Slide 1
Antibiotic Prophylaxis in SurgeryAn Adapted Clinical Practice
GuidelineFirst Edition 2013Presented ByDr. Tarek
Altokhais,Consultant, Pedia Surgery & Head of Surgery CPG
Subcommittee, Surgery DepartmentDr. Yasser Amer,CPG General
Coordinator, CPG Committee, QMD09 JAN 20141Antibiotic Prophylaxis
in Surgery
09 JAN 2014Antibiotic Prophylaxis in Surgery2
09 JAN 2014Antibiotic Prophylaxis in Surgery3
Evidence-to-PracticeClinical Care GAP
Current Practice
Best Practice
CPGsDecrease Practice variation Informed clinical decision
makingImplementation ScienceKnowledgeTranslationQuality/
Performance Improvement Patient Safety/ Care & Satisfaction09
JAN 20144Antibiotic Prophylaxis in Surgery
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Clinical Practice Guidelines (CPGs) Program of King Saud
University Hospitals/ Medical CityKSUHs Taskforce Responsible Staff
from:Clinical Practice Guidelines Committee;Quality Management
Department;Clinical Departments (CPGs subcommittees);Shaikh
Abdullah Bahamdan Research Chair for Evidence-Based Health Care and
Knowledge Translation;Top Management & Leadership of College of
Medicine and University Hospitals (Future KSU Medical City)09 JAN
20145Antibiotic Prophylaxis in Surgery
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18 CPGs Subcommittees - - ->> 21Department of Pediatrics
[12+1]Department of Critical Care [2+1]Department of Psychiatry
[2]Department of Community & Family Medicine (Family Medicine
Unit) FMC [1+6]Department of Pharmacy [3+16]Department of Emergency
Medicine [+11] Department of Medicine [8]Department of Orthopedic
Surgery [1+1]Department of Otorhinolaryngology [1]Department of
Ophthalmology [1]Department of Cardiac Sciences (Cardiology Cardiac
Surgery) KFCC [3]Department of Surgery [2] Department of Obstetrics
& Gynecology [1+3]Department of Dermatology [1]Department of
Anesthesiology [1]Department of Laboratory Medicine & Pathology
[+15]Department of Radiology [+3]Department of Nursing
[1]NewDepartment of Occupational Health & Safety [2]Department
of Rehabilitation Medicine [+1]Health Education Center [+3]
09 JAN 20146Antibiotic Prophylaxis in Surgery
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Adapted from Source CPGs
CPG for Antimicrobial Prophylaxis in SurgeryDeveloped byAmerican
Society of Health System Pharmacists, Infectious Diseases Society
of America, Society for Healthcare Epidemiology of America and
Surgical Infection Society. 1999 (updated 2013)09 JAN
2014Antibiotic Prophylaxis in Surgery7
7
8
Hospital-Wide Policy & Procedure for Hospital CPGs
AdaptationSEPT 2013NEW
9
CPG objective
To provide practitioners with a standardized approach to the
rational, safe, and effective use of antimicrobial agents for the
prevention of surgical-site infections (SSIs) based on currently
available clinical evidence and emerging issues
09 JAN 201410Antibiotic Prophylaxis in Surgery
CPG Authorship group (CPG Champions)Adaptation working
groupReview group
Dr. Danny Rabah, Consultant UrologyDr. Badr Aljabri, Consultant
Vascular SurgDr. Wassim Hajar, Consultant Thoracic SurgDr. Mohammad
Qattan, Consultant, Plastic SurgDr. Yaser Alfakey, Consultant
OphthalmologyDr. Khalid Alsaleh, Consultant Orthopedic Surg/Spine,
Head Ortho CPGDr. Neama Meriki, Consultant OBGYN, MFM, Head OBGYN
CPG
09 JAN 2014Antibiotic Prophylaxis in Surgery11Dr. Tariq
Altokhais, Head CPG Surg SubC, Consult. Pedia SurgDr. Abdelmonim
El-Tarifi, Consult. UrologyDr. Khalid Alawi, Consult. SurgDr.
Yasser Amer, CPGC, QMDSupport group: Dorothy Villena, CPGCSheila
Rivera, CPGC
Search and Selection of source CPGs
09 JAN 201412Antibiotic Prophylaxis in Surgery8 CPGs internet
databases searched27 source CPGs retrieved25 CPGs excluded based on
HQ and selection criteria & 2 CPGs included for further
appraisal by AGREE II Instrument.
Health Questions (PIPOH)
P: Patient/target population:Adult (age 19 years or older) and
pediatric(age 118 years) patients undergoing
surgery.Disease/Condition:Postoperative infections (i.e., initial
infection following surgical procedures) without any other
co-morbidities
Note: These CPGs do not specifically address newborn (premature
and full-term) infants.While the CPGs do not address all concerns
for patients with renal or hepatic dysfunction, antimicrobial
prophylaxis often does not need to be modified for these patients
when given as a single preoperative dose before surgical
incision.
09 JAN 201413Antibiotic Prophylaxis in Surgery
PIPOHI: Intervention and practices considered and CPG Category:
Assessment of Therapeutic Effectiveness and Prevention.Primary
antimicrobial prophylaxis (i.e., prevention of an initial
infection) for surgical procedures, including antibiotic choice,
dose, and dosage regimen.
09 JAN 201414Antibiotic Prophylaxis in Surgery
P: Professionals and Intended Users (target users/ stakeholders)
and Clinical Specialty:Physicians, Nurses, Allied Health Personnel
and Clinical Pharmacists in Departments of Surgery and all Surgical
subspecialties (Colon and Rectal Surgery, Gastroenterology, Plastic
Surgery, Urology, Thoracic Surgery, Vascular Surgery and
Neurological Surgery), Obstetrics and Gynecology, Orthopedic
Surgery, Ophthalmology and Pharmacology.
09 JAN 201415Antibiotic Prophylaxis in SurgeryPIPOH
O: Major Outcomes Considered Postoperative infection rates
Postoperative Morbidity and Mortality rates Duration and cost of
health careAdverse effects
09 JAN 201416Antibiotic Prophylaxis in SurgeryPIPOH
King Saud University Hospitals (KKUH/ KAUH) or KSU Medical City
Tertiary/ Governmental/ University Hospital Departments and clinics
(mentioned in the clinical specialty)
09 JAN 201417Antibiotic Prophylaxis in SurgeryPIPOH
Note: These CPGs reflect recommendations for peri-operative
antibiotic prophylaxis to prevent SSIs and do not apply for
prevention of opportunistic infections in immunosuppressed
transplantation patients (e.g. for antifungal or antiviral
medications).
09 JAN 2014Antibiotic Prophylaxis in Surgery18
Inclusion / Exclusion source CPGs Selection Criteria
1) Methods of Development; Evidence-Based CPGs: (Detailed
Methodology of Development Documented; link Recommendations with
Evidence; link to Systematic Reviews) rather than Consensus-based
CPGs (Expert opinion)2) Author(s) Organization (CPG development
group) from CPGs Database & Specialized Society (clinical
specialty) NOT single authors.3) Country: international NOT
national CPGs.4) Date of Publication: range of year of
publications: last 3 years(2011 2013) NOT older.5) Language:
English CPGs only6) Status: only Original source CPG (de novo
developed) NOT adapted CPGs
09 JAN 201419Antibiotic Prophylaxis in Surgery
AGREE II Domain Scores for the 2 source CPGs ASHP 2013 &
ICSI 2012
09 JAN 201420Antibiotic Prophylaxis in SurgeryAGREE II
DOMAINSASHP 2013 CPG (%)ICSI 2012 CPG (%)D1: Scope & Purpose80
72 D2: Stakeholder Involvement94 61 D3: Rigour of Development86 69
D4: Clarity & Presentation94 69D5: Applicability42 52D6:
Editorial Independence83 79Overall AssessmentYesNoThis table uses
the AGREE II Domain Score Colour Coding proposed by Dr. Lubna
Alansary(< 40% red - > 41 70% yellow - > 71 % green)
Evidence-Based Recommendations09 JAN 2014Antibiotic Prophylaxis
in Surgery21
Accreditation Canada International
09 JAN 201422Antibiotic Prophylaxis in Surgery
Current ROP
09 JAN 201423Antibiotic Prophylaxis in SurgeryWhen to START
?When to STOP ?2 Questions !!
Preoperative-dose Timing
Optimal time for administration of pre-operative antibiotics
first dose is within 60 minutes before surgical incision (within
120 minutes for Vancomycin or Fluoroquinolones due to prolonged
infusion times).
09 JAN 201424Antibiotic Prophylaxis in Surgery
Dosing & Re-dosingSingle dose prophylaxis is usually
sufficient, the duration of prophylaxis for most procedures should
be less than 24 hours.The shortest effective duration of
antimicrobial administration for preventing SSI is unknown;
however, evidence is mounting that postoperative antimicrobial
administration is not necessary for most procedures.Re-dosing may
be required if surgery duration is 2 half lives of chosen
antimicrobial or if blood loss is excessive.
09 JAN 201425Antibiotic Prophylaxis in Surgery
Dosing & Re-dosing (contd)If an agent with a short half-life
is used:-(e.g. cefazolin, cefoxitin) it should be re-administered
if the procedure duration exceeds the recommended redosing
interval.Re-administration:- warranted If prolonged or excessive
bleeding or if other factors shorten the half-life of the
prophylactic agent (e.g. extensive burns).Not be warranted for
patients in whom the half-life of the agent may be prolonged (e.g.
renal insufficiency or failure).
09 JAN 201426Antibiotic Prophylaxis in Surgery
Route of administrationIV route typically preferred due to
rapid, reliable, and predictable tissue and serum
concentrations
09 JAN 201427Antibiotic Prophylaxis in Surgery
Select Antimicrobial based onAgent active against most common
pathogens for given procedure but with as narrow spectrum as
possible.Safety profile of drug.Patient allergies and
co-morbidities.
09 JAN 2014Antibiotic Prophylaxis in Surgery28
Rating Scheme for the Strength/ Levels of the Evidence
09 JAN 2014Antibiotic Prophylaxis in Surgery29Level of
EvidenceType of StudyLevel IEvidence from large, well conducted,
randomized, controlled clinical trials or a meta-analysisLevel
IIEvidence from small, well conducted, randomized, controlled
clinical trialsLevel IIIEvidence from well conducted cohort
studiesLevel IVEvidence from well conducted casecontrol
studiesLevel VEvidence from uncontrolled studies that were not well
conductedLevel VIConflicting evidence that tends to favor the
recommendationLevel VIIExpert opinion or data extrapolated from
evidence for general principles and other procedures
Rating Scheme for the Strength/ Levels of RecommendationsGrade
of R. (GoR)Level of E. (LoE)Category ALevels I-IIICategory BLevels
IV-VICategory CLevel VII
EVIDENCE-BASED RECOMMENDATIONSThoracic Procedures
09 JAN 201430Antibiotic Prophylaxis in SurgeryRecommended Agents
& DosageCefazolin 2 g*Ampicillin-sulbactam 3 g**Alternative
agents in Patients with B-Lactam AllergyClindamycin 900
mgVancomycin 15 mg/kgStrength of Evidence (accord. To procedure)A,
C
Gatsrodudenal Procedures
09 JAN 201431Antibiotic Prophylaxis in SurgeryRecommended Agents
& DosageCefazolin 2 gAlternative agents in Patients with
B-Lactam AllergyClindamycin 900 mg orVancomycin 15 mg/kg +
aminoglycoside orAztreonam 2 g orFluoroquinoloneStrength of
Evidence (accord. To procedure)A
Biliary tract - Open Procedure
09 JAN 201432Antibiotic Prophylaxis in SurgeryRecommended Agents
& DosageCefazolin 2 g*Cefoxitin 2 gCefotetan 2 gCeftriaxone 2
gAmpicillin-sulbactam 3 g**Alternative agents in Patients with
B-Lactam AllergyClindamycin 900 mg orVancomycin 15 mg/kg +
aminoglycoside*** or Aztreonam 2 g or
fluoroquinolone****Metronidazole 500 mg + aminoglycoside*** or
fluoroquinolone****Strength of Evidence (accord. To procedure)A
Biliary tract - laparoscopic procedure
09 JAN 201433Antibiotic Prophylaxis in SurgeryRecommended Agents
& DosageElective, low-risk: noneElective, high-risk:Cefazolin 2
g*Cefoxitin 2 gCefotetan 2 gCeftriaxone 2 gAmpicillin-sulbactam 3
g**Alternative agents in Patients with B-Lactam AllergyElective,
low-risk: noneElective, high-risk:Clindamycin 900 mg or Vancomycin
15 mg/kg + aminoglycoside*** or Aztreonam 2 g or
fluoroquinolone****Metronidazole 500 mg + aminoglycoside*** or
fluoroquinolone****Strength of Evidence (accord. To procedure)A
Appendectomy for uncomplicated appendicitis
09 JAN 201434Antibiotic Prophylaxis in SurgeryRecommended Agents
& DosageCefoxitin 2 gCefotetan 2 gCefazolin 2 g* +
metronidazole Alternative agents in Patients with B-Lactam
AllergyClindamycin 900 mg or vancomycin + aminoglycoside*** or
aztreonam 2 g or fluoroquinolone****Metronidazole 500 mg +
aminoglycoside*** or fluoroquinolone****Strength of Evidence
(accord. To procedure)A
Appendectomy for uncomplicated appendicitis
09 JAN 201435Antibiotic Prophylaxis in SurgeryRecommended Agents
& DosageCefoxitin 2 gCefotetan 2 gCefazolin 2 g* +
metronidazole Alternative agents in Patients with B-Lactam
AllergyClindamycin 900 mg or vancomycin + aminoglycoside*** or
aztreonam 2 g or fluoroquinolone****Metronidazole 500 mg +
aminoglycoside*** or fluoroquinolone****Strength of Evidence
(accord. To procedure)A
Vascular Procedures
09 JAN 201436Antibiotic Prophylaxis in SurgeryRecommended Agents
& DosageCefazolin 2 g*Alternative agents in Patients with
B-Lactam AllergyClindamycin 900 mgVancomycin 15 mg/kgStrength of
Evidence (accord. To procedure)A
Urologic procedure
09 JAN 201437Antibiotic Prophylaxis in SurgeryRecommended Agents
& DosageLower tract instrumentation with risk factors for
infection:-Fluoroquinolone (e.g. ciprofloxacin
400mg)Trimethoprim-sulfamethoxazoleCefazolin 2 g*Clean without
entry into urinary tract:-Cefazolin 2 g*; addition of single dose
of aminoglycoside may be recommended for placement of prosthetic
materialIf involving implanted prosthesis:Cefazolin 2 g* with or
without aminoglycosideCefazolin as dosed above with or without
aztreonam 2gAmpicillin-sulbactam 3 g**Clean with entry into urinary
tract:-Cefazolin 2 g*; addition of single dose of aminoglycoside
may be recommended for placement of prosthetic
materialClean-contaminated:-Cefazolin 2 g*+ metronidazole 500
mgCefoxitin 2 gLoEA
Urologic procedures
09 JAN 201438Antibiotic Prophylaxis in SurgeryAlternative agents
in Patients with B-Lactam AllergyLower tract instrumentation with
risk factors for infection:Aminoglycoside*** with or without
clindamycin 900 mgClean without entry into urinary
tract:Clindamycin 900 mgVancomycin 15 mg/kgIf involving implanted
prosthesis, consider adding aminoglycoside*** or aztreonam 2 g to
either regimenClean with entry into urinary
tract:Fluoroquinolone****Aminoglycoside*** with or without
clindamycin 900
mgClean-contaminated:Fluoroquinolone****Aminoglycoside*** +
metronidazole 500 mg or clindamycin 900 mgLoEA
Orthopedic procedures
09 JAN 201439Antibiotic Prophylaxis in SurgeryRecommended Agents
& DosageClean operations involving hand, knee, or foot and not
involving implantation of foreign materials:-None.
Spinal procedures with and without instrumentation, hip fracture
repair, implantation of internal fixation devices, total joint
replacement: Cefazolin 2 g*LoEC, A
Orthopedic procedures
09 JAN 201440Antibiotic Prophylaxis in SurgeryAlternative agents
in Patients with B-Lactam AllergyClean operations involving hand,
knee, or foot and not involving implantation of foreign
materials:NoneSpinal procedures with and without instrumentation,
hip fracture repair, implantation of internal fixation devices,
total joint replacement:Clindamycin 900 mgVancomycin 15
mg/kgLoEA
Plastic surgery -Clean with risk factors or
clean-contaminated
09 JAN 201441Antibiotic Prophylaxis in SurgeryRecommended Agents
& DosageCefazolin 2 g*Ampicillin-sulbactam 3 g**Alternative
agents in Patients with B-Lactam AllergyClindamycin 900
mgVancomycin 15 mg/kgStrength of Evidence (accord. To
procedure)C
Excluded recommendationsThe panel decided to exclude the
recommendations related to:-Cardiac Surgery Procedures (Separate
CPG)Organ Transplantation Procedures (not currently practiced in
KSUMC)09 JAN 2014Antibiotic Prophylaxis in Surgery42
Implementation Strategies & ToolsTOOLS/ Resources:
STRATEGIESQuick Reference Guides (Key
Recommendations)ProtocolStanding Orders: Paper OR CPOE: Integration
into New HIS (e-SIHI) as CPOE (Power Plans or Power Charts)Patient
Education Guide (in Ar/ Eng)Clinical Audit tools/ Performance
measuresDissemination Process (print/ e-/website)Local Clinical
Champions.Awareness raising/ training activities.Networking and
linking with existing projects.Patients as champions for
change.Regular M & E.09 JAN 2014Antibiotic Prophylaxis in
Surgery43
Thank YOU all for listening 09 JAN 2014Antibiotic Prophylaxis in
Surgery44