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Antimicrobial Prophylaxis in Surgery

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Table 4. Antimicrobial Recommendations for Surgical Prophylaxis Stratified by Type of Procedure (cont'd) Factors that indicate a high risk of infectious complications in laparoscopic cholecystectomy include emergency procedures, diabetes, long procedure duration, intraoperative gallbladder rupture, age >70 years, conversion from laparoscopic to open cholecystectomy, higher American Society of Anethesiologists (ASA) classification, episode of colic within 30 days prior to procedure, reintervention in <1 month for noninfectious complication, acute cholecystitis, bile spillage, jaundice, pregnancy, nonfunctioning gallbladder, immunosuppression, and insertion of prosthetic device. Because a number of these risk factors are not possible to determine prior to surgical intervention, it may be reasonable to give a single dose of antimicrobial prophylaxis to all patients undergoing laparoscopic cholecystectomy. i For procedures in which pathogens other than staphylococci and streptococci are likely, an additional agent with activity against those pathogens could be considered. For example, if there are surveillance data showing that gram-negative organisms are a cause of surgical site infections for the procedure, practitioners should consider combining clindamycin or vancomycin with another agent (cefazolin if the patient is not β-lactam allergic; aztreonam, gentamicin, or single-dose fluoroquinolone if the patient is β-lactam allergic). j For most patients, a mechanical bowel preparation combined with oral neomycin sulfate plus oral erythromycin base, or with oral neomycin sulfate plus oral metronidazole should be given in addition to intravenous prophylaxis. The oral antibiotics should be given as three doses over approximately 10 hours the afternoon and evening before the operation and after the mechanical bowel prep. k Where there is increasing resistance to 1st and 2nd generation cephalosporins among gram negative isolates from SSIs, a single dose of ceftriaxone plus metronidazole may be preferred over routine use of carbapenems. l Prophylaxis should be considered for patients at highest risk for postoperative gastroduodenal infections, such as those with increased gastric pH (eg, those receiving histamine H2-receptor antagonists or proton-pump inhibitors), gastroduodenal perforation, decreased gastric motility, gastric outlet obstruction, gastric bleeding, morbid obesity, or cancer. Antimicrobial prophylaxis may not be needed when the lumen of the intestinal tract is not entered. m Prostheses excludes tympanostomy tubes. n The necessity of continuing topical antimicrobials postoperatively has not been established. o Procedures involving internal fixation devices (eg, nails, screws, plates, wires). p These guidelines reflect recommendations for perioperative antibiotic prophylaxis to prevent surgical site infections and do not provide recommendations for prevention of opportunistic infections in immunosuppressed transplantation patients (eg, for antifungal or antiviral medications). q Patients who have left ventricular assist devices as a bridge and who are chronically infected might also benefit from coverage of the infecting microorganism. r The prophylactic regimen may need to be modified to provide coverage against any potential pathogens, including gram-negative (eg, P. aeruginosa) or fungal organisms, isolated from the donor lung or the recipient before transplantation. Patients undergoing lung transplantation with negative pretransplantation cultures should receive antimicrobial prophylaxis as appropriate for other types of cardiothoracic surgeries. Patients undergoing lung transplantation for cystic fibrosis should receive 7–14 days of treatment with antimicrobials selected according to pretransplantation culture and susceptibility results. This treatment may include additional antibacterial agents or antifungal agents. s The prophylactic regimen may need to be modified to provide coverage against any potential pathogens, including vancomycin-resistant enterococci, isolated from the recipient before transplantation. t Includes transrectal prostate biopsy. u The addition of a single dose of an aminoglycoside may be recommended for placement of prosthetic material (eg, penile prosthesis). v Prophylaxis is not routinely indicated for brachiocephalic procedures. Although there are no data in support, patients undergoing brachiocephalic procedures involving vascular prostheses or patch implantation (eg, carotid endarterectomy) may benefit from prophylaxis. h 13

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