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Prevention of Surgical Infections

By

Paul K. Mohabir

, MD, Stanford University School of Medicine;


André V Coombs

, MBBS, Texas Tech University Health Sciences Center

Last full review/revision Nov 2020| Content last modified Nov 2020
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Topic Resources

Most surgical procedures do not require prophylactic or postoperative antibiotics. However, certain patient-related and procedure-related factors alter the risk/benefit ratio in favor of prophylactic use.

Patient-related risk factors suggesting need for antibiotics include

Procedures with higher risk involve areas where bacterial seeding is likely:

  • Mouth

  • Gastrointestinal tract

  • Respiratory tract

  • Genitourinary tract

In so-called clean (likely to be sterile) procedures, prophylaxis generally is beneficial only when prosthetic material or devices are being inserted or when the consequence of infection is known to be serious (eg, mediastinitis after coronary artery bypass grafting).

Choice of antibiotics is based on the Surgical Care Improvement Project (SCIP) guidelines (see Perioperative Management). There is strong evidence that standardizing antibiotic choices and adhering to SCIP protocols or another standardized and validated protocol reduce the risk of surgical infection. Some regions of the US that followed SCIP guidelines were able to decrease surgical site infections by 25% from 2006 to 2010. Drug choice is based on the drug's activity against the bacteria most likely to contaminate the wound during the specific procedure (see Table: Antibiotic Regimens for Certain Surgical Procedures). The antibiotic is given within 1 hour before the surgical incision (2 hours for vancomycin and fluoroquinolones). Antibiotics may be given orally or IV, depending on the procedure. For most cephalosporins, another dose is given if the procedure lasts > 4 hours. For clean procedures, no additional doses are needed, but, for other cases, it is unclear whether additional doses are beneficial. Antibiotics are continued > 24 hours postoperatively only when an active infection is detected during surgery; antibiotics are then considered treatment, not prophylaxis.

The Center for Disease Control has published guidelines for prevention of surgical site infections that address topical and nondrug antiseptic measures (eg, bathing, sealants, irrigation, prophylaxis for prosthetic devices).

Table
icon

Antibiotic Regimens for Certain Surgical Procedures

Surgical Procedure

Approved Antibiotics

Cardiac or vascular

Cefazolin, cefuroxime, or vancomycin

If beta-lactam allergy: Vancomycin or clindamycin

Hip/knee arthroplasty

Cefazolin,cefuroxime, or vancomycin

If beta-lactam allergy: Vancomycin or clindamycin

Colon

Cefotetan, cefoxitin, ampicillin/sulbactam, or ertapenem or cefazolin plus metronidazole or cefuroxime plus metronidazole or ceftriaxone plus metronidazole

If beta-lactam allergy: Clindamycin plus gentamicin or clindamycin plus ciprofloxacin or clindamycin plus aztreonam or metronidazole plus gentamicin or metronidazole plus ciprofloxacin

Hysterectomy

Cefotetan, cefazolin, cefoxitin, cefuroxime, or ampicillin/sulbactam

If beta-lactam allergy: Clindamycin plus gentamicin or clindamycin plus ciprofloxacin or clindamycin plus aztreonam or metronidazole plus gentamicin or metronidazole plus ciprofloxacin or vancomycin plus aminoglycoside or vancomycin plus aztreonam or vancomycin plus quinolone

More Information

The following English-language resources may be useful. Please note that The Manual is not responsible for the content of these resources.

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NOTE: This is the Professional Version. CONSUMERS: Click here for the Consumer Version
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