Re: Surgical Prophylaxis Done Right
From: Rafael Haciski (haciski@earthlink.net)
Tue Jul 28 21:12:29 2009
Thanks, I will check this out with my administration.
––––––––––––––––––––––––––––––––––––––––
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 2:47 PM, Myer S. Bornstein wrote:
> I just checked with my abstracter for SCIP and any completely
> laparoscopic procedure is exclude from the SCIP pre-op antibiotics.
> However if the vagina is breached antibiotics are needed
> Myer Bornstein
> I am Medical Director for my hospital and deal with this all the time
>
> -----Original Message-----
> From: "Rafael Haciski" <haciski@earthlink.net>
> Sent 7/28/2009 11:56:15 AM
> To: "Multiple recipients of list OB-GYN-L" <ob-gyn-l@mail.obgyn.net>
> Subject: Re: Surgical Prophylaxis Done Right
>
> 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?
>
> ––––––––––––––––––––––––––––––––––––––––
> 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
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