Table 6-6 Prophylactic Use of Antibiotics

Site Cardiovascular surgery Gastroduodenal area Biliary tract with active infection (e.g., cholecystitis) Colorectal surgery, obstructed small bowel Head and neck Neurosurgical procedures Orthopedic surgery Breast, hernia

Antibiotic Cefazolin, cefuroxime Cefazolin, cefotetan, cefoxitin, ampicillin-sulbactam Ampicillin-sulbactam, ticarcillin-clavulanate, piperacillin-tazobactam Cefazolin plus metronidazole, ertapenem, ticarcillinclavulanate, piperacillin-tazobactam Cefazolin Cefazolin Cefazolin, ceftriaxone Cefazolin

Alternative (e.g., penicillin all Vancomycin Fluoroquinolone

Fluoroquinolone plus clindamy metronidazole

Gentamicin or fluoroquinolone clindamycin or metronidazole Vancomycin Vancomycin Vancomycin

Aminoglycoside plus clindamy

Table 12-11 -- Antimicrobial Prophylaxis for Surgery NATURE OF OPERATION COMMON PATHOGENS Cardiac Staphylococcus aureus, S. epidermidis RECOMMENDED ANTIMICROBIALS cefazolin or cefuroxime OR vancomycin[3] Gastrointestinal Esophageal, gastroduodenal Biliary tract Colorectal Enteric gram-negative bacilli, gram-positive cocci Enteric gram-negative bacilli, enterococci, clostridia Enteric gram-negative bacilli, anaerobes, enterococci High risk[4] only: cefazolin[7] High risk[5] only: cefazolin[7] Oral: neomycin + erythromycin base[6] OR metronidazole[6] Parenteral: cefoxitin[7] OR cefazolin + metronidazole Appendectomy, nonperforated[8] Enteric gram-negative bacilli, anaerobes, enterococci cefoxitin[7] OR cefazolin + metronidazole[7] OR ampicillin/sulbactam Genitourinary Gynecologic and Obstetric Vaginal, abdominal, or laparoscopic hysterectomy Cesarean section Enteric gram-negative bacilli, anaerobes, Gp B strep, enterococci same as for hysterectomy cefoxitin[7] or cefazolin[7] OR ampicillin/sulbactam cefazolin[7]
[7] [7]

ADULT DO BEFORE S 1-2 g IV[2] 1.5 g IV[2] 1 g IV 1-2 g IV 1-2 g IV

1-2 g IV 1-2 g IV 0.5 g IV 3 g IV 1-2 g IV 1-2 g IV 0.5 g IV 3 g IV

OR ampicillin/sulbactam

Enteric gram-negative bacilli, enterococci

High risk only: ciprofloxacin

[9]

500 mg PO o IV 1-2 g IV 3 g IV

1-2 g IV afte

NATURE OF OPERATION COMMON PATHOGENS Abortion same as for hysterectomy

RECOMMENDED ANTIMICROBIALS

ADULT DO BEFORE S clamping

First trimester, high risk[10]: aqueous penicillin 2 mill units I G OR doxycycline Second trimester: cefazolin[7] 1-2 g IV

300 mg PO[1

Head and Neck Surgery Incisions through oral or pharyngeal mucosa Anaerobes, enteric gramnegative bacilli, S. aureus clindamycin + gentamicin OR cefazolin Neurosurgery Ophthalmic S. aureus, S. epidermidis S. epidermidis, S. aureus, streptococci, enteric gramnegative bacilli, Pseudomonas spp. cefazolin OR vancomycin
[3]

600-900 mg 1-2 g IV 1-2 g IV 1 g IV

1.5 mg/kg IV

gentamicin, tobramycin, ciprofloxacin, multiple dro gatifloxacin, levofloxacin, moxifloxacin, over ofloxacin, or neomycin-gramicidin-polymyxin 2 to 24 hour B cefazolin

100 mg subconjunct 1-2 g IV 1.5 g IV

[3],[12]

Orthopedic

S. aureus, S. epidermidis

cefazolin[12] or cefuroxime[12] OR vancomycin

1 g IV 1-2 g IV 1.5 g IV 1 g IV 1-2 g IV 1 g IV 1-2 g IV

Thoracic (Non-Cardiac)

S. aureus, S. epidermidis, streptococci, enteric gramnegative bacilli

cefazolin or cefuroxime OR vancomycin[3] cefazolin OR vancomycin[3] cefazolin OR vancomycin

[3]

Vascular Arterial surgery involving a prosthesis, the abdominal aorta, or a groin incision Lower extremity amputation for ischemia S. aureus, S. epidermidis, enteric gram-negative bacilli S. aureus, S. epidermidis, enteric gram-negative bacilli, clostridia

1 g IV

Table 12-12 -- Suggested Initial Dose and Time Until Redosing of Antimicrobial Drugs Commonly Used for Surgical Prophylaxis

RENAL HALF-LIFE (hr)

Patients With EndPatients With Stage RECOMMENDED RECOM Normal Renal Renal INFUSION STANDARD WEIGHT-BASED DOSE REDOSI ANTIMICROBIAL Function Disease DURATION DOSE RECOMMENDATION[*] INTERV Aztreonam Ciprofloxacin Cefazolin Cefuroxime Cefamandole Cefoxitin Cefotetan Clindamycin 1.5-2 3.5-5 1.2-2.5 1-2 0.5-2.1 0.5-1.1 2.8-4.6 2-5.1 6 5-9 40-70 15-22 12.318[] 6.5-23 13-25 3-5 min,[] 20-60 min[] 60 min 3-5 min,[] 15-60 min[] 3-5 min,[] 15-60 min[] 3-5 min,[] 15-60 min[] 3-5 min,[] 15-60 min[] 3-5 min,[] 20-60 min[] 1-2 g IV 400 mg IV 1-2 g IV 1.5 g IV 1 g IV 1-2 g IV 1-2 g IV 600-900 mg IV 20-40 mg/kg 20-40 mg/kg 2 g maximum (adults) 400 mg 3-5 4-10

20-30 mg/kg (if <80 kg, use 2-5 1 g; if >80 kg, use 2 g) 50 mg/kg 3-4 3-4 2-3 3-6

3.5-5.0[] 10-60 min (do not exceed 30 mg/min) 5-6 NA

If <10 kg, use at least 37.5 3-6 mg; if >10 kg, use 3-6 mg/kg NA

Erythromycin base[**] 0.8-3

1 g PO 19, 18, 9-13 mg/kg and 9 hr before surgery 1.5 mg/kg IV[#] [#]

Gentamicin Neomycin[**]

2-3

50-70

30-60 min

3-6 NA

2-3 (3% 12-24 or NA absorbed under longer normal gastrointestinal conditions) 6-14 7-21; no 30-60 min change

1 g PO 19, 18, 20 mg/kg and 9 hr before surgery 0.5-1 g IV 15-mg/kg initial dose (adult); 7.5 mg/kg on subsequent doses

Metronidazole

6-8

44.11 g over 60-min 1 g IV 10-15 mg/kg (adult) 6-12 406.4 period (use longer (CCR infusion time if dose <10 >1 g) mL/min) Adapted from Bratzler DW, Honck PM: Antimicrobial prophlyaxis for surgery: An advisory statement from the National Sur Infection Prevention Project. Clin Inf Dis 38:1706-1715, 2004.

Vancomycin

4-6

Table 6-7 Risk Factors for Development of Surgical Site Infections

Patient factors Older age Immunosuppression Obesity Diabetes mellitus Chronic inflammatory process Malnutrition Peripheral vascular disease Anemia Radiation Chronic skin disease Carrier state (e.g., chronic Staphylococcus carriage) Recent operation Local factors Poor skin preparation Contamination of instruments Inadequate antibiotic prophylaxis Prolonged procedure Local tissue necrosis Hypoxia, hypothermia Microbial factors Prolonged hospitalization (leading to nosocomial organisms) Toxin secretion Resistance to clearance (e.g., capsule formation)

Table 6-8 Wound Class, Representative Procedures, and Expected Infection Rates

Wound Class Clean (class I) Clean/contaminated (class II) Clean/contaminated (class II) Contaminated (class III)

Examples of Cases Hernia repair, breast biopsy Cholecystectomy, elective GI surgery (not colon) Colorectal surgery Penetrating abdominal trauma, large tissue injury, enterotomy during bowel obstruction

Expected In Rates 1.05.4% 2.19.5% 9.425% 3.413.2%

Dirty (class IV) Perforated diverticulitis, necrotizing soft tissue infections 3.112.8% Table 12-10 -- National Research Council Classification of Operative Wounds and Rates of Wound Infection Clean (class I) Nontraumatic 2.1% No inflammation No break in technique Respiratory, alimentary, or genitourinary tract not entered Clean-contaminated (class II) Contaminated (class III) Gastrointestinal or respiratory tract entered without significant spillage Major break in technique Gross spillage from the gastrointestinal tract Traumatic wound, fresh Entrance into the genitourinary or biliary tracts in the presence of infected urine or bile Dirty and infected (class IV) Acute bacterial inflammation encountered, without pus Transection of clean tissue for the purpose of surgical access to a collection of pus Traumatic wound with retained devitalized tissue, foreign bodies, fecal contamination, or delayed treatment, or all of these, or from a dirty source Table 12-13 -- Surgical Care Improvement Project (SCIP) Guidelines GUIDELINE INF, infection guideline. SCIP INF 1 Prophylactic antibiotic received within 1 hour before surgical incision SCIP INF 2 Prophylactic antibiotic selection for surgical patients SCIP INF 3 Prophylactic antibiotics discontinued within 24 hours after surgery completion time (48 hours for cardiac patients) SCIP INF 4 Cardiac surgery patients with controlled 6 AM postoperative serum glucose SCIP INF 5 Postoperative wound infection diagnosed during index hospitalization (outcome) SCIP INF 6 Surgery patients with appropriate hair removal 7.1% 3.3% 6.4%

GUIDELINE INF, infection guideline. SCIP INF 7 Colorectal surgery patients with immediate postoperative normothermia

Table 12-14 -- Perioperative Concerns and Recommendations for Eight Herbal Medicines COMMON NAME OF PREOPERATIVE HERB PERIOPERATIVE CONCERNS RECOMMENDATIONS Echinacea Ephedra Allergic reactions; decreased effectiveness of immunosuppressants; potential for immunosuppression with long-term use Risk for myocardial ischemia and stroke from tachycardia and hypertension; ventricular arrhythmias with halothane; long-term use depletes endogenous catecholamines and may cause intraoperative hemodynamic instability; life-threatening interaction with monoamine oxidase inhibitors Potential to increase risk for bleeding, especially when combined with other medications that inhibit platelet aggregation Potential to increase risk for bleeding, especially when combined with other medications that inhibit platelet aggregation Hypoglycemia; potential to increase risk for bleeding; potential to decrease anticoagulative effect of warfarin Potential to increase sedative effect of anesthetics; potential for addiction, tolerance, and withdrawal after abstinence unstudied No data Discontinue at least 24 hr before surgery

Garlic Ginkgo Ginseng Kava

Discontinue at least 7 days before surgery Discontinue at least 36 hr before surgery Discontinue at least 7 days before surgery Discontinue at least 24 hr before surgery Discontinue at least 5 days before surgery

St. John's wort Induction of cytochrome P-450 enzymes, with effect on cyclosporine, warfarin, steroids, protease inhibitors, and possibly benzodiazepines, calcium channel blockers, and many other drugs; decreased serum digoxin levels Valerian

Potential to increase sedative effect of anesthetics; benzodiazepine-like No data acute withdrawal; potential to increase anesthetic requirements with long-term use Adapted from Ang-Lee MK, Moss J, Yuan C-S: Herbal medicines and perioperative care. JAMA 286:208-216, 2001.

Table 9-1 Macrophage Activities during Wound Healing

Activity Phagocytosis Dbridement Cell recruitment and activation

Mediators Reactive oxygen species Nitric oxide Collagenase, elastase Growth factors: PDGF, TGF Cytokines: TNFFibronectin , IL-1, IL-6 , EGF, IGF

Matrix synthesis

Growth factors: TGF Cytokines: TNFProstaglandins Nitric oxide

, EGF, PDGF , IL-1, IFN-

Enzymes: arginase, collagenase

Angiogenesis

Growth factors: FGF, VEGF Cytokines: TNFNitric oxide

EGF = epithelial growth factor; FGF = fibroblast growth factor; IGF = insulin-like growth factor; IFN-

= interferon=

; IL = interleukin; PDGF = platelet-derived growth factor; TGF = transforming growth factor beta; TNFtumor necrosis factor alpha; VEGF = vascular endothelial growth factor.

Table 9-2 Growth Factors Participating in Wound Healing

Growth Factor PDGF

Wound Cell Origin Platelets, macrophages, monocytes, smooth muscle cells, endothelial cells

Cellular and Biologic Effects Chemotaxis: fibroblasts, smooth muscle, monocytes, neutrophils Mitogenesis: fibroblasts, smooth muscle cells Stimulation of angiogenesis Stimulation of collagen synthesis

FGF

Fibroblasts, endothelial cells, smooth muscle cells, chondrocytes

Stimulation of angiogenesis (by stimulation of endothelial cell proliferation and migration) Mitogenesis: mesoderm and neuroectoderm Stimulates fibroblasts, keratinocytes, chondrocytes, myoblasts

Keratinocyte growth Keratinocytes, fibroblasts factor EGF Platelets, macrophages, monocytes (also identified in salivary glands, duodenal glands, kidney, and lacrimal glands) Keratinocytes, platelets, macrophages

Significant homology with FGF; stimulates keratinocytes Stimulates proliferation and migration of all epithelial cell types Homology with EGF; binds to EGF receptor Mitogenic and chemotactic for epidermal and endothelial cells

TGF

TGF isoforms:
2

(three
1

Platelets, T lymphocytes, macrophages, monocytes, neutrophils

Stimulates angiogenesis TGF 1 stimulates wound matrix production (fibronectin, collagen glycosaminoglycans); regulation of inflammation

TGF Insulin-like growth factors (IGF-I, IGFII)

inhibits scar formation

Platelets (IGF-I in high concentrations in liver; Promote protein/extracellular matrix IGF-II in high concentrations in fetal growth); synthesisIncrease membrane glucose transport likely the effector of growth hormone action Similar to PDGF Mitogen for endothelial cells (not fibroblasts) Stimulates angiogenesis

Vascular endothelial Macrophages, fibroblasts, keratinocytes growth factor

GranulocyteMacrophage/monocytes, endothelial cells, Stimulates macrophage macrophage colony- fibroblasts differentiation/proliferation stimulating factor EGF = epidermal growth factor; FGF = fibroblast growth factor; PDGF = platelet-derived growth factor; TGF = transforming growth factor.