See also SSI
1. Target tissue
- need highest concentration at time of incision and until closure.
- IV administration <1 hr before incision, often at induction
prior to incision is best)
- if oral, ensure timing is accurate for type.
- there is still small benefit if dose given interoperatively, but
2. Cover long procedures
- if <2hrs, single dose adequate
- additional doses beyond wound closure = no evidence of benefit.
Antibiotics with short half-lives (<2hrs, eg cefazolin,
re-dosed every 3-4hrs if prolonged
- final dose may still be given just prior to wound closure.
3. When to use prophylaxis
Usually indicated in clean-contaminated and contaminated operations.
- nb, where operation is 'dirty', antibiotics are being used for
treatment, not prevention.
- clean-contaminated biliary surgery when high risk only (eg
diabetics, recent instrumentation in biliary tract); vast majority
lap choles = no benefit.
Any procedure with high rate of bacteraemia in at-risk pts (eg heart
Clean surgery is controversial
- indicated in all foreign body implants when infective complication
- in breast, hernia, RCTs show some evidence for benefit, but
confounded by high risk of infection in control group.
- can argue for use in high-risk pts undergoing relatively clean
surgery (eg gastric)
- or where stress / work delay / reoperation risk would justify it.
4. Administer correctly
If not administered correctly may be harmful instead of beneficial.
- do not use prolonged cover for drains, catheters etc.
- prolongation leads to C dif and increased later noscomial
as well as drug resistance.
2. Appropriately narrow spectrum
- never a quinolone or 3rd gen cefalosporin
3. Cover Staph aureus
- always cover staph for clean / highrisk celan-contaiminated
of biliary / upper GI.
- 1st gen cef good choice / clindamycin when history of anaphylaxis
- vanc where institutional MRSA >20% of all SSIs, god-forbid.
4. Cover most likely microbes to
infect at site.
- cefotetan or ceftriaxone
- nb not actually prophylaxis; cipro if really needed due to
- coliforms, enterococci,
anaerobes in obstruction
- coamoxyclav or cephazolin or ceftriaxone.
- cefotetan or coamoxyclav or cefuroxime and metronidazole.
- coamoxyclav or cephazolin and metronidazole.
- cefotetan or coamoxyclav.
Orthopaedic hip (staph,
- cephazolin or cefamandole or teicoplanin.
- coamoxyclav or flucloxacillin +/- metronidazole.
- ciprofloxacin, ceftazidime.
Multiple studies unequivocally prove that 24hrs with 2nd gen cef
that is required for penetrating abdo trauma.
- even when shock and colonic injury.
Integrated basic surgical sciences.
Barie et al. Surg Clin N Am, 85(2005):1115-35.