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literaturesearch.They had no
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66
A n t i m i c r o b i a lP r o p h y l a x i sf o r S u r g i c a lP r o c e d u r e s
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C D - R O M ( 1 9 1 9t o 1 9 9 9 )a n d h a n ds e a r c h e s
flom 2000 to oresent
67
Panali-ean,
MD, FPSMID,FPCP,AntonioA. Arrastasio.
MD, FPCS,RenatoR. Montenegro,
MD, FPCS,Anthony
R. Perez,MD. FPCSand Maita TlreresaP. Rigor,MD.
FPCS.
TbeTeclrnicalWorkingGrouppreparedtheevidencebasedrepoftbasedon the articlesretrievedandappraised.
and validity appraisal,
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N o m i n a lG r o u pt e c h n i q u eT.h e E v i d e n c e - B a s C
e dl i n i c a l
of expertsreviewedthe interim repoft at the Bayauihan
Practice
CLridelines
for AntibioticProphylaxis
in Elective
Hall,UnitedLaboratories,
Inc.(LINILAB)in Mandalr.ryorrg
SurgicalProcedures
rvhich was preparedin 2001 was
CityonNovenber27,2004.ThemodifiedDelphitechnique
reviervedtogetherwith the prirnaryliteraturebetweenthe
was tlren used to deterntinethe degree of colrsensr-rs
clateof thosepreviousgLridelines
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regardi ng the recommendations.
studiesrverethenassessed
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developers.
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qualitiesof the studieswere appraisedby at leasttwo
Alex A. Erasmo,RenatoR. Montenegro,
MaitaTlreresa
P.
inclepenclen
r et v i e w e r su s i r r g a q L r a l i t ya s s e s s r r e r l t
Rigoraud AnthonyR. Perez.The invitedntembelswele
instrurment
developecl
by the PhilippineCardiovascular'Drs.Gr"racla
pe V i I IanLreva
Ir"r
and R i cardoM. Manalastas.lr.
Research
GroLrp,
as usedirrtlre previoLrs
editionof these (POGSrepresentatives)
andDrs. IsaacDavidE. Anrpil ll
guidelirres.'
and RaymundoJoa.qr-rirr
F. Erese(ResearchCourmittee
The clinical evidencewas rateclaccor"ding
to the representatives).
Otherexpeftpanelistscantefi'oll Metro
assessnlent
systemof tlie InfectioLrs
DiseaseSocietyof Manilahospitalsrepreserrted
by Drs. EdgardoR. Cortez.
America:as usedin the flrst eclitionof tlresegLridelines.iJoseAntonioM Salud,Artulo S.DelaPeiia,MaximinoDy
R. Efgar,FranciscoY. Arcellana Jr., Rey MelchorF.
L e v e lI E v i d e n c eo b t a i n e df r o r r a t l e a s t o n e Santos,
l(im Shi C. Tan,ReynaldoSinamban,
Dominador
properlydesigned
randomized
controlled M. ChiongJr'.,LeonardoL. CLraand JesusV. Valencia:
t l i a l o r n r e t a - a n a l y s iosf r a n d o m i z e d Drs.EdwinM. ConzagaandElvisL. Bediafrom Southern
controlledtrials
TagalogChapter;
Dr.JoseC. BLrgayorrgJr.
fromCordillera
Levelll - Evidence
obtainedfrom at leastonewell- ChapterlDr.Vitus S.Hobayanfi'orrCentralLuzon
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designecl
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S.Siguanfi"omCebLr-Eastern
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arralyticstudies (preferablyfrolrr one Northern Mindanao Chapter.Drs. .lasonL. Letranancl
center),fi"ornrl ultip le t i me-series,
or fronr DennisP. Serrano(PUA representatives),
Drs.EnricoP.
d r a n r a t i c r e s u l t s i n u n c o n t r o l l e d R a g a z a a n d H e r r n o g e n e sJ . M o n r o y ( P C R C S
expelirlents
representatives),
Drs.AnclresD. BorrorleoandErlily H.
LevelIII - Evideuce
obtained
fi'ourexpeftconrurittee Tanchuling(POA representatirzes).
Drs. Willy L. Lopez
reports
ol opirrionsof respected
atrtholities andLouieC. Racelis
(AFN representatives),
Drs,Napoleon
o n t h e b a s i so f c l i n i c a l e x o e r i e n c o
e r De Guznran,
Emrrranuel
SanPedroandAntouioB. Rarnos
descriotivestLrcl
i es.
(TCVS representatives),
Drs.AlbertoB. Roxas,Mark R.
Kho,lda MalieT. Lirn,andOrl i no C. B isqLrera
Jr'..( Cancer
TheTechnicalWorkingGroLrpwascomposed
of the Cornnritteerepresentati
ves)
The strengthof recomrrrendations
rurerrbers
of tlre PCS Conrmitteeon Surgicallnfectiorr:
for theguidelines
accordingto the level of agreenrent
of
D o r n i n g oS . B o n g a l aJ r . , M D , F P C S - C l r a i r ,A l e x P . was categorized
ea
, r i o M . t h e p a n e lo f e x p e r t sa f t e ra v o t e b y t h e p a r t i c i p a r r t s :
E r a s r l o , M D , F P C S - R e g e n t - i r r - C l r a r gM
PCSC.onrnrittcconStrrgica|]nf.ections,I999.200'
p r o c e d L r r ePsh. i l i p. l S L r r gS p e c2 0 0 2 : 5 7 ( 4 ) : I 3 5 -1 6 1 .
2006
PJSSVot.61,No.2, APril-June'
68
was approvedby
CategoryA - Recommendation
of at least75 perceritof the mLrlticonsensLts
6.
sectoralexPertPanel
Recommendationwas soruewhat
Category B
controversialand did not meetconsensus
C a t e g o r y C - R e c o r n m e n d a t i o uc a u s e d r e a l
among membersof the expert
disagreernent
panel
Summaryof Guidelines
A n t i n i i c r o b i a lp r o p h y l a x i si s r e c o m m e n d e df o r
oncologicheadandneck
electiveclean-contaminated
surgery.(I-A)
antimicrobialsfor prophylaxis
The recomtnended
t endc o l o g i ch e a da n d
i n e l e c t i v ec l e a r r - c o n t a m i n a o
c
l
i
n
d
a
m
y
c
i
n 3 0 0 n r g I V p r e - 7 . A r r t i m i c r o b i a lp r o p h y l a x i s i s N O T r o L r t i n e l y
a
r
e
neck surgery
my i n
i c choIecystecto
fo r Iaparoscop
recorrnrerrdecl
operativelytherr300 mg IV every 8 hoLrrsfor 24
l o w - r i s kp a t i e n t s(.l - A )
1.7 mg/l<g/
hours in conibinatiorrwith -eentarnicin
IV
dose IV pre-operativelytlien l'7 tt'tglkgldose
8 . A n t i m i c r o b i a l p r o p h y l a x i s i s r e c o r n t n e n c l ef odr
every 8 hoursfor 24 liours.(l-A)
c o l o r e c t aol p e r a t i o n s( .l - A )
may ltoweverbe administered
T'hearninoglycoside
T h e r e c o n r n e n d e dt ' e g i m e nf o r p r o p h y l a x i si n
a s a s i r r g l ed o s e .( l l l - A )
inistered
colorectalsttrgerycottsistsof an orally-adnr
antimicrobial combirred with a parenteral
2. Antimicrobial prophylaxisis NOT roLrtinely
a n t i m i c r o b i a l . T h e r e c o l l l m e n c l e do r a l l y for clean head and neck procedures
recorntrrended
n 0 0m g
a d m i n i s t e r eadn t i m i c r o b i ai ls c i p r o f l o x a c i 5
such as thyroidectomy. parotidectomyand
for 3 dosesire-operatively.(l-A)
s u b m a n d i b u l agrl a n de x c i s i o n (. l I - A )
d n t i m i c r o b i a l sf o r s y s t e m i c
The reconrtnendea
p r o p h y l a x i sa. r e A m o x y c i l l i n - c l a v u l a n iacc i d 1 . 2
3 . A n t i i m i c r o b i a lp r o p h y l a x i si s N O T r o u t i n e l y
g r a r n sl V s i n g l e d o s e A m p i c i l l i n - s u l b a c t a1r .n5
for breastsurgery.(l-A)
reconrurended
g r a n r sI V s i n g l ed o s eC e f o x i t i n2 g r a n r sI V s i n g l e
d o s eC e f a z o l i n2 g r a r n sT V p l L r sM e t r o n i c l a z o5l e0 0
4. Antimicrobial prophylaxisis NOT routirrely
m g I V s i n g l ed o s e( l - A )
for electivegroinherniasurgeryusittg
recourmeuded
l.
p r i r n a r yt i s s u er e p a i r .( l - A )
prophylaxisis likewiseNOT roirtinely
Arrtimicrobial
for electivegroinherniasurgeryusirrg
recotnmetrded
m e s hr e p a i r . ( l - A )
5 . A n t i m i c r o b i a l p r o p h y l a x i s i s r e c o r n r l e n d e df o r
electivegastricarrddtrodenalsurgery.(l-A)
T h e r e c o r r r t n e n daendt i r n i c r o b i af ol r p r o p h y l a x i isn
e l e c t i v eg a s t r o d u o d e nsaul r g e r yi s c e f t t r o x i t n e1 . 5
g r a m sI V s i n g l ed o s e .( l l - A )
9 . A r r t i m i c r o b i a lp r o p h y l a x i si s r e c o m t n e r r d efdo r
( I -A )
iovascltlar procedr-rres.
thoracic uotr-card
ad
n t i r n i c r o b i af ol r p r o p h y l a x i isn
T h er e c o m n t e r r d e
sllrgeryis cefazolinI
thoracicnort-cardiovascular
(
l
A
)
d
o
s
e
.
g r a ml V s i n g { e
1 0 . A n t i n r i c r o b i a lp r o p l r y l a x i si s r e c o t n n r e n d efdo r
v i d e o - a s s i s t etdh o r a c o s c o p i cs t r r g e r y( V A T S ) .
(rr-A)
A n t i m i c r o b i aP
l r o p h y l a x i sf o r S u r g i c a lP r o c e d u r e s
69
Tlrerecommended antirnicrobi
als for vi deo-assisted
ic surgeryareArnpici I Iin-suI bactarnI .5
thoracoscop
g r a r x sI V s i n g l ed o s eA m o x y c i l l i n - c l a v u l a n a
i cc i d
2.4 grans IV singledose (II-A)
l 1 A n t i r r r i c r o b i apl r o p h y l a x i si s r e c o m m e n d e df o r
cardiacsurgery.(l-A)
T h e r e c o m r n e n d eadn t im i c r o b i a sl f o r p r o p h y l a x i s
in cardiacsurgeryare Cefazolin I grarn IV preopelativelythen I grarn IV every 8 hours for 48
h o u r s C e f u r o x i m e1 . 5 g r a m s I V p r e - o p e r a t i v e l y
t h e n 1 . 5 g r a m sI V e v e r y l 2 h o r " r r fso r 4 8 l r o u r s
(I-A)
l r o p h y l a x i si s r e c o m m e n d e df o r
1 2 . A n t i n r i c r o b i ap
peripheralvascular surgery.(l-A)
antirnicrobialfor prophylaxisin
The recommended
peripheralvascularsLrrgeryis cefazolirrI gram IV
pre-operatively
therrI grarnIV every6 hoursfor24
h o L r r s( .l - A )
A n a l t e r n a t i v ree g i m e ni s c e f u r o x i r n e1 . 5g r a r n sI V
pre-operatively
then 1.5 gramsIV everyB hoursfor
2 4 h o L r r s( l. - A )
for total
13. Ant i m icrobi al prophyIaxis i s recomrnended
joirrt replacementsurg'rryand electivefixation of
closedlorrgbonefractures.(l-A)
antirlicrobialfor prophylaxisin
The recornrnended
sLrrgery
andelectivefixation 17. Antimicrobial prophylaxis is recommendedfor
totaljoint replacement
of closedlong bonefi'acturesis cefazolinI grarnIV
craniotomy.(l-A)
pre-operatively
therrI gramIV every8 hoursfor24
The recomnlendedantirnicrobialsfor prophylaxis
h o u r s (. l - A )
i n c r a n i o t o r l y a r e C l o x a c i l l i n 1 g r a r r tI V p r e r e g i m e na
s r e :C e f u r o x i t l eI . 5 g r a m sI V
Alternative
operativelytheu I grarn IV every 6 hours for 24
pre-operativelythen
750nrg lV every8 hoursfor24
y en 1
h o u r sO x a c i l l i n 1 g r a m I V p r e - o p e r a t i v e tl h
l r o u r s o r C e f t r i a x o n e2 g r a m s I V s i n g l e d o s e
granrIV every 6 hours for 24 hours (l-A)
(I-A)
If the patienthas a pre-operativestay of at least3
days,the additionof gentamicin240 rng IV single
1 4 . A r r t i r n i c r o b i apl r o p h y l a x i si s r e c o n r n r e n d efdo r
Iistedregirnensis
doseto either of the previor-rsly
transurethralresectionof the prostateto prevent
(llI-A)
recomrrrended.
p o s t o p e r a t i vbea c t e r i u r i aa n d c l i n i c a l s e p t i c e m i a .
(I-A)
antimicrobialfor prophylaxisin
The recomnrended
transnrethralresection of the prostate is
ciprofloxacin500rngtabletper oremBiD for 3 days
(I-A)
for both
18.Antimicrobialprophylaxisis recontntended
electiveand emergeucycesareansections.(l-A)
The recommendedantirnicrobialsfor prophylaxis
i n c e s a r e a ns e c t i o n sa r e A r n p i c i l l i n 2 g r a m s I V
10
P J S SV o l . 6 1 , N o . 2 , A p l i l - J u r r e2, 0 0 6
c n t it r i c r o b i a l s in c et hi s i s
s i n g l ed o s ep r e - o p e r a t i v e ol yr a f l e r c o r d c l a n r p i u g a c l ni rni s t e r i n gp r o p h y l a c t i a
grams
pre-opelatively
concern
for surgeons.
lV singledose
or" the main outconreof
Cefazolin2
atier cord clamping (l-A)
T h e f o l l o w i n gg e n e r a pl r i n c i p l e si n a n t i r t t i c r o b i a l
1 9 . A n t i r r r i c r o b i apl r o p h y l a x i si s r e c o u r r r r e n d ef odr p r o p h y l a x i sw e r e u s e c la s t h e b a s i sf b r c h o o s i n gt l r e
s t h i sa r t i c l e :
a p p r o p r i a taen t i t r i o t i c /i n
a b d o m i n ahl y s t e r e c t o r n(yl .- A )
ad
n t i n r i c r o b i af bl r p r o p h y l a x i isn l . T h ec h o i c eo f t h ea n t i r n i c r o b i sahl o L r lLcrle[ - r a s e c l o n
T h er e c o n i r n e n d e
Iogyo1'ex pectecl
a b d o r r r i n ahl y s t e r e c t o u riys c e f a z o l i n I g r a r r il V
the paranretersof efll cacy,epi dcrni c.l
(
l
A
)
s i n g l ed o s e .
p a t h o g e r r l,o c a l r e s i s t a n c ep a t t e r n s ,s a f e t y a t n c l
l vailability.
a d v e r s er e a c t i o n sc,o s t a n c a
Introduction
2 . T l r ec h o s e na n t i m i c r o b i af lo r p r o p h y l a x issl r o L l lbcel
a d n r i r r i s t e r ewdi t h i r r2 h o u r sb e f o l et l t es t a r to f t h e
S u r g i c a l s i t e i r r l ' e c t i o ni s a p o s t o p e r a t i v e
proceclu
re.
ct-rnrp
I icationwh iclrresults i n signi ficarrtrnorbidity ancl 3 . T h e a c l r n i t r i s t e r edcols e o f t h e a r t t i t n i u ' o b i af lc r r '
. ecause
n t o r t a l i t ay n dm a r k e d l yi n c r e a s ehso s p i t acl o s t sB
p r o p h y l a x i s h o u l cnl o t b e l o w e rl'l t a t tt h e s t a r r c l a r c l
t h i s c o m p l i c a t i o ni s q L r i t ec o m n l o n a n c l h a s w i d e
t l i e r a p e u t iccl o s eo f t h e d r u g .
, a sd e e t t t e nd e c e s s a t ' y4 . I n u r o s t e l e c t i v e p r o c e cul r e s . s i n g l e c o
l se
s o c i o e c o r r o mci oc n s e q u e n c ei st w
t o l e e x a r r r i ut eh e p r a c t i c eo f a r r t i n t i c r o b i aplr o p l r 1 , l 2 n 1 t a n t i n irc r o bi a l p r o p h yal x i s i s r e c o n i n i e n c l e c l .
e s p e c i a l lw
y i t h t h ec o n t i n u e d i v e r s i t yi r ra n t i m i c r o b i a l 5 . 1 1 ' ap r o c e d u r el a s t sl o n g e rt h a r rt h e h a l f ' l i f ' eo l ' t h e
prophylaxisrlethodsofferedto patientsby incliviclual
p l o p l r y l a c t ia
c n t i n t i c r o b i agl i v e n .a s e c o n ccll o s ei s
thereforeuseclttrore
ThesepracticegLridelines
surgeons.
i f ttecessaly
shottlcl
lecorrr
mencled.
Subsequentcloses
a
l
t
i
c
l
e
s
i
n
i
n
c
l
u
s
i
o
n
o
f
s
c
i
e
n
t
i
f
i
c
s t r i n g e nct r i t e r i af c r r
b e g i v e na t i r t t e r v a l ns o t l o r t g e tr l t a t t t , v i c teh e h a l f - t l r e e v a l u a t i o no f a d n r i s s i b l e v i c l e n c ef o r t r e a t u r e n t
l i [ eo f t h e c l r u g .
e f f i c a c y i n o r c l e l t o p r o r r r o t et h e i n t e g r a t i o na r t d 6 . T h e u s e o l ' a n t i n r i c r o b i a ;l r r o p h y l a x i iss t t o t z t
i n t e r p r e t a t i o no f v a l i c l , i n t p o r t a n ta n c l a p p l i c a b l e
I practi ces,pfopel'
for goocli nf'ectioucontt'o
substitLrte
veclevidence.
research-cleri
p a t i e n tp r e p a l a t i o ng, o o d s u r g i c a lt e c h n i q u ea, n
T h e c l i n i c a lq u e s t i o n as d d r e s s e bd y t h e g u i c l e l i n e s
a c l e q u a toep e r a t i n gl o o t n e n v i r o u l n e n ta, n c lg o o c l
a r e l ) i s a n t i m i c r o b i apl r o p h y l a x i sr e c o m r t t e n c l feodr
cl i n ical-juclgnrerr
t.
t h e s u r g i c a l p r o c e d u r e ,a n d 2 ) i f a n t i n r i c r " o b i a l" 7 . T h e f i r r a lc l e c i s i o rn^ e g a irrcrlgt l r eb e r r e l ' i a
t st t dr i s l < s
rvhatis/
fbr the procedr,rre,
prophylaxisis recornrrrended
o f p r o p l r y l a x ifso r a r ri r r d i v i c l u awli l l d ep e r r coll t t l r e
dose/saudduratiou
antirnicrobial/s,
arethe appropriate
p a t i e n t 'rsi s l <o f s u r g i c asl i t ei n f e c t i o nt,h ep o t e n t i a l
o f p r o p l r y l a x i sT? h e g L r i c l e l i n easd d r e s st h e t t e e df o r '
s e v e r i t y o f t h e c o l ' l s e q u e l l c eo sf s u r g i c a ls i t e
p r o p h y l a x ifso r o p e r a t i o nisr r v o l v i n gt h e h e a da n dn e c k ,
i n f e c t i o n t, h e e f f e c t i v e n e sosf p r o p l r y l a x i isr i t h a t
b li ,l i a r y .c o l o r e c t a l .
b r e a s tg, r o i nh e r n i ag, a s t r o d u o d e n a
of ;:rophylaxisl'or
operatiott,anclthc'consecluences
r ,r t h o p e c l i cu, r o l o g i c ,
t h o r a c i ca n d c a r d i o v a s c u l a o
t l r a tp a t i e r r t
n e u r o s u l g i c aaln do b s t e t r i ca n d g y n e c o l o g i sc u r g e r y .
S i g n i f i c a nut p d a t e fsi ' o r nt h ep r e v i o u sv e r s i o no f t h e
regarding
reflectcurrentl<nowleclge
ThesegLriclelines
s r ' a n t i r n i c r o b i aplr o p h y l a x i si t t s L r t ' g e a
g u i d e l i n e si n c l u d et h e d e v e l o p m e not f g L r i d e l i n ef o
l yt t h e t i n r eo f i t s
t eudc o l o g i ch e a da n d n e c k p r e p a r a t i o nG
c l e a na n dc l e a n - c o n t a r n i n a o
. i v e n t l r e c l y n a r n i cn a t u f eo l ' s c i e r r t i f i c
isted
thoracoscopic
surgery,vascular' i n f o r r n a t i oann ctl e c h n ol o g y ,p e r i o ci cl r e vi e w ,u p c l a rt rig ,
video-ass
surgery,
s L r r g e r y s, p i n a l s L l r g e r y ,c e s a r e a r ld e l i v e l y a u d a r r dr e v i s i o na r e t o b e e x p ec t e c l .
. h e g L r i d e l i n el si k e w i s ef o c u s e c l
T h e s eg L r i c l e l i n ne rsa yn o t b e a p p r o p r i a tfeo r u s ei n
- g y r r e c o l o gsiuc r g e r yT
o n t h e p r e v e n t i o no f s u r g i c a l s i t e i n f e c t i o n a s t h e a l l c l i n i c a l s i t u a t i o n s .D e c i s i o r r st o f o l l o w t h e s e
significanteud-pointwhen evaluatiugtlre efficacy of r e c o m r n e n d a t i o n
msu s t b e b a s e do n t h e p r o f e s s i o n a l
7l
2006
PJSSVol. 61,No.2, APril-June'
11
with an intervention.
complicationsand costsassociated
Therefore,an exactcorrelationdoesnot exist betweenthe
"quality of' evidence" and the "strengthof a
recommendation.
"
for SurgicalProcedures
Prophylaxis
Antimicrobial
I3
Results
Head and Neck Surgery
A. Clean-ContaminatedHead and Neck Surgery
l.
I s a n t i r n i c r o b i a lp r o p h y l a x i sr e c o m m e n d e df o r
oncolosicheadandneck
electiveclean-contaminated
surgery?
A n t i r n i c r o b i a lp r o p h y l a x i si s r e c o m m e t r d e fdo r
oncologicheadand neck
electiveclean-contaminated
s u r g e r y(. C A T E G O R YA R E C O M M E N D A T I O N )
Summary of Evidence
74
P J S SV o l .6 1 ,N o .2 , A p r i l - J u n e , 2 0 0 6
Summary of Evidence
75
double-blind placebo-control
A randornized,
ledtrial
(Platt, I 990) was doneto determinethe efficacy of preoperativecefonicidcomparedto placeboin preventing Summary of Evidence
surgicalsite infectionsin a mixed group of breastand
herniapatients.A subgroupof 606 patientsunderwent
A meta-analysis
of 5 randomizedcontrolledtrials
t h e f o l l o w i n g e l e c t i v e b r e a s t s u r g i c a l p r o c e d u r e s : on primary tissuerepair and 2 randomizedcontrolled
lumpectomy,local excision,or simple mastectomyin trialson meshrepair(Sanchez-Manuel,
2003)enrolling
percent,
rnodified
percent,
54
radicalmastectomy
in 36
2,660 patientswas done to determinethe efficacy of
in 4 percent,andreduction antimicrobialprophylaxiscomparedto placeboin the
axillarylymphnodedissection
rrrammoplasty
in 6 percent. There was no statistically p r e v e n t i o n o f s u r g i c a l s i t e i n f e c t i o n a f t e r g r o i n
significantd ifferencebetweenthe 2 groups(p = 0.206) herniorrlraphy.There was no statisticallysignificant
with 5.61 percent(17 of 303 patients)in the cefonicid difference in the over-all surgical site infection rate
grolrp and 8.58 percent (26 of 303 patients) in the b e t w e e nt h e 2 g r o u p s( p : 0 . 1 4 )w i t h 3 . 0 8p e r c e n(t 4 0
p l a c e b og r o L r pd e v e l o p i r r gs u r g i c a l s i t e i n f e c t i o n s . of l,297 patients) in tlre prophylaxisgroup and 4.69
(LEVEL I EVIDENCE)
percent(64 of 1,363 patients) in the control grolrp
A p r o s p e c t i v e ,r a n d o r n i z e d ,d o L r b l e - b l i n dt r i a l developingsurgicalsite infectionsfor an oddsratio of
( W a g m a n ,1 9 9 0 )e n r o l l i n g I l 8 p a t i e n t sw a s d o n e t o 0 . 6 1( 9 5 % C l : 0 . 3 2t o I . 1 7 ) .T h e a u t h o r sc o n c l u d e tdh a t
theefficacyof cefazolincomparedto placebo there was no evidencethat the use of prophylactic
determine
in the preventionof surgical site infection in breast antimicrobialsreducedthe surgicalsite infectionrate
in the stLrdywere thosewho after herniarepair.(LEVEL I EVIDENCE)
surgery.PatientsinclLrded
u n d e r w e n tt h e f o l l o w i n g e l e c t i v e b r e a s t s u r g i c a l
analysis of 5 randomizedtrials using
Sr-rbgroup
p r o c e d u r e s :t o t a l m a s t e c t o m yw i t h a x i l l a r y n o d e prirnarytissuerepair(Sanchez-Manuel,
2003)enrolling
percent,
with
in
segmental
mastectomy
dissectiorr 65
1,867patientsshowedthat there was no statistically
axillarynodedissectionin 29 percent,totalmastectomy significantdifference in surgical site infection rates
in 5 percent,and segrnentalmastectomyin I percent. betweenthe two groupswith 3.78 percent(35 of 924
Therewas no statisticallysignificant differencebetween patients)in the prophylaxisgroup and4.87 percent(46
t h e 2 g r o u p s( p : 0 . 7 2 ) w i t h 5 . 0 8 p e r c e n t( 3 o f 5 9 o f 9 4 3 p a t i e n t s ) i n t h e c o n t r o l g r o u p d e v e l o p i n g
and 8.47percent(5 of 59 infectionsfor,an odds ratio of 0.84 (95% Cl: 0.53 to
patients)in thecefazolingroLrp
p a t i e n t si)r rt h e p l a c e b og r o u pd e v e l o p i n gs u r g i c a sl i t e 1 . 3 4 ) "( L E V E L I E V I D E N C E )
i n f e c t i o n s .T h e a u t l r o r sc o n c l u d e dt h a t t h e u s e o f
Subgroupanalysis of 2 randomizedtrials using
prophylacticantibioticsdid not significantlyreducethe meslr repair (Sanchez-Manuel,2003) enrolling 793
i ncidenceof surgical sitei nfectionsafterbreastsurgery. patientsshowedthattherewasno statisticallysignificant
(LEVEL I EVIDENCE)
difference in surgical site infection ratesbetweenthe
two groupswith 1.3 percent(5 of 373 patients)in the
Groin Hernia Surgery
proplrylaxisgroup and4.2 percent(18 of 420 patients)
in the control group developinginfectionsfor an odds
l r o p h y l a x i sr e c o m m e u d e df o r r a t i o o f 0 . 2 8 ( 9 5 % C I : 0 . 0 2 t o 3 . 1 4 ) . ( L E V E L I
l . I s a n t i r n i c r o b i ap
electivegroin herniasurgery?
EVIDENCE)
A r r t i m i c r o b i a lp r o p h y l a x i s i s N O T r o u t i n e l y Gastric and Duodenal Surgery
for electivegroin lrerniasurgeryusing
recornmended
A l . I s a n t i m i c r o b i a lp r o p h y l a x i s r e c o m m e n d e df o r
primary tissue repair. (CATEGORY
RECOMMENDATION) Antimicrobial prophylaxisis
surgery?
electivegastro-duodenal
76
Summary of Evidence
Subgroupanalysisof 96 patientswho underwent
(Stone,
trial
double-blind
randomized
A prospective
gastric surgery in a prospectiverandomizeddor-rble1 9 7 6 )e n r o l l i n g4 0 0 p a t i e n t sw a s d o n et o d e t e r m i n teh e blindtrial (Stone,1976)showedthat patientswho were
efficacy of antimicrobialprophylaxis in preventing given cefazolin i gram IM the eveningbeforesLrrgery,
surgicalsite infectionafter electivegastric,biliary and I gram[M orrcallto the operatingroom and I grarnlM
colonic surgery.Ninety-sixpatientsunderwentgastric on tlreeveningof the operationfor a total of 3 dosesor
operationsfor gastriccancer,gastriculcer or duodenal cefazolin I gram IM on call to the operatingroom, 1
ulcer.Therewasa statisticallysignificantdifferencein gramlM on the eveningof the operatiortand 1 granrIM
surgicalsite infectionratebetweenthe 2 groupswith 4 on the morningaftersurgeryfor a total of 3 doseshada
percentof thosewho were given cefazolin 1 gram IM
significantly lower surgical site infection rate of 4
either I hour or 8 to 12 hoLrrspreoperativelyand 19
percentcomparedto patientswho wereeitlrernot given
p e r c e n to f t l r o s e e i t h e r r r o t g i v e n a n t i m i c r o b i a l
a n t i m i c r o b i a losr i n w h o mt l r ea n t i m i c r o b i a l w asst a r t e d
p r o p h y l a x i so r i n w h o m a n t i b i o t i c s w e r e s t a r t e d
who hada l9 percerrtinfectionrate.Tlre
postoperatively
postoperatively
developinginfectionsfor an ARR of 15
p
e
rcena
t n d t l r e R e l a t i v eR i s k R e d u c t i o n
ARR was l5
p e r c e n (t p : 0 . 0 a 6 ) (. L E V E L I E V I D E N C E )
=
(LEVEL I EVIDENCE)
A p r o s p e c t i v rea n d o m i z e d o u b l e - b l i n dp, l a c e b o - w a s 7 9 p e r c e n (t p 0 . 0 4 6 ) .
A p r o s p e c t i v er a, u d o r n i z eccol n t r o I I e tdr i a l( M o r r i s .
c o n t r o l l e dt r i a l ( N i c h o l s ,1 9 8 2 )e n r o l l i n g3 9 p a t i e n t s
1
9
8
4 )e n r o l l i n g7 8 p a t i e n t su n d e r g o i r regl e c t i v eg a s t r i c
was done to determinethe efficacy of antimicrobial
slrrgery
was doneto comparecefuroximeI .5 gramsIV
2 gramsIV administered
prophylaxisusingcefamandole
2 g r a m sI V s i n g l ed o s e .
then I gram IV 4 hoLrrsand 8 s i n g l ed o s ew i t h r n e z c l o c i l l i n
one hour preoperatively
hoursafter incisioncomparedwith placebofor gastro- T h e r e w a s a s t a t i s t i c a l l ys i g n i f i c a n t d i f f e r e r r c ei n
2.5 percent
performedbecause
ofgastriccancer, infectiouratesbetweenthe two groups.',vith
duodenal
operations
c h r o n i c o r b l e e d i n gg a s t r i c t t l c e r s ,a n d b l e e d i r r go r i n t l r e c e f u r o x i m e g r o r - r pa n d l 8 p e r c e n t i r r t l r e
. l l p a t i e n t si n c l L r d ei dn t h e m e z c l o c i l l i n
o b s t r u c t i ndgu o d e n aul l c e r sA
g r o l r pd e v el o p i n gi r r f e c t i o nfso r a nA R R o f
stLrdyhadclirricalfeaturesthat placedthem at high risk 1 5 . 5p e r c e n t(. L E V E L I I E V I D E N C E )
for the developmentof postoperativesurgical site
Although studieshave shown that cefazolingiven
infection.The surgicalsite infectionrate of 5 percent intramuscu
s for prophyIaxis in gastrolarly is efficacioLt
prophylaxisgroup duodenalsurgery,the expert panel believesthat it is
( I of 19 patients)in the cefamandole
was significantlylower tlran the 35 percentinfection i n d p p r o p r i a tteo a d n r i n i s t etrh e a n t i m i c r o b i at lh r o u g h
rate(7 of 20 patients)in the placebogroupfcrran ARR t h i s r o u t eb e c a u s o
e f t h e p a i n ,r i s l < sa t t di n c o n v eine n c e
. l t h o u g ht h et r i a l
o f 3 0 p e r c e r i ( 9 5 % C I : 2 . 3t o 5 7 . 1 % ) A
dith intranrttsc'ular
t o t h e p a t i e r ritn h e r e n t l ya s s o c i a t ew
w a s I i m i t e d b y t h e s m a l l s a r n p l es i z e , t h e a u t h o r s
i n j e c t i o r r sI t. w a st h e c o n s e t t s uosf t h e e x p e l tp a n e l t h a t
concIudedthat short-termantimicrobialprophylaxisis
c e f a z o l i n l g r a m l V s i n g l e d o s e i s a d e q u a t ef o r
surgicalsiteinfectionsin patients
effectivein preventing
prophylaxis in gastro-duodenalsLrrgeryand thus a
u n d e r g o i r r gg a s t r o d u o d e n asl u r g e r y . ( L E V E L I l
s L r i t a b lael t e r n a t i v ree g i m e t t(.L E V E L I I I E V I D E N C E )
EVIDENCE)
dose/s Biliary Surgery
2. What is/arethe appropriateantirnicrobial/s,
and durationof prophylaxis?
A. Open Biliary Surgery
prophylaxis
in
antirnicrobialfor
The recorrrrlended
surgeryis cefuroximeI .5 grams l . l s a n t i m i c r o b i a lp r o p h y l a x i s r e c o m t n e n d e fdo r
electivegastroduodenal
biliary surgery?
I V singledose(CATEGORY A RECOM MENDATION)
77
Prophylaxis
for SurgicalProcedures
Antimicrobial
A n t i m i c r o b i a lp r o p h y l a x i si s r e c o m m e n d e df o r
p a t i e n t sw h o w i l l u r r d e r g ot l i e f o l l o w i n g b i l i a r y
procedures:
Cholecystectorny
Sphincterotomy
plus sphincterotomy
Cholecystectomy
Choledochoenterostomy
(Choledochoduodenostomy,
plus sphincterotomy,
CIroledochoduodenostomy
Choledochojejunostomy)
C hoIecystoje.iunostomy
C o m m o nb i l e d u c t e x p l o r a t i o n
(CATEGORY A RECOMMENDATION)
c o n c o m i t a n t a l i m e n t a r y p r o c e d u r e s .T h e a u t h o r s
concludedthatantimicrobialprophylaxisin biliarytract
surgeryis effectiveespeciallyin high risk patientsand
that theseresultsindicatethat this is evidenceagainst
tlre further use of no-treatmentcontrols. (LEVEL I
EVIDENCE)
2.
dose/s,
What is/aretheappropriateantimicrobial/s,
prophylaxis?
and durationof
antirnicrobialfor proplrylaxisin
The recommended
biliary surgery is cefazoliri I gratn IV single close.
(CATECORY A RECOMMENDATION)
An alternativeregirnenis cefitroxime1.5gramslV
s i r r g l ed o s e .( C A T E G O R YA R E C O M M E N D A T I O N )
Summary of Evidence
Summary of Evidence
of 60 randomizedcontrolledtrials
A meta-analysis
(Meijer, 1990) for operationson the gallbladderand
s f I I r a n d o m i z etdr i a l se n r o l l i n g
Subgroua
pnalysio
c o m l n o n b i l e d r r c t , i n c l u d i n g c h o l e c y s t e c t o m y , I , 1 2 8 p a t i e n t si n a m e t a - a n a l y s i(sM e i . i e r ,1 9 9 0 )w a s
e x p l o r a t i o n o f t h e c o n l m o n b i l e d u c t a n d done to evaluatethe effectivenessof first generation
was done to determinethe cephalosporins
choledochoenterostomy
comparedwith secondorthirdgeneration
for prophylaxisin biliarysurgery.There
efficacyof antimicrobialprophylaxisfor open biliary ceplialosporins
significantdiffererrcein strrgical
in
the
meta-analysis
no
statistically
42
trials
was
of
A subgroup
sLrrgery.
enrollirig 4,129 patientscomparedthe surgical site site infection rates between the two groups with a
differenceof 0.5 percent(95% Cl:
infection rates amoltg patients given prophylactic cornrnonpercentage
o
/
o
)
1
.
5
a n dp o o l e do d d sr a t i oo f I . l 8 ( 9 5 % C l :
%to2.5
a n t i m i c r o b i a l sw i t h a c o n t r o l g r o u p n o t g i v e n
>
p
0 . 0 5 ) .( L E V E L I E V I D E N C E )
t
o
2
.
0
0
,
0
.
6
9
Tlie resultsshoweda significantlylower
antimicrobials.
S
u
b
g
r
o
u
p
a
n
a
l y s i so f I 5 r a n d o mi z e dt r i a l se n r ol l i r r g
surgicalsite infection rate of 2.1 percent in the
patients
in
a
meta-analysis(Mei.ier,1990)rvas
1,226
prophylaxisgroupcomparedto the 15 percentirrfection
of a singledoseof a
tlre
doneto evaluate effectiveness
rate in the control group for an over-all percentage
prophyIactic
antimicrobialcomparedwith rnultipledose
d iffererrceof 9 percent(.95%CI: 7 %oto 11 %) in favor
regimensfor propliylaxisin biliary surgery.Therewas
o f a n t i b i o t i cp r o p h y l a x i sa, p o o l e do d d s r a t i o o f 0 . 3 0
no statisticallysignificant differencein surgicalsite
( 9 5 % C l : 0 . 2 3 t o 0 . 3 8 )a n d a n N N T o f 1 1 . S u b g r o u p
infectionratesbetweenthe two groupswith a commol.l
analysisfor the two factors that appearedto lrave a percentage
differenceof 0.4 percent(95 % Cl: - I . | %oto
differencesshowed
significanteffecton the percentage
1. 9 % ) a n da p o o l e do d d sr a t i oo f 0 . 8 ( 9 5 % C I : 0 . 4I t o
a significantlystrongerprotectiveeffect of prophylaxis 1 . 5 7 , p> 0 . 0 5 ) ,( L E V E L I E V I D E N C E )
f o r h i g h r i s k p a t i e n t sw l i i l e t h e t i r n i n g o f w o u n d
double-blind multicentertrial (Meijer,
A randornized
inspection rnarkedly influenced the treatment effect 1993) enrolling 1,004 patientswas doneto comparethe
reported.Patientswho were labeledas high risk were efficacy of a single pre-operativedose of cefuroxime
those who had acuteclrolecystitiswithin 4 weeks of a g a i n s tm u l t i p l e d o s e so f t h e s a m e a n t i m i c r o b i a il r r
sLrrgery,emergencycholecystectomy,common dltct p r e v e n t i n gs u r g i c a l s i t e i n f e c t i o n s .T h e r e w a s r t o
stone or ductal exploration,jaundice at the time of statisticallysignificantdifferencein majorsurgicalsite
ageover60years,previousbiliarytractsurgery, infectionratesbetweenthe two groupswith 3.8 percent
sLrrgery,
of the gallbladderon in tlre singledosegroup and4.6 percentin the rnultiple
rnorbidobesity,non-visualization
d
i
a
b
e
t e s m e l l i t u s , a n d dose group developinginfectionsfor an ARR of 0.8
c
h
o
l
e
c
y
s
t
o
g
r
a
p
h
y
,
oral
18
p e r c e n (t 9 5 % C l : - 1 . 7t o 3 . 3 ; p : 0 . 5 2 ) . T h e a u t h o r s
concludedthat there is no significant advantageto
g i v i n gr n u l t i p l ed o s ep r o p h y l a x i cs o m p a r e d
with single
doseprophylaxisin biliary operationsto preventpostoperativeincisionalsurgicalsite irrfections.(LEVEL I
EVIDENCE)
P J S SV o l .6 1 ,N o .2 , A p r i l - J u n e , 2 0 0 6
Antimicrobial
Prophylaxis
for SurgicalProcedures
A n t i m i c r o b i a l p r o p h y l a x i si s r e c o m m e n d e df o r
e l e c t i v e c o l o r e c t a l p r o c e d u r e s .( C A T E G O R Y A
RECOMMENDATION)
79
f o r a n A R R o f 6 . 7 p e r c e n t( 9 5 % C l : 2 . 3 t o 1 1 . l % ;
p <0.01). In the 9 trialsfrom I 976 onwards,
themortality
rateof 3 .4 percent(15 of 443patients)in theprophylaxis
group was significantly lower comparedto the 8.7
Summary of Evidence
percentmortalityrate(34of 390 patients)in the control
group for an ARR of 5.3 percent(950/o
CI: I .9 to 8.7 o/o:
A meta-analysis
of 26 randomizedcontrolledtrials p < 0.01).The pooledmortality rateof 3.9 percent(36
( B a u n r ,1 9 8 1 )p u b l i s h e df r o m I 9 6 5 t o 1 9 8 0e n r o l l i n g o f 9 12 p a t i e r r t s )i n t h e p r o p h y l a x i s g r o u p w a s
2,052 patientswas done to detennine the efficacy of significantlylowercomparedto the9.7 percentrate(64
v a r i o u s a n t i m i c r o b i a lr e g i m e n sf o r p r o p h y l a x i si n of 657 patients)in the control groupfor an ARR of 5.8
colorectalsurgery conrparedto no antimicrobial in percent.(LEVEL I EVIDENCE)
p r e v e n t i n gs u r g i c a I s i t e i r r f e c t i o n s( 2 6 t r i a l s ) a n d
A meta-analysis
of I 47 randomizedcontrolledtrials
o p e r a t i v em o r t a l i t y( 1 7 t r i a l s ) .O r a l b o w e l - s t e r i l i z i n g( S o n g , i 9 9 8 ) r v a s d o n e t o a s s e s st h e e f f i c a c y o f
r e g i m e n s w e r e u s e d i n f i v e t r i a l s , p a r e n t e r a l antimicrobialprophylaxisin the preventionof sLrrgical
a n t i m i c r o b i a lisn l 3 t r i a l s ,t o p i c a la g e n t si n o n e t r i a l , siteinfectionin patientsr-rndergoing
colorectalsLlrgery.
a n d c o m b i n a t i o nosf t h e s ei n 7 t r i a l s . I n t h e l 2 t r i a l s For,rrtrials
irrclLrded
irr the meta-analysis
whiclr were
through 1975,the sr"rrgical
site iufectiou rate of 21.8
p u b l i s h e ds i n c e 1 9 8 4 t h a t c o m p a r e dp a t i e r r t sg i v e r r
percent(199 of 475 patients)in the prophylaxisgroLrp
antirnicrobialprophylaxiswith a no treatrnentcontrol
was significantlylower conrparedto the 35.7 percent
groupconsistentlyshowedthatthesurgicaI site i nfectiorr
r a t e( 1 3 8 o f 3 8 7 p a t i e n t s )i n t h e c o n t r o lg r o u p f o r a n
A R R o f I 3 . 9 p e r c e n t ( 9 5 %C l : 7 . 9 t o 1 9 . 9% ; p < 0 . 0 1 ) r a t e o f 1 3 p e r c e n t i n t h e p r o p h y l a x i s g r o l r p w a s
andanNNT of 8. In the I 4 trialsfrom 1976onwards,the significantlyIowertlranthe 40 percentinfectionrate in
s L r r g i c asli t e i n f e c t i o nr a t eo f 1 6 . 3p e r c e n t( 9 1 o f 5 5 8 tlrecontrolgroupfor an ARR of 27 percentandan odds
p a t i e n t s )i n t h e p r o p h y l a x i sg r o u p w a s s i g n i f i c a n t l y r a t i o o f 4 . 0 8 ( 9 5 % C l : 2 . 3 3 t o 7 . 1 3 ) . T h e a u t h o r s
lower conrparedto the 4 I .9 percentrate ( 199 of 415 c o n c l u d e tdh a ta n t i m i c r o b i apl r o p h y l a x i iss e f f e c t i v ei n
patients)in thecontroI groLrp
for an ARR of 25.6percent t h e p r e v e n t i o no f s u r g i c a ls i t e i n f e c t i o ni n c o l o r e c t a l
( 9 5 %C I : 1 9 . 6t o 3 1. 6 % ; p < 0 . 0 1 ) T
. h e p o o l e ds u r g i c a l sLrrgery.
(LEVEL I EVIDENCE)
rateof I 9.2 percent (229 of 1, I 90 patients)
siteinf.ection
i n t l r e p r o p h y l a x i sg r o u p w a s s i g n i f i c a n t l y l o w e r 2. {lrat is/arethe appropriateantimicrobial/s,
dose/s,
conrpared
to the 39.1 percerrtrale(337 of 862 patients)
arr"il'd
r-rrati
on of prophylaxi s?
i n t h e c o n t r o lg r o L r pf o l a n A R R o f 1 9 . 9p e rc e n t .T h e
a u t h o r sc o n c l u d e dt h a t a n t i m i c r o b i apl r o p l r y l a x i w
s as
T h e r e c o m m e n d e dr e g i m e n f o r p r o p l r y l a x i si n
preventing
effectivein
sLrrgical
site infectionsand that colorectalslrrgeryconsistsof an orally-adnrinistered
a n y f u r t h e r t r i a l s o n a r r t i u r i c r o b i apl r o p h y l a x i s i n
antiniicrobialcombinedwith a parenteral
antirni crobial.
colorectalsurgeryshoLrldernploya previouslyproven
Therecommended
orally-adrnin
isteredantirnicrobial
standardinsteadof no treatrnerltcolttrols.(LEVEL I
is ciprofloxacin500 mg for 3 doses,startedtheday prior
EVIDENCE)
(CATEGORY A RECOMMENDATION)
to
Seventeen
randonrized
trials in the meta-analysis surgery.
T h e r e c o n t m e n d e da n t i r n i c r o b i a l sf o r s y s t e m i c
(Baum,1981)alsocomparedthe mortalityratesbetweerr
p
r
o
p
h y l a x i sa r e a m o x y c i l l i n - c l a v u l a nai c i d 1 . 2g r a m s
the prophylaxisgroup and the no treatmentcontrol
5g r a m sl V s i n g l e
grolrp.In the B trialsthrouglt1975, tlremortalityrateof I V s i n g l ed o s eA m p i c i l i n - s r , r l b a c t1a.m
4.5 percent(21 of 469patients)i n the prophylaxis group dose Cefoxitin 2 grarnslV single dose Cefazolin 2
was significantlylower comparedto the I 1.2 percent g r a m sI V s i n g l ed o s ep l L r sM e t r o r r i d a z o l5e0 0 m g I V
nrortalityrate(30 of 267 patients)in the controlgroup s i n g l ed o s e( C A T E G O R Y A R E C O M M E N D A T I O N )
80
p < 0 . 0 0 1 )a l l f a v o r e dt h e c o r n b i n e d
o r a l p l r . rssy s t e m i c
group.
The authorconcltrded
antimicrobialprophylaxis
(Song,1998)was doneto compare thattheuseofcombinedoralandsystemicantirnicrobials
A meta-analysis
severaI d iffe rentairtimi crobial regirnensfor prophylaxis f o r p r o p h y l a x i s w a s s u p e r i o r t o u s i n g s y s t e mi c
g amoxiciI lin-clavulanic antirnicrobials
alonein preventing
surgicalsiteinfections
i nclLrdin
in colorectalsLrrgery
(
L
E
VEI- I EVIDENCE)
a c i d . a m p i c i l l i n - s r - r l b a c t acme,f o x i t i n . i n t i p e r t e n r ,i r re l e c t i v ec o l o r e c t asl u r g e r y .
l ss e di n
c e f a z o il n p l Lsr m e t r o n i d a z o l e ,c e f u r o x i m e p l u s
O f t h e o r a l l ya d m i n i s t e r eadn t i m i c r o b i a u
i r rt h e
i s c u r r e n t l ya v a i l a b l e
m e t r o n i d a z o l eg, e n t a r n i c i np l L r sm e t r o n i d a z o l eo r t l r et r i a l s ,o r r l yc i p r o f l o x a c i u
bv the expert
c l i n d a m y c i n ,a n d c i p r o f l o x a c i np l u s m e t r o n i d a z o l e . local market so this was recomrnended
Therewas r1osignificantdifferencein the surgicalsite p a n el .
infectionratesbetweenthe variousproplrylacticagents
alone,doxycycline Thoracic and Cardiovascular Surgery
but regimenssuclrasmetronidazole
a l o n e , p i p e r a c i l l i na l o n e a n d o r a l n e o m y c i np l u s
erytlrromycinalonegiven the day beforethe operatiott A. Thoracic Non-CardiovascularSurgery
(LEVEL I EVIDENCE)
appearedto be inadeqLrate.
S e v e n t e erna n d o m i z e dt r i a l s i n t h e m e t a - a n a l y s i s l . I s a n t i m i c r o b i a pl r o p h y l a x i sr e c o n r m e r r d ef odr
( S o n g ,I 9 9 8 )e n r o Il i n g 2 , 4 5 0p a t i e n t cs o n r p a r eadsi n g l e
larsurgery?
t h o r a c i cn o n - c a r ido v a s c u
d o s e r e g i u r e na d m i r r i s t e r e dp r e o p e r a t i v e l yw i t h a
m u l t i p l e - d o sree g i m e nu s i n gt h e s a m ea n t i m i c r o b i aol r
A r r t i r n i c r o b i apl l o p h y l a x i s i s r e c o m n r e n d e fdo r
. ATEGORY
a c o m b i n a t i o no f a n t i r n i c r o b i a l sN. o n e o f t h e t r i a l s t h o r a ci c r t o n - c a ri do v a s c lua r p r o c e d u r e (sC
found a significantdiffereucein surgicalsite infection A R E C O M M E N D A T I O N )
r a t e sb e t w e e a
n s i n g l ed o s ea n da m u l t i p l e - d o sree g i r n e n
w i t h a p o o l e do d d sl a t i oo f L l 7 ( 9 5 % C l : 0 . 9 t o 1 . 5 3 ) . S u m m a r y o f E v i d e n c e
( t , E V E LI E V I D E N C E )
S i x r a n d o n r i z etdr i a l s i n t h e m e t a - a n a l y s (i sS o n g ,
l ctl r i a l ( A z n a r ,
l d c o r r t r ol e
A r a n d o r inz e dd o u b l e - bi n
p
a
t
i
e
n
t
s
a
f
i
r
s
t
g
e
n
e
r
a
t
i
o
r
r
5
5
1
c
o
m
p
a
r
e
d
I 9 9 B )e n r o l l i n g
s r r r d e r ignogt l r o r a c isct r f g e r y
19 9 I ) e n r o l l i n g1 2 7p a t i e n t L
c e p h a l o s p o r i nw i t h a s e c o n d -o r t h i r d - g e n e r a t i o t t was done to evaluatethe effectivenessof cefazolinI
c e p h a l o s p o r fi o
n r p r o p h y l a x i sN. o n e o f t h e t r i a l sf o r . r n d g r a mI V s i n g l e ' d o sper e o p e r a t i v ecl yo m p a r etdo p l a c e b o
a statisticallysignificant difference in surgical site i n p r e v e r r t i n gs u r g i c a ls i t e i n f e c t i o r r T
. lre irrcisional
infectionratesbetweentlre two groupswith a pooled s u r g i c a ls i t e i n f e c t i o nr a t e o f 1 . 5 p e r c e n t( l o f 7 0
o d d s r a t i o o f 1 . 0 7( 9 5 % C l : 0 . 5 4 t o 2 . 1 2 ) .( L E V E L I p a t i e n t si)n t h e c e f a z o l i ng r o L r p
w a ss i g n i f i c a n t l lyo w e r
EVIDENCE)
t h a nt h e 14 p e r c e nitn f e c t i o nr a t e( 8 o f 5 7 p a t i e n t si )n t h e
A r r e t a - a n a l y soi sf l 3 r a n d o r n i z ecdo n t r o l l e dt r i a l s p l a c e b og r o u pf o r a r e l a t i v er i s l io f 3 . 2 1( 9 5 %C l : I . 5 t o
(Lewis. 2002) enrolling 2,065 patietttswas done to 1 1 . 5 )a n d a n A R R o f 1 2 . 5 .T h e a u t l r o r sc o r r c l u d etcl rl a t
prophylaxiscompared a s i n g l ep r e o p e r a t i vcel o s eo f c e f a z o l i ni s e f f e c t i v ei n
efficacyof systernic
determinethe
to combinedoralandsystemicprophylaxisfor colorectal r e d r - r c i nt hge r a t eo f i n c i s i o n asl u r g i c asl i t ei n f e c t i o n isn
The orally non-card
in preventingsurgicalsiteirrfections.
sLlrgery
(LEV EL I EV I D ENCE)
iacthoracicprocedures.
a d m i r r i s t e r eadn t i m i c r o b i a l Ls r s e di n t h e v a r i o r - rt sr i a l s
i n c l u d e d r l e o l r y c i n - e r y t h r o m y c i u , n e o n t y c i l t - 2 . W h a ti s / a r et h ea p p r o p r i a taen t i m i c r o b i a l /ds o
, se/s,
n r e t r o n i d a z o l er ,r e o m y c i u - t i n i d a z o l ek .a n a m y c i n a n d d u r a t i o no f p r o p h y l a x i s ' ?
de a n
n dc i p r o f l o x a c i nT.h e u r r w e i g h t em
n r e t r o n i d a z oal e
T h e r e c o m n r e u c l eacnl t i n r i c r o b i aflo r p l o p h y l a x i s
r i s k d i f f e r e n c ei n t h e r a t eo f s u r g i c a sl i t e i n f e c t i o n so f
sLrrgeryis cefazolin I
0 . 6 9 ( 9 5 % C I : 0 . 3 9 t o 0 . 9 9 ) ,t l r e w e i g h t e dm e a nr i s k iu thoracicnon-carcliovascrtlar
<
p
(
9
5
%
C
l
:
0
.
2
6
1
o
0.86;
0 . 0 1 )a t t d g r a m l V
single dose. (CATEGORY A
diff-ererro
ce
f 0.56
t h es u n r m a rrye l a t i v er i s ko f 0 .5 1 ( 95 % C L :0 . 2 4t o 0 .7 8 ; RECOMMENDATION)
Summary of Evidence
8l
Summary of Evidence
controlledtrial (Aznar,
doLrble-blind
A randornized
thoracicsurgery
199 I ) enroll ing127patientsLrndergoing
was doue to evaluatethe effectivenessof cefazolin 1
comparedto placebo
gramlV singledosepreoperatively
i
n
f
e
c
t i o n .T h e i n c i s i o n a l
s
i
t
e
s
L
r
r
g
i
c
a
l
p
r
e
v
e
n
t
i
l
r
g
iu
percent (1 of 70
1'5
of
rate
site irrfectiorl
sr-rrgical
lower
group
was
sigrrificarrtly
patieuts)in the cefazolin
patients)
in the
(8
of
57
tharithe l4 percetttinfectionr:ate
(95%
.5 to
CI:
1
placebogroupfor a relativerisk of 3 .27
that
I 1.5)and an ARR of 12.5.Tlre authorscoriclLrded
doseof cefazolin is effectivein
a singlepreoperative
site infectiottsin '
therateof incisionalsr-rrgical
reclucing
(LEVEL I EVIDENCE)
thoracicprocedures.
non-carcliac
c o n t r o l l e dt r i a l ( O l a l < ,
A r a n c i o m i z eddo u b l e - b l i n d
the
1 9 9 1 )e n r o l l i n g2 0 8 p a t i e n t sw a s d o n et o c o n r p a r e
efficacy of one doseversussix dosesof cefazolinas
prophylaxisin generalthoracicsurgery' Therewas no
drfferencein the rateof surgical
statisticallysigrrificant
with no infections
two groLlps
the
betweerf
infections
site
g
r
o
u
p and only two
s
i
r
r
g
l
e
d
o
s
e
i
r
r
t
h
e
occurring
group (95% CI:
six-dose
irr
tlre
infectionsoccurring
t h a tg i v i n gs i x
- 0 . 0 0 8t o 0 . 0 4 8 ) .T h e a L r t h o rcso n c l u d e d
doses of cefazolin does not confer any clinically
irnportantbenefit beyondthat obtainedfrorn a single
siteinfectionin elective
dosefor prophylaxisof sLrrgical
(LEVEL
I EVIDENCE)
surgery.
generalthoracic
B. Video-AssistedThoracoscopicSurgery (VATS)
l.
I s a n t i m i c r o b i a lp r o p h y l a x i s r e c o n r t r l e n d efdo r
t hdo r a c o s c o p iscu r g e r y( V A T S ) ?
video-assiste
for
A r r t i u r i c r o b i apl r o p h y l a x i si s r e c o m t n e n d e d
(
V
A
T
S
)'
v i c l e o - a s s i s t e tdh o r a c o s c o p i c s L r r g e r y
(CATEGORY A RECOMMENDATTON)
Summary of Bvidence
(Rovera,2003)enrolling
cohortstLrdy
A prospective
346 patientswas done to determineand cotnparethe
incidencearrdtypes of infectionsoccurringafter two
differentVATS procedures:lung wedgeresectionand
massesand to identify
or rnediastinal
biopsyof pleLrral
risk parameters'The
infection
of
value
predictive
the
was 4.9 percentbut
rate
infection
overallpostoperative
82
C. Cardiac Surgery
l.
I s a n t i m i c r o b i a lp r o p h y l a x i s r e c o m m e n d e df o r
cardiacsurgery?
A n t i n i i c r o b i a lp r o p h y l a x i si s r e c o m m e n d e df o r
cardiac surgery. (CATEGORY A RECOMMENDATION)
Summary of Evidence
Subgroupanalysisof for-rrplacebo-controlled
trials
i n a m e t a - a n a l y s(iK
s r e t e ra n d W o o d s ,1 9 9 2 )e n r o l l i n g
405 patientswas done to determinethe efficacy of
a n t i m i c r o b i a l p r o p h y l a x i s f o r c a r d i a c s L r r g e r ya s
compared
to placebo.
Therewasa statistically
significant
reductionin the sLrrgical
site infectionrate in the group
given antimicrobialprophylaxiswith a summaryodds
ratioof 4.96(95% Cl:2.06to9.72).Tliis corresponds
to
a s i g r r i f i c a nr e
t d L r c t i oi n t h e s u r g i c a l s i t ei n f e c t i o nr a t e
l'ronrabout20 -25 percentin theplacebogroupcompared
t o t h e4 - 5 p e r c e nrta t ei n t h ea n t i t n i c r o b i apl r o p h y l a x i s
g r o u p .( L E V E L I E V I D E N C E )
2. What is/arethe appropriateantimicrobial/s,
dose/s,
and durationof prophylaxis?
P J S SV o l .6 1 ,N o .2 , A p r i l - J u n e2,0 0 6
significantdifferencebetweenthe cefazolilrgroupand
the cefamandole
or cefuroximegroupwhen sternaland
legwound infectionsiteswere analyzedseparately.
The
summaryoddsratio of I .58 (95% Cl: 1.03to 2.45) after
analysisof tlre cornbinedsternaland leg inf-ection
rates
howeversuggests
thatdespitethegenerallylow 5 percent
surgicalsite infectionrate in the cefazoliugroup,there
is a furtherreductionin infectionratesto approximately
3 percentwith the use of tlre secondgeneration
c e p h a l o s p o r i r (r L
s .E V E L I E V I D E N C E )
A r a n d o n r i z e dd o u b l e - b l i n d c o n t r o l l e d t r i a l
( T o w n s e r r d1,9 9 3 )e n r o l l i n gI , 6 4 1p a t i e n t w
s a sd o n et o
comparetlre efficacy of cef'amandole.
cefazolinand
cefuroxinrein preventingsLlrgicalsite irrfectionsafler
cardiacsurgery.There was no statisticallysigrrificant
differerrcein surgical site infectiou rates among the
t l r r e eg r o u p s( p = 0 , 9 2 ) w i t h 8 . 4 p e r c e n t( 4 6 o f 5 4 9
patients)in the cefamarrdole
groLrp,8.4 percent(46 of
547 patients)in the cefazolingroup,and 9 pelcent(49
o f 5 4 5 p a t i e n t s )i r r t h e c e f u r o x i m eg r o L l pd e v e l o p i n g
irrfections.In addition,tlrere was also no significant
differencewith respectto the sitesof irrfectiotrs
andthe
depth of tissue involvementamong the three groups.
(LEVELI EVIDENCE)
A meta-arralysis
of four randomizedcontrolledtrials
(l(riaras,2000) was done to evaluatetlre effect of a
T h e r e c o m m e r r d eadn t i r n i c r o b i a lfso r p r o p h y l a x i s r e d u c t i o ui n t h e d u r a t i o no f p r o p h y l a c t i ac n t i m i c r o b i a l
i n c a r d i a c s u r g e r ya r e C e f a z o l i n l g r a r n I V p r e - r e g i m e n s i n m a j o r c a r d i o v a s c u l a rs u r g e r y o n
operativelythen I gram IV every 8 hours for 48 lrours postoperative
i nfectioLts
colrrp I ications.A randomized
(CATEGORY A RECOMMENDATION)
a n d trial errrolling569 patientswas doneto cot'npare
a long
CefuroximeI .5gramsIV pre-operatively
then I .5 grams d u r a t i o ror f p r o p h y l a x i sL r s i n g
c e f a z o l i n5 0 0 r n gI V p e r
I V e v e r y 8 h o u r s f o r 4 8 h o u r s ( C A T E G O R Y A d a y f o r 4 d a y s w i t h a s h o r t d u r a t i o no f a n t i b i o t i c
RECOMMENDATION)
adririnistration
r-rsing
cefuroxime1.5granrsIV per day
f o r 2 d a y s . T h e r e w a s n o s t a t i s t i c a l l ys i g n i f i c a n t
Surnmary of Evidence
differencebetweentlre two groltpswith a 2.5 percent
surgicalsite infectionrateand 5.7 percent30-daytotal
Subgroupanalysisof six randomizedtrials in a infectionrate in the cefazolingroup and a 1.1percent
meta-ana
lysis (KreterandWoods, 1992) eriroI I ingZ,630 surgicalsite infectionrateand 5.3 percent30-daytotal
patientswas doneto comparethe efficacy of tlre first- infection rate in the cefuroxime group. (LEVEL I
generatiorrcephalosporincefazolin with the second E V I D E N C E )
generationcephalosporins
cefamandoleor cefuroxime
A r a n d o m i z ecdo n t r o l l e d
t r i a le n r o l l i n g8 8 3p a t i e r r t s
for prophylaxisof surgical site infection in cardiac wasdonetocompareceftriaxone2 gramsIV singledose
surgery.The total surgicalsite infectionratesranged with cefazolin500 mg IV every6 hoursfor I day.There
from 2.5 percentto 16.7percentfor tl-recefazolingroup was no statisticallysignificantdifferencebetweenthe
and from 0 percentto 13.5percentin the cefamandole- two groupswith a 0.4percenttotalsLrrgical
siteinfection
or cefuroxime-treated
patients.Tlrerewasno statisticaI ly rate and 5 percent30-day total infection rate in the
83
A prospectiverandonrizedstudy (Edwards,1992)
enrolling559 patientswas done to determinewhether
the incidenceof vascular sr-rrgical
site infectionsin
p a t i e n t sL r n d e r g o i n a
g b d o r n i n a la o r t i c a n d l o w e r
extremityperipheralvascularsr"rrgical
procedurescan
S u m m a r yo f E v i d e n c e
be redLrcedby administeringa more beta-lactamaseA p r o s p e c t i vbel i n d e dr a n d o m i z e tdr i a l ( P i t t , 1 9 8 0 ) s t a b l ec e p h a l o s p o r i nl i k e c e f u r o x i m e1 . 5 g r a m s I V
Iy, 750 mg IV every3 hours duri ng operation
enrolling217 patientswas done to determinewhether preoperative
p r o p h y l a c t iacn t i m i c r o b i a w
l so u l d r e d u c et h e i n c i d e n c e and750 mg IV every6 hoursfor 24 hourspostoperatively
500
of infection in peripheralvascularprocedureswith a ascomparedto cefazolinI grarnIV preoperatively,
84
2006
PJSSVot.61,No.2, April-June,
a n t i m i c r o b i a l s i n p a t i e n t s u n d e r g o i n gs u r g i c a l
of hip or otlrerlorrgbonefracturesreduces
management
the incidenceof surgicalsiteandotherhospital-acqtrired
infectionsS
. u b g r o u pa n a l y s i so f s e v e t lt r i a l s w l r i c h
compareda siugle pre-operativedose of a parenteral
antibiotic with placeboor tro treatruentslrorvedthat
s i n g l e d o s e a n t i m i c r o b i apl r o p l r y l a x i s i g n i f i c a n t l y
sLrrgicalsite irrfections
reducedthe rate of sLrperficial
(
9
5
%
0
. 5 0 t o 0 . 9 5 )a n d d e e p
C
I
:
0
.
6
9
R
R
o
f
with arr
o f 0 . 4 0( 9 5 % C l : 0 . 2 4
w
i
t
h
a
n
R
R
s u r g i c asl i t ei n f e c t i o n s
t o 0 . 6 7 ) .T e n t r i a l s w h i c h c o n r p a r e cal p r e - o p e r a t i v e
d o s ep l u s2 o r m o r ep o s t o p e r a t i vdeo s e sw i t h p l a c e b o r
n o t r e a t m e n ts h o w e dt h a t t h e u s e o f r n u l t i p l ed o s e
a n t i r n i c r o b i apl r o p h y l a x i sa l s o s i g n i l ' i c a n t l yr e d r r c e d
witlt an RR
surgicalsiteirrl'ectiorrs
the rateof sLrperficial
o f 0 . 4 8( 9 5 % C l : 0 . 2 8t o 0 . 8 1 5 )a r r dd e e ps u r g i c asl i t e
i r i f e c t i o nw
s i t h a r rR R o f 0 . 3 6 ( 9 5 % C l : 0 . 2 1t o 0 . 6 5 ) '
(LEVEL I EVIDENCE)
A m e t a - a n a l y soi sf 15 r a n d o m i z e cdo n t r o l l e dt r i a l s
(SoLrthr,vetl-Keely,
2004) enrolling 2,417 patientswas
d o n e t o e v a l u a t et h e e f f e c t i v e n e s os f a n t i r n i c r o b i a l
s l r o h a c sl t r r g i c ailn t e r v e n t i o n
p r o p h y l a x i fso r p a t i e r l t w
after a proxinialfenloralft'acture.Otttcontesmeasured
ttrinarytt'actittfection,
siteinf-ectiorts,
sLrrgicaI
incILrded
a n dr n o r t a l i t yO. f t h e t e nt r i a l si r r c l L r d ewdh i c hs o u g h t t o
determine whether antinricrobial prophylaxis
s i g n i f i c a n t l yr e d u c e do v e r - a l l s L r r g i c asl i t e i n f e c t i o n
showed
rateswhencomparedwith placebo,threestr'rdies
a s t a t i s t i c a l l y ' s i g n i f i c a nbt e r r e f i tf o r t h e u s e o f
a n t i m i c r o b i a l sf i,v e s t u d i e ss h o w e da t r e n di t t f a v o ro 1 '
a n t i b i o t i c s ,a n d t w o s t u d i e s f a v o r e d p l a c e b o 'T h e
0rthopeclic Surgery
rredresultsshoweda slllnlllaryoddsratioof 0.55
cour.bJ
for total ( 9 5 % C l : 0 . 3 5 t o 0 . 8 5 )f a v o r i r r gt l r eu s eo f p r o p h y l a c t i c
prophylaxisrecolnmended
1. ls antitnicrobial
(LEVEL I EVIDENCE)
-ioint replacetnentarrd elective fixation of closed a r r t i m i c r o b i a l s .
fractures?
long bone
2 . W h a ti s / a r et h ea p p r o p r i a taen t i r n i c r o b i a l /dso. s e / s ,
a n dd L r r a t i oor rf p r o p h y l a x i s ?
for totaI
ArrtirnicrobiaI prophyIaxis is recommended
surgeryandelectivefixatiorrof closed
-iointreplacetnent
T h e r e c o m m e n d eadn t ir l i c r o bi a l f b r p r o p h yl a xi s i n
A
fractures. (CATEGO RY
b on e
l o r rg
joint replacemetrt
surgeryand electivefixationo1'
total
RECOMMENDATION)
is cefazolin I gram IV prefractures
long
bone
closed
'l
every 8 lroursfbr 24 lrours
grarn
lV
operativelytlten
S u m m a r yo f E v i d e n c e
( C A T E G O R YA R E C O M M E N D A T I O N )
trials
controlled
of 22 randomized
A rneta-analysis
( G i l l e s p i e2, 0 0 4 )e n r o l l i n g8 , 3 0 7p a t i e n t sw a s d o n et o Alternativeregimensare:
t h e n7 5 0 m g
determinewhetlrerthe prophylacticadtninistrationof C e f u r o x i m e1 . 5g r a m s[ V p r e - o p e r a t i v e l y
mg every4 hoursduringoperation,and 1 gramevery6
hours postoperativelyfor 24 hottrs.Tlie study showed
that tlrere was lto statisticallysignificant difference
betweenthe two groups with 2.6 percent (7 of 272
patients)in the cefuroximegroup and 1.0percent(3 of
287 patients)in the cefazolirrgroup developingdeep
i n c i s i o n a l s u r g i c a l si irtref e c t i o n( sp = 0 . 2 ) .T h ea u t h o r s
c o n c l u d e dt h a t a l t h o u g h t h e d i f f e r e r r c ew a s n o t
statisticallysignificant,the trend in infection rates
suggeststhat at tlre dosesused in the study, cefazolin
prophylaxisthan
providesmoreeffectiveperi-operative
(LEVEL
I
EVIDENCE)
cefuroxime.
A r a n d o n r i z e dt r i a l ( H a l l , 1 9 9 8 ) e n r o l l i n g 3 0 2
p a t i e n t sw a sd o n et o c o m p a r et h e i n c i d e r r coef s u r g i c a l
s i t e i n f e c t i o n a f t e r v a s c u l a rs l l r g e r y f o l l o w i r r g t h e
a d r n i n i s t r a t i oonf t i c a r c i l l i n3 . 0 g r a r l s / c l a v u l a n a0t e.I
grarrrIV either as a single pre-operativedose or as a
multiple-doseregirnenat 6 hourly intervalsafter the
initial dosefor a maximum of 20 doses'There was a
s t a t i s t i c a l l sy i g n i f i c a n dt i f f e r e n c ei n t h e i n c i d e n c eo f
s e t w e e nt h e t w o g r o l l p sw i t h l 8
s u r g i c asl i t ei n f e c t i o n b
p e r c e n(t2 8o f 15 3 p a t i e n t si)n t h es i n g l ed o s eg r o u pa n d
l 0 p e r c e n (t 1 5 o f 1 4 9 p a t i e n t s i)n t h e n r u l t i p l ed o s e
g r o u p d e v e l o p i n gi n f e c t i o n sf o r a r e l a t i v er i s k o f 2 . 0
( 9 5 Y "C l : - 1 . 0 2t o 3 . 9 2 ) .T h e a u t h o r sc o n c l u d e dt h a t a
le-doseratlrerthana singledoseregimenprovides
mr-rltip
optirnalprophylaxisagainstsurgicalsite infectionfor
p a t i e n t su n d e r g o i n gv a s c u l a r s u r g e r y . ( L E V E L I
EVIDENCE)
85
86
P J S SV o l .6 1 ,N o .2 , A p r i l - J u n e2,0 0 6
Antimicrobial
Prophylaxis
for SurgicalProcedures
81
Neurosurgery
smallertreatmenteffectsfor antimicrobialr"rse
with arr
odds ratio of 0.30, tlrerewas no evidenceof different
A. Spinal Surgery
treatmenteffects witlr tlre inclusion of grarn-rregative
coverageover gram-positive
coveragealone(oddsratio
I . Is antinricrobialprophylaxis
recorlmende
d for spirral o f 0 . 5 4 . p : 0 . 5 ) . T h e a r - r t h o rf sa i l e d t o i d e n t i f ya n y
surgery?
additionalbenefitwhenantimicrobialcoverage
incIuded
Antimicrobialprophylaxisis recommended
in spinal gram-negative
organisnrs.
One trial (Rubinstein,I994)
o p e r a t i o n ss u c l r a s l a m i n e c t o r l i e s ,f u s i o n s , a n d usedcefazolinsingledosewhile anothertrial (Redjian.
d i scectonr
ies.(CATEGORY A RECOMMENDATION) 1990) utilized oxacillin for 24 hours as prophylaxis.
(LEVEL I EVIDENCE)
Summary of Evidence
Four randornized
trials in a meta-analysis
(Barker,
2002)
pre-operative
used
only
and
intra-operative
dosirig
A meta-analysis
of 6 randomizedcontrolledtrials
w
h
i
l
e
t
w
o
t
r
i
a
l
s
u
s
e
d
a
d
d
i
t
i
o
n
a
p
l
o
s
t
o
p
e
r
a
t
i
v
eo s i r r g
d
(Barl<er,2002) enrolling 843 patients was done to
for
12
to
24
hours.
There
was
no
evidence
of different
d e t e r m i n ew h e t h e r a n t i mi c r o b i a l p r o p h y l a x i s w a s
beneficialfor spinaloperationsdespitethe prevailing treatmenteffects witli the different dosing periods
low infectionratewithout pre-operative
antibiotics.In a l t h o u g h t h e t r i a l s L l s i n g p o s t o p e r a t i v ed o s i n g
prophylaxis
group,
the antibiotic
2.2 percent( I 0 of 451 demonstratedslightly smaller treatmenteffects for
( o d d sr a t i oo f 0 . 5 2v e r s u s0 . 3 4 ,p = 0 . 9 6 ) .
patients)developed
sr"rrgical
siteinfectionscomparedto a n t i b i o t i cL r s e
The
authors
failed
to identify any additiorralbenefit
5.9 percent(23 of 392 patients)in the pooledcontrol
regimerrs
wereusedasconrpared
to
armsof thetrials.Tlrerarrdom-effects
pooledodds-ratio whenmr"rltiple-dose
o f 0 . 3 7( 9 5 % C l : 0 . I 7 t o 0 . 7 8 ;p < 0 . 0 1 )d e r n o n s t r a t e ds i n g l e - d o sree g i n r e n s( .L E V E L I E V I D E N C E )
s t a t i s t i c a l l y s i g n i f i c a r r te v i d e n c e o f e f f i c a c y f o r
prophylaxis.
antirnicrobial
It alsodemonstrated
a pooled B. CSF Shunts
risk difference of 2.9 percent favoring the use of
l . I s a n t i m i c r o b i a lp r o p h y l a x i sr e c o m m e n d e df o r
prophylacticantinricrobials.
A meta-analysis
of 6 norrcerebrospiua
f llu i d s h u n t i n gp r o c e d u r e s ?
izedtrialssirnilarlydemonstrated
ranclom
lowerinfection
patientswith an odds
rates among autibiotic-treated
A n t i m i c r o b i a l p r o p h y l a x i s i s r e c o m m e n d e cf ol r
ratioof 0 .22(95% CI: 0 . I 5 to 0.33 , p < 0 .00 I ). (LEV EL
c
e
r
e
b r o s p i n fal lL l i ds h u n t i n gp i o c e d u r e s( C
. ATECORY
I EVIDENCE)
A RECOMMENDATION)
2.
Whatis/arethe appropriate
antimicrobial/s,
dose/s,
Sum:rparyof Eviclence
and clLrration
of proplrylaxis?
T h e r e c o m m e n d eadn t i m i c r o b i af lo r p r o p h y l a x i isn
s p i n a l s u r g e r yi s c e f a z o l i n I g r a m l V s i n g l e d o s e
( C A T E G O R YA R E C O M M E N D A T I O N )
A n a l t e r n a t i v ree g i n r e ni s o x a c i l l i n I g r a ml V p r e operativelythen 500 mg IV every6 hoursfor 24 houls.
( C A T E C O R YA R E C O M M E N D A T T O N )
S u m m a r yo f E v i d e n c e
Threerandomized
(Barker,
trials in a meta-analysis
2002) r-rsedantibioticswith both granr-positiveand
gram-negative
coveragewlrile three randomizedtrials
usedgram-positive
coveragealone.Althoughthe trials
with granr-negativecoveragedemonstratedslightly
A m e t a - a n a l y so
i sf 9 r a n d o m i z e d
c o n t r o l l e dt r i a l s
( H a i n e s ,I 9 9 4 ) e n r o l l i n g 1 , 0 4 4p a t i e r r t w
s a s d o r r et o
d e t e r m i n teh e e f f i c a c yo f a n t i n r i c r o b i aplr o p h y l a x ifsb r
cerebrosp
i ualfl u iclshuntoperations.
OnestLrdy
appearecl
t o s h o w a h i g h e r i n f e c t i o nr a t e i n t h e a n t i r n i c r o b i a l
prophylaxisgroup tlran tlre placebogroup, 3 studies
showedessentiallyno effect for pLophylaxis.
3 studies
s h o w e ds t a t i s t i c a l liyn s i g ni f i c a n t r e n d sf a v o r i r r gl o w e r
infectionratesin the antimicrobial-treated
group,and2
studiesshowedstatistically si gni ficanteffectsfavoling
the antirni crobi aI-treatedgroup. I n the anti b i ot i c-treatecj
g r o u p s ,7 . 2 p e r c e n t( 3 7 o f 5 1 7 p a t i e n t s )d e v e l o p e d
surgicalsite irrfectiollscolxparedto12.9percent(68 of
527 patients)in the pooled control arms of the trials.
88
89
CesareanSection
dose/s,
2. What is/aretheappropriateantimicrobial/s,
zinddurationof prophylaxis?
Summary of Evidence
of 51 randomizedcontrolledtrials
A meta-analysis
of 7 randomizedcontrolledtrials (Smaill and Hofmeyr,2002) was done to comparetlre
A meta-analysis
(Chemlow,2001)wasdoneto determinethe efficacyof di fferentantirni crobials givenfor prophyIaxi s i u cesareatr
. he efficacy of ampicillin irr preventing
section' s e c t i o t t s T
antimicrobialprophylaxisfor electivecesarean
significantreductionin tlie risk p o s t o p e r a t i v ei r i f e c t i o n s w a s s i m i l a r t o t h e f i r s t Therewasa statistically
90
9l
. e t a a n a l y s io
s f r a n d o n r i z e dc o n t r o l l e d
preventing
i n f e c t i o nw i t h O R o f 0 . 3 7( p : 0 . 0 0 0 1 ) . T h e 2 . M e i j e r W S , S c h r n i t zP I , . l e e k e.l1 M
c l i n i c a l t r i a l s o f a n t i b i o t i c p r o p h y l a x i s i n b i l i a r y t r a c t s u r g e r y .B r . l
intravenousroute was significantly superior to the
Surg 1990;77:283-290.
intramuscular
routeof administrationwith OR of 0.66
(p < 0.005).(LEVEL I EVIDENCE)
Lrparoscopic Cholecystectorny
l.
References
A l - G h n a n i e m R , B e n j a m i n I S . P a t e l A C . M e t a - a n a l y s i ss u g g e s t s
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ap
l e r a t i o n sA
. nr.lSurg1982t OrthopedicSurgery
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| . G i l l e s p i eW a n d W a l e n l i a r n C
p . A n t i b i o t i cp r o p h y l a x i sf o r s u r g e r yf b r
2 . S t o n e l - l H , H o o p e rC l A . K o l b L D . e t a l . A n t i b i o t i c p r o p h y l a x i si n
p r o x i r n a l f e n r o r a l a n d o t l r e r c l o s e c ll o n g b o n e h ' a c t L r r e(sC o c h r a n e
g a s t r i c b, i l i a l ya n d c o l o n i cs u r g e r y .A n n S L r r g1 9 7 6 ; 1 8 4 ( 4 ) : 4 4 3 - 4 5 2 .
R e v i e w ) .I n : T h e C o c h r a n eL i b r a l y . l s s u e2 . 2 0 0 - 1 C
. h i c h e s t c rU
. K:
3 . M o r r i s D I - , Y o u n g D , B u r d oDnW , e t a l . P r o s p e c t i v e r a n d o m i z e d t n a l
J o l r nW i l e y & S o n s .L t d .
o { ' s i n g l e d o s e c e f u r o x r n r ea g a i n s tn r e z c l o c i l l i ni n e l e c t i v eg a s t r i c
2 . S o u t h r v e l l - K e e l yR
. l .u s s oR . M a r c h L , c t a l . A n t i b i o t i cp r o p h y l a x i si n
s u r g e r y .. l l - l o s pI n l ' e c tI 9 8 4 : 5 ( 2 ) : 2 0 0 - 2 0 4i n t h e D a t a b a s c o f A b s t r a c t s
h i p f i a c t L r r es u r g e r y :a t n e t a - a n a l v s i sC.l i n O r t h o p ? 0 0 4 . 4 1 9 . 1 7 9 o f R e v i e u , so f E l ' l e c t i v e n e si ns t l r e C o c l r r a n eL i b r a r v .I s s L r el . 1 9 9 9 .
I B4.
O x f b r d : U p d a t eS o l l r v a r e .U p d a t e dQ u a r t e rl 1 ' .
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