Escolha do antibiético ‘+ 0s antibidticos escolhidos devem ser efetivos contra os patégenos esperados para aquele sitio: + Devem-se utilizar antibidticos de espectro de aco reduzido; ‘= Pacientes colonizados com bactérias multirsistentes (MRSA, MRSE) ou ambientes com alta prevaléncia de bactérias multiresistentes e em procedimentos de alto risco (cardiacos, neurocirurgia, prétese vascular: = Emcaso de pacientes portadores de bacterias multirresistentes devera ser solcitada avaliaczo prévia do SCIH quanto necessidade de antibioticoprofilaxiacirdrgica especial; = Antibicticoprofilaxia com DROGAS APROPRIADAS (ex: vancomicina); = Descolonizagso prévia (mupirocina nasal) + Pacientes alérgicos a beta-lactéimicos: = Desenvolveram urticéria, angioedema, broncoespasmo, hipotenséo, aritmia, edema laringeo, necrélise epidérmica tdxica ou febre por droga apés uso de medicamentos dessa classe; = Clindamicina é a substituta usual; = Vancomicina deve ser usada em situagSes especiicas. + Pacientes alérgicos a sulfemetoxazoi/trimetoprim devem usar ciprofloxacim; la por metronidazol se houver + Em cirurgias abdominais, a clindamicina pode ser substit impedimento do uso do primeiro antibistico. {rag por via venosa (exceto em recomendacées para procedimentos especificos); + AadministracSo do antibiético deve estar completa no periodo preferencial de até 30 min antes da inciséo cindirgica. Observacéo: = Observar 0 tempo recomendado de infusio de cada antibidtico; -. Vancomicina, quando indicada, deve ser infundida 60 2 120 min antes da inci min antes da inciséo cirurgica. 0 da Observacio: = Observar 0 tempo recomendado de infusio de cada antibiotico; = Vancomicina, quando indicada, deve ser infundida 60 @ 120 min antes da incisao da pele em infusio de eproximadamente 1 hora (risco de sindrome do homem vermetho) + A dose utilizada deve ser a mesma empregada para o tratamenta de infeccio; + Sehouver necessidade de utilizar torniquete na cirurgia, a dose do antibidtico deve estar completamente infundida antes da insuflaggo do mesmo. 028 Amibicticoprofinds Grigics EEEss | SECTION ll Perioperative Management no benefit compared with placebo for prevention of SSIs (OR, (0.68: 959% Cl, 0.24-1.91), major infection, or distant infection Anuibiotic prophylaxis is indicated for high-risk biliary surgery; high risk is conferred by age older than 70 yeats, diabetes mellitus, ora recenty instrumented biliary tract (e.. biliary stend. lective colon surgery is a clean-contaminaced procedure in which preparatory practices are in evolution,’”="” although the evidence of benefit of systemic antibiotic prophylaxis is unequivo- cal. Antibiotic bowel preparation, standardized in the 1970s by the oral administration of nonabsorbable neomycin and erythro- ‘mycin base in addition to mechanical cleansing, reduced the risk of SSIs to the present rate of approximately 15%. However, mechanical bowel preparation and preoperave oral anibtoucs are omitted increasingly according, to the belief that there is no additive benefc beyond parenteral antibiocic prophylaxis and thar the risk of anastomotic dehiscence and C_ diffctl-associated discase (CDAD) may be increased. Current SCIP guidelines for antibiotic prophylaxis of elective colon surgery give equal ing to oral prophylaxis alone, parenteral prophylaxis alone, or the combination (See Table 11-2), despite the fact that two meta- analyses (that asked different questions) are in conflict about the efficacy of oral prophylaxis for colorectal surgery. Song and Glenny" have compared oral antbioties alone with oral or sys- temic antibiotic prophylaxis (five trials) and found a higher SSI zare with oral prophylaxis alone (OR, 3.34; 95% Cl, 1.66-6.72) In contrast, Lewis ™ performed a metacanalysis of 13 randomized tials of systemic versus combined oral and systemic prophylaxis and showed significant benefit for the combined approach (RR, 0515 95% CI, 0.24-0.78). Anuibiocic proohulaxis of dean surverv is controversial, When bone is incised (eg. craniotomy, sternotomy) or a prosthesis 1 insorted, antibiotic prophylaxis is gencrally indicated. Some con- tuoversy persists with clean surgery of solt tissues (eg., breast, hhcrnia). Meta-analysis of randomized controlled trials has shown, some benef of antibiotic prophylaxis of breast cancer surgery without immediate reconstruction” but no decrease of SSI rare for groin hernia surgery” even when nonabsorbable mesh is implanted. ‘Arterial reconstruction with a prosthetic praft isan example of clean surgery in which the risk of infection is high, especially infa-inguinal. In a meta-analysis!” of 23 randomized controlled tials of prophylactic systemic antibiotics for peripheral arterial reconstruction (lable 11-6), it was found that prophylactic sys- temic antibiotics reduced the risk of SSI ately 75% ‘Sd of ani gal coe by dour 69 The war ao bene to prophylaxis for longer than 24 hours of antibiotic bonding to the graft matetial itself or preoperative bathing with an antiseptic agent compared with unmedicated bathing, Four principles guide the administration of an antimicrobial agent for prophylaxis" 1. Safety 2. An appropriate narrow spectrum of coverage of relevant Fina scent ae Bluse SP aceon (because of the possible induction of resistance with heavy ux) Administration within 1 hour before surgery and for a defined brief period thereafter (no longer than 24 hours, 48 hours for cardiac surgery, and ideally a single dose) According to these principles, quinolones or carbapenems are undesirable agents for surgical prophylaxis, although prophylaxis with ertapenem and quinolone has been endorsed by the SCIP 3B eee Un ace ee er foeueutie No. OF TRIALS ‘opps INTERVENTION RATIO 95% cl Seri abo: polio Suga te inetion > ours pps Ey galt infection 0 12 om vox om-1s8 onnss Fifampcin bonding of polyester ras Graft nection (tron) Gra incon (2 years) Suction wound drainage, goin ‘Surgical site infetion Pracperatie antiseptic bath ‘arial sit infocon Init surgical echrique Surgical site infection 08 105 o-1a8 096-240 om omt6 om om os oata7e From Stowart A, Byers PS, Fainshav J Prevention of infection in artoral reconstruction. Cochrane Daiabaso Syst Rev 3:CDoWs073, 2008. for prophylaxis of colon surgery (the lacter with metronidazole for penicilinallergic patients; see Table 11-2). ‘Most SSIs are caused by gram-positive cocci, so prophylaxis should be divecd primarily arainststanhvlococei for clean cas dnd for high-risk: clean-contaminated, clective biliary and gastric surgery cascs. A first-generation cephalosporin is preferred in almost all cizcumstaness (lable 11-7), with clindamycin used for penicillin-allergi patients. If gram-negative or anaerobic cover age is required, a second-generation cephalosporin or the combi- nation of a frst-gencration agent plus metronidazole is the first-choice repimen of most experts. Vancomycin prophylaxis is genetally appropriate only in insicutions in which the incidence ‘of MRSA infection is high (20% of all SSIs caused by MRSA). “The optimal time to give parenteral antibiotic prophylaxis is seithin | hout before incision." Antibiotics given sooner are ineF- fective, as are agents given after the incision is closed. A 2001, audit of prescribing practices in the United States indicated that ‘only 56% of patients who recived prophylactic antibiotics did so >within 1 hour before the ski incisions timeliness was documented in only 76% of cases in a 2005 audit in Department of Veterans Affairs hospitals" Mosc inappropriately timed first doses of pro- phylactic antibiotic occur too carly: changing institutional pro ‘cscs to administer the drug in the operating room can improve ‘compliance with best practices. Antibiotics with short halflives (ti2<2 hours: eg. ceftzolin or cefoxitin) should be redosed every the operation is prolonged or n associated with pro- longed prophylaxis"'°” as has the emergence of SSI caused by MRSA”