Surgical Site Infections (SSI): Impact

• 27 MILLION surgeries per year
• SSIs account for 38% of nosocomial infections in surgical patients
• 67% incicional
• 33% organ/space
• 7.3 extra hospital days, $3152 per SSI

• avoid routine vancomycin
• colorectal surgery
• nonabsorbable PO abx
• enemas, cathartics
• high-risk c-sections: give abx immediately after cord-clamp

Choice of Agent

• Choose abx for most common (not necessarily all) pathogen
• Usually cefazolin
• Colorectal, appendectomy: cefoxitin or cefotetan (both have better anaerobic coverage than cefazolin)
• Avoid 3rd/4th generation cephalosporins (cefotaxime, ceftriaxone, ceftizoxime, cefepime)

Timing vs. Efficacy
 

Time Abx Given	SSI Rate
Early: 2-24 hrs before incision	3.8%
Correct: <2 hrs before incision	0.6%
Periop: 0-3 hrs after incision	1.4%
Postop: 3-24 hrs after incision	3.3%

With 27 million procedures annually, appropriate timing becomes important despite the relatively low percentage differences.

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Timing of Antibiotic Administration

• < 30minutes before surgery
• Extra doses if
• surgery >4 hrs
• major blood loss
• short half-life antibiotic used (e.g., cefazolin)

Cardiac: Prosthetic valve, CABG, pacemakers

• cefazolin 1-2 gm IV or
• cefuroxime 1-2 gm IV or
• vancomycin 1 gm IV

Head and Neck: Incisions through oral or pharyngal mucosa

• clindamycin 600-900 mg IV AND
• gentamicin 1.5 mg/kg IV

Gastrointestinal

• High risk :esophageal, gastroduodenal, biliary tract (age >70y, acute cholecystitis, nonfunctioning gallbladder)
• cefazolin 1-2 gm IV
• Colorectal
• PO
• neomycin + erythromycin base
• IV
• cefoxitin 1-2 gm or
• cefotetan 1-2 gm or
• cefazolin 1-2 gm AND metronidazole 0.5gm

Gynecologic, Obstetric

• Vaginal or abdominal hysterectomy
• cefazolin 1-2 gm IV or
• cefotetan 1-2 gm IV or
• cefoxitin 1 tm IV
• C-section or 2nd trimester abortion, high risk (fever, prolonged ROM, failed vaginal delivery)
• cefazolin 1-2 gm IV after cord clamp
• Abortion, 1st trimester
• penicillin G 2 MU IV or
• doxycycline 300mg PO

Genitourinary (positive urine culture, foley), High risk

• ciprofloxacin 500 mg PO or 400 mg IV

Neurosurgery: Craniotomy

• cefazolin 1-2 gm IV or
• vancomycin 1 gm IV

Orthopedic, Total joint replacement or internal fixation of fractures

• cefazolin 1-2 gm or
• vancomycin 1 gm

Ophthalmic: Procedures that invade the globe

• gentamicin, tobramycin, ciprofloxacin, ofloxacin, or neomycin-gramicidin-polymixin B (multiple drops topically over 2-24 hrs)
• cefazolin 100mg SC

Thoracic (noncardiac)

• cefazolin 1-2 gm IV of
• cefuroxime 1-2 gm IV or
• vancomycin 1gm IV

Vascular

• Arterial surgery involving a prosthesis, the abdominal aorta, or a groin incision
• cefazolin 1-2 gm IV or
• vancomycin 1 gm IV
• Lower extremeity amputation
• cefazolin 1-2 gm IV or
• vancomycin 1 gm IV

Contaminated Surgery

• Ruptured viscus
• cefoxitin 1-2 gm IV q6h or cefotetan 1-2 gm IV q12h +/- gentamicin 1.5 mg/kg IV q8h or
• clindamycin 600 mg IV q8h AND gentamicin 1.5 mg/kg IV q8h
• Traumatic wound
• cefazolin 1-2 gm IV q8h