCIP guidelines tell us when we
> should administer antibiotics and how long prophylaxis should
> continue post-closure. Let's take a moment to brush up on these
> important infection prevention guidelines.
>
> Choosing the right drug
> "Selecting the Right Antibiotic" outlines specific types of
> outpatient surgical procedures and the acceptable antibiotics for
> prophylaxis associated with each. The recommendations for
> prophylactic agents are based on the bacterial flora that usually
> colonize the surgical site or the organisms most frequently
> encountered as the cause of an infection for each type of procedure.
> For example, the majority of post-operative infections after
> neurological or orthopedic/podiatry surgeries are Gram-positive
> cocci such as Staphylococcus aureus or S. epidermidis. For such
> surgeries, a first-generation cephalosporin, oxacillin or nafcillin
> are the 3 drugs of choice, as they penetrate the areas well and are
> most active against these bacteria. If you know the patient is
> colonized with methicillin resistant S. aureus (MRSA), vancomycin is
> typically used, as other antibiotics don't kill or inhibit MRSA.
>
> Timing is everything
> In addition to administering the most effective antibiotic, it's
> just as important to be certain that the antibiotic is present in a
> good concentration at the incision site and the surgical area. In
> order to accomplish this, you have to start the antibiotic early
> enough so that it can diffuse and reach equilibrium. Start the IV
> antibiotic 1 hour before incision; most of the recommended
> antibiotics are given over a 30-minute period, and good drug levels
> are attained within the following half hour. However, because
> vancomycin and the quinolones should be given over a 1-hour period,
> it's best to start these IV drugs 2 hours before incision.
>
> For longer surgeries, it may be necessary to give a second dose,
> since the body begins to clear the antibiotics quickly. For example,
> the half-life (the time it takes to remove half of the drug from the
> blood) of cefazolin is about 2 hours. The general guide is to give a
> second dose after 2 half-lives; in the case of cefazolin, that would
> be 4 hours after the first dose was started.
>
> A surgical site infection is most likely to begin within 24 hours
> post-closure. Literature has shown that sufficient healing
> (formation of granulation tissue) at the surgical site takes place
> within 12 to 24 hours, which should prevent the majority of
> bacterial contamination where healing is taking place. Many
> publications have shown that post-op antibiotic prophylaxis is of no
> proven value when continued for more than 24 hours after surgery,
> and some research has shown that continuation of antibiotics post-
> closure has no effect at all on decreasing post-op infections. There
> are other good reasons for not continuing antibiotics for more than
> 24 hours after surgery, including the risk of increasing antibiotic
> resistance and the potential overgrowth of other pathogens.
>
> Decisions about when to stop surgical antibiotic prophylaxis depend
> on the surgery, the surgeon and the recommendation of professional
> societies. For example, orthopedic surgeons used to treat patients
> with antibiotics for 48 to 72 hours post-closure, but most have cut
> back to 24 hours or less. On the other hand, because of the
> seriousness of post-op infections in certain cardiac procedures, the
> 2 surgical cardiology societies still say up to 48 hours of
> antibiotic treatment is OK. To avoid confusion, always inform your
> patients about the rationale behind their antibiotic regimen.
>
> Selecting the Right Antibiotic
>
> Surgical Procedure
>
> Approved Antibiotics
>
> Cardiac (pacemakers or AICDs) or Vascular
>
> • cefazolin or cefuroxime or vancomycin*
>
> • If b-lactam allergy: vancomycin* or clindamycin
>
> Orthopedic/Podiatry
>
> • cefazolin or cefuroxime or vancomycin*
>
> • If b-lactam allergy: vancomycin* or clindamycin
>
> Genitourinary
>
> Transrectal prostate biopsy
>
> • quinolone†
> • or 3rd generation cephalosporin
> • or aminoglycoside + clindamycin
> • or aztreonam + clindamycin
>
> • or 2nd generation cephalosporin
> • or aminoglycoside + metronidazole
> • or aztreonam + metronidazole
>
> Penile prosthesis insertion, removal, revision
>
> • ampicillin/sulbactam or ticarcillin/clavulanate or piperacillin/
> tazobactam
> • or aminoglycoside + 2nd generation cephalosporin
> • or aztreonam + 1st generation cephalosporin
> • or aztreonam + clindamycin
>
> • or aminoglycoside + 1st generation cephalosporin
> • or aminoglycoside + vancomycin*
> • or aminoglycoside + clindamycin
> • or aztreonam + 2nd generation cephalosporin
> • or aztreonam + vancomycin*
>
> Gastric/Biliary
>
> PEG placement, PEG revision
>
> • cefazolin or cefuroxime
> • or clindamycin + quinolone
> • or vancomycin* + aminoglycoside
>
> • If b-lactam allergy: clindamycin + aminoglycoside
>
> Gynecological
>
> Laparoscopically-assisted hysterectomy;
> Vaginal hysterectomy
>
> • cefazolin or cefuroxime
> • or ampicillin/sulbactam
> • or metronidazole + quinolone
> • or clindamycin + aminoglycoside
> • or metronidazole monotherapy
>
> • or cefoxitin or cefotetan
> • If b-lactam allergy: metronidazole + aminoglycoside
> • or clindamycin + quinolone
> • or clindamycin monotherapy
>
> Pubovaginal sling
>
> • 1st generation cephalosporin
> • or ampicillin/sulbactam
> • If b-lactam allergy: aminoglycoside + clindamycin
> • or aztreonam + metronidazole
>
> • or 2nd generation cephalosporin
> • or quinolone†
> • or aminoglycoside + metronidazole
> • or aztreonam + clindamycin
>
> Head and Neck
>
> • cefazolin or cefuroxime
>
> • or clindamycin ± aminoglycoside
>
> Neurological
>
> • nafcillin or oxacillin
> • vancomycin* or clindamycin
>
> • cefazolin or cefuroxime
>
> Special Considerations
>
> *Vancomycin is acceptable with a physician/APN/PA documented
> justification for its use.
> †The only operations for which oral antibiotics alone are acceptable
> are transrectal prostate biopsy and pubovaginal sling procedures.
>
> "b-lactam" refers to antibiotics in the penicillin and cephalosporin
> classes.
> 1st generation cephalosporin is cefazolin.
> 2nd generation cephalosporins include cefoxitin, cefotetan and
> cefuroxime.
> 3rd generation cephalosporins include ceftriaxone, cefotaxime and
> ceftazidime.
> Quinolones include levofloxacin (used most frequently),
> ciprofloxacin, moxifloxacin and gatifloxacin.
> Aminoglycosides include gentamicin, tobramycin and amikacin.
> Data adapted from QualityNet specification manual for 7/1/09.
>
> One caveat
> Remember that these guidelines are indicated when no pre-op
> infection is present or expected. If you suspect an infection, treat
> the patient with antibiotic therapy instead of prophylaxis and
> choose drugs based on the infecting bacteria or the organisms
> usually present in the area.
>
> Keep Up With SCIP
>
> CMS has added to its Surgical Care Improvement Project requirements
> since the program was first enacted several years ago. For example,
> 1 addition that applies to both inpatient and outpatient surgeries
> concerns hair removal: If hair has to be removed (and that isn't
> always necessary), it must be done with a clipper or a depilatory,
> and it should be done just before the procedure begins. This helps
> avoid abrasions and small nicks, which can become the site of a post-
> op infection. Visit http://www.qualitynet.org for updates on the latest
> SCIP recommendations and initiatives.
>
> http://www.outpatientsurgery.net/2009/07/infection_prevention.php
>
> Gail
>
> Msg sent via Internet America Webmail - http://www.internetamerica.com
