Antibiotic Prophylaxis in Surgery
An Adapted Clinical Practice Guideline
First Edition 2013

Presented By

Dr. Tarek Altok...
09 JAN 2014

Antibiotic Prophylaxis in Surgery

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09 JAN 2014

Antibiotic Prophylaxis in Surgery

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Clinical
Care GAP

Best
Practice

Knowledge
Translation
09 JAN 2014

Antibiotic Prophylaxis in Surgery

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Clinical Practice Guidelines (CPGs) Program of King Saud
University Hospitals/ Medical City
KSUHs Taskforce Responsible St...
18 CPGs Subcommittees - - ->> 21
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Department of Pediatrics...
Adapted from Source CPGs

CPG for Antimicrobial
Prophylaxis in Surgery
Developed by
American Society of Health System Phar...
Hospital-Wide Policy & Procedure for

Hospital CPGs Adaptation
SEPT 2013
CPG objective
To provide practitioners with a
standardized approach to the
rational, safe, and effective use of
antimicrob...
CPG Authorship group (CPG Champions)
Review group

Adaptation working group
1. Dr. Tariq Altokhais, Head
CPG Surg SubC, Co...
Search and Selection of source CPGs

•8 CPGs internet databases searched
•27 source CPGs retrieved

•25 CPGs excluded base...
Health Questions (PIPOH)
P: Patient/target population:
Adult (age 19 years or older) and pediatric
(age 1–18 years) patien...
PIPOH
I: Intervention and practices considered and
CPG Category:
Assessment of Therapeutic Effectiveness and
Prevention.
P...
PIPOH
P: Professionals and Intended Users (target
users/ stakeholders) and Clinical Specialty:
Physicians, Nurses, Allied ...
PIPOH
O: Major Outcomes Considered
1. Postoperative infection rates
2. Postoperative Morbidity and Mortality
rates
3. Dura...
PIPOH

King Saud University Hospitals (KKUH/
KAUH) or KSU Medical City – Tertiary/
Governmental/ University Hospital –
Dep...
Note: These CPGs reflect recommendations
for peri-operative antibiotic prophylaxis to
prevent SSI’s and do not apply for
p...
Inclusion / Exclusion source CPGs
Selection Criteria
1) Methods of Development; Evidence-Based CPGs: (Detailed
Methodology...
AGREE II Domain Scores for the 2
source CPGs ASHP 2013 & ICSI 2012
AGREE II DOMAINS

ASHP 2013 CPG (%) ICSI 2012 CPG (%)

...
Evidence-Based
Recommendations

09 JAN 2014

Antibiotic Prophylaxis in Surgery

21
Accreditation Canada International
Current ROP

09 JAN 2014

Antibiotic Prophylaxis in Surgery

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2 Questions !!

When to START ?

When to STOP ?
09 JAN 2014

Antibiotic Prophylaxis in Surgery

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Preoperative-dose Timing
Optimal time for administration of pre-

operative antibiotics first dose is within 60
minutes b...
Dosing & Re-dosing

Single dose prophylaxis is usually
sufficient, the duration of prophylaxis for most
procedures should...
Dosing & Re-dosing (cont’d)
If an agent with a short half-life is used:(e.g. cefazolin, cefoxitin) it should be readminis...
Route of administration
IV route typically preferred due to
rapid, reliable, and predictable tissue
and serum concentratio...
Select Antimicrobial based on
1. Agent active against most common

pathogens for given procedure but
with as narrow spectr...
Rating Scheme for the Strength/ Levels of the Evidence
Level of Evidence

Type of Study

Level I

Evidence from large, wel...
EVIDENCE-BASED RECOMMENDATIONS
Thoracic Procedures
Recommended
Agents & Dosage

Cefazolin 2 g*
Ampicillin-sulbactam 3 g*...
Gatsrodudenal Procedures
Recommended
Cefazolin 2 g
Agents & Dosage
Alternative agents
Clindamycin 900 mg or
in Patients w...
Biliary tract - Open Procedure
Recommended •Cefazolin 2 g*
Agents &
•Cefoxitin 2 g
Dosage
•Cefotetan 2 g
•Ceftriaxone 2 g
...
Biliary tract - laparoscopic procedure
Recommended Elective, low-risk: none
Elective, high-risk:
Agents &
•Cefazolin 2 g...
Appendectomy for uncomplicated appendicitis
Recommended •Cefoxitin 2 g
Agents &
•Cefotetan 2 g
Dosage

•Cefazolin 2 g* + m...
Appendectomy for uncomplicated appendicitis
Recommended •Cefoxitin 2 g
Agents &
•Cefotetan 2 g
Dosage

•Cefazolin 2 g* + m...
Vascular Procedures
Recommended
Agents &
Dosage

Cefazolin 2 g*

Alternative
agents in
Patients with
B-Lactam
Allergy

Cli...
Recommended Agents & Dosage

Urologic procedure
Lower tract instrumentation with risk factors for infection:•Fluoroquinol...
Alternative agents in Patients
with B-Lactam Allergy

Urologic procedures
Lower tract instrumentation with risk factors f...
Orthopedic procedures
Recommended Clean operations involving hand,
Agents &
knee, or foot and not involving
Dosage
implan...
Alternative agents in Patients
with B-Lactam Allergy

Orthopedic procedures
Clean operations involving hand, knee, or
foo...
Plastic surgery -Clean with risk factors or cleancontaminated
Recommended
Agents & Dosage

•Cefazolin 2 g*
•Ampicillin-sul...
Excluded recommendations
 The panel decided to exclude the

recommendations related to:1. Cardiac Surgery Procedures (Sep...
Implementation Strategies & Tools
TOOLS/ Resources:
 Quick Reference Guides

STRATEGIES
 Dissemination Process (print/

...
Thank YOU all for listening

09 JAN 2014

Antibiotic Prophylaxis in Surgery

44
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Adaptation and Implementation of Evidence-Based Clinical Practice Guidelines for Antibiotic Prophylaxis in Surgery in King Saud University Hospitals in Riyadh, Saudi Arabia

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Antimicrobial prophylaxis in surgery

  1. 1. Antibiotic Prophylaxis in Surgery An Adapted Clinical Practice Guideline First Edition 2013 Presented By Dr. Tarek Altokhais, Consultant, Pedia Surgery & Head of Surgery CPG Subcommittee, Surgery Department Dr. Yasser Amer, CPG General Coordinator, CPG Committee, QMD 09 JAN 2014 Antibiotic Prophylaxis in Surgery 1
  2. 2. 09 JAN 2014 Antibiotic Prophylaxis in Surgery 2
  3. 3. 09 JAN 2014 Antibiotic Prophylaxis in Surgery 3
  4. 4. Clinical Care GAP Best Practice Knowledge Translation 09 JAN 2014 Antibiotic Prophylaxis in Surgery 4
  5. 5. Clinical Practice Guidelines (CPGs) Program of King Saud University Hospitals/ Medical City KSUHs 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 2014 Antibiotic Prophylaxis in Surgery 5
  6. 6. 18 CPGs Subcommittees - - ->> 21 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. Department 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] New Department of Emergency Medicine [+11] 1. Department of Occupational Department of Medicine [8] Health & Safety [2] 2. Department of Rehabilitation Department of Orthopedic Surgery [1+1] Medicine [+1] Department of Otorhinolaryngology [1] 3. Health Education Center [+3] 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] 09 JAN 2014 Antibiotic Prophylaxis in Surgery 6
  7. 7. Adapted from Source CPGs CPG for Antimicrobial Prophylaxis in Surgery Developed by American 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 2014 Antibiotic Prophylaxis in Surgery 7
  8. 8. Hospital-Wide Policy & Procedure for Hospital CPGs Adaptation SEPT 2013
  9. 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 2014 Antibiotic Prophylaxis in Surgery 10
  10. 10. CPG Authorship group (CPG Champions) Review group Adaptation working group 1. Dr. Tariq Altokhais, Head CPG Surg SubC, Consult. Pedia Surg 2. Dr. Abdelmonim ElTarifi, Consult. Urology 3. Dr. Khalid Alawi, Consult. Surg 4. Dr. Yasser Amer, CPGC, QMD Support group: Dorothy Villena, CPGC Sheila Rivera, CPGC 09 JAN 2014 1. 2. 3. 4. 5. 6. 7. Antibiotic Prophylaxis in Surgery Dr. Danny Rabah, Consultant Urology Dr. Badr Aljabri, Consultant Vascular Surg Dr. Wassim Hajar, Consultant Thoracic Surg Dr. Mohammad Qattan, Consultant, Plastic Surg Dr. Yaser Alfakey, Consultant Ophthalmology Dr. Khalid Alsaleh, Consultant Orthopedic Surg/Spine, Head Ortho CPG Dr. Neama Meriki, Consultant OBGYN, MFM, Head OBGYN CPG 11
  11. 11. Search and Selection of source CPGs •8 CPGs internet databases searched •27 source CPGs retrieved •25 CPGs excluded based on HQ and selection criteria & 2 CPGs included for further appraisal by AGREE II Instrument. 09 JAN 2014 Antibiotic Prophylaxis in Surgery 12
  12. 12. Health Questions (PIPOH) P: Patient/target population: Adult (age 19 years or older) and pediatric (age 1–18 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 fullterm) 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 2014 Antibiotic Prophylaxis in Surgery 13
  13. 13. PIPOH I: 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 2014 Antibiotic Prophylaxis in Surgery 14
  14. 14. PIPOH 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 2014 Antibiotic Prophylaxis in Surgery 15
  15. 15. PIPOH O: Major Outcomes Considered 1. Postoperative infection rates 2. Postoperative Morbidity and Mortality rates 3. Duration and cost of health care 4. Adverse effects 09 JAN 2014 Antibiotic Prophylaxis in Surgery 16
  16. 16. PIPOH King Saud University Hospitals (KKUH/ KAUH) or KSU Medical City – Tertiary/ Governmental/ University Hospital – Departments and clinics (mentioned in the clinical specialty) 09 JAN 2014 Antibiotic Prophylaxis in Surgery 17
  17. 17. Note: These CPGs reflect recommendations for peri-operative antibiotic prophylaxis to prevent SSI’s and do not apply for prevention of opportunistic infections in immunosuppressed transplantation patients (e.g. for antifungal or antiviral medications). 09 JAN 2014 Antibiotic Prophylaxis in Surgery 18
  18. 18. 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 Consensusbased 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 only 6) Status: only Original source CPG (de novo developed) NOT adapted CPGs 09 JAN 2014 Antibiotic Prophylaxis in Surgery 19
  19. 19. AGREE II Domain Scores for the 2 source CPGs ASHP 2013 & ICSI 2012 AGREE II DOMAINS ASHP 2013 CPG (%) ICSI 2012 CPG (%) D1: Scope & Purpose 80 D2: Stakeholder Involvement D3: Rigour of Development 94 72 61 86 69 D4: Clarity & Presentation 94 42 83 Yes 69 D5: Applicability D6: Editorial Independence Overall Assessment 52 79 No This table uses the AGREE II Domain Score Colour Coding proposed by Dr. Lubna Alansary (< 40% red - > 41 – 70% yellow - > 71 % green) 09 JAN 2014 Antibiotic Prophylaxis in Surgery 20
  20. 20. Evidence-Based Recommendations 09 JAN 2014 Antibiotic Prophylaxis in Surgery 21
  21. 21. Accreditation Canada International Current ROP 09 JAN 2014 Antibiotic Prophylaxis in Surgery 22
  22. 22. 2 Questions !! When to START ? When to STOP ? 09 JAN 2014 Antibiotic Prophylaxis in Surgery 23
  23. 23. 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 2014 Antibiotic Prophylaxis in Surgery 24
  24. 24. Dosing & Re-dosing Single 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 2014 Antibiotic Prophylaxis in Surgery 25
  25. 25. Dosing & Re-dosing (cont’d) If an agent with a short half-life is used:(e.g. cefazolin, cefoxitin) it should be readministered 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 2014 Antibiotic Prophylaxis in Surgery 26
  26. 26. Route of administration IV route typically preferred due to rapid, reliable, and predictable tissue and serum concentrations 09 JAN 2014 Antibiotic Prophylaxis in Surgery 27
  27. 27. Select Antimicrobial based on 1. Agent active against most common pathogens for given procedure but with as narrow spectrum as possible. 2. Safety profile of drug. 3. Patient allergies and co-morbidities. 09 JAN 2014 Antibiotic Prophylaxis in Surgery 28
  28. 28. Rating Scheme for the Strength/ Levels of the Evidence Level of Evidence Type of Study Level I Evidence from large, well conducted, randomized, controlled clinical trials or a meta-analysis Level II Evidence from small, well conducted, randomized, controlled clinical trials Level III Evidence from well conducted cohort studies Level IV Evidence from well conducted case–control studies Level V Evidence from uncontrolled studies that were not well conducted Level VI Conflicting evidence that tends to favor the recommendation Level VII Expert opinion or data extrapolated from evidence for general principles and other procedures Rating Scheme for the Strength/ Levels of Recommendations Grade of R. (GoR) Category A Levels I-III Category B Levels IV-VI Category C 09 JAN 2014 Level of E. (LoE) Level VII Antibiotic Prophylaxis in Surgery 29
  29. 29. EVIDENCE-BASED RECOMMENDATIONS Thoracic Procedures Recommended Agents & Dosage Cefazolin 2 g* Ampicillin-sulbactam 3 g** Alternative agents Clindamycin 900 mg in Patients with B- Vancomycin 15 mg/kg Lactam Allergy Strength of Evidence (accord. To procedure) 09 JAN 2014 Antibiotic Prophylaxis in Surgery A, C 30
  30. 30. Gatsrodudenal Procedures Recommended Cefazolin 2 g Agents & Dosage Alternative agents Clindamycin 900 mg or in Patients with BVancomycin 15 mg/kg + Lactam Allergy aminoglycoside or Aztreonam 2 g or Fluoroquinolone     Strength of Evidence (accord. To procedure) 09 JAN 2014 Antibiotic Prophylaxis in Surgery A 31
  31. 31. Biliary tract - Open Procedure Recommended •Cefazolin 2 g* Agents & •Cefoxitin 2 g Dosage •Cefotetan 2 g •Ceftriaxone 2 g •Ampicillin-sulbactam 3 g** Alternative •Clindamycin 900 mg or agents in •Vancomycin 15 mg/kg + aminoglycoside*** Patients with or B-Lactam •Aztreonam 2 g or fluoroquinolone**** Allergy •Metronidazole 500 mg + aminoglycoside*** or fluoroquinolone**** Strength of Evidence (accord. To procedure) 09 JAN 2014 A Antibiotic Prophylaxis in Surgery 32
  32. 32. Biliary tract - laparoscopic procedure Recommended Elective, low-risk: none Elective, high-risk: Agents & •Cefazolin 2 g* Dosage •Cefoxitin 2 g •Cefotetan 2 g •Ceftriaxone 2 g •Ampicillin-sulbactam 3 g** Alternative agents in Patients with B-Lactam Allergy Elective, low-risk: none Elective, 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. 09 JAN 2014 To procedure) A Antibiotic Prophylaxis in Surgery 33
  33. 33. Appendectomy for uncomplicated appendicitis Recommended •Cefoxitin 2 g Agents & •Cefotetan 2 g Dosage •Cefazolin 2 g* + metronidazole Alternative agents in Patients with B-Lactam Allergy Strength of Evidence (accord. To procedure) 09 JAN 2014 •Clindamycin 900 mg or vancomycin + aminoglycoside*** or aztreonam 2 g or fluoroquinolone**** •Metronidazole 500 mg + aminoglycoside*** or fluoroquinolone**** A Antibiotic Prophylaxis in Surgery 34
  34. 34. Appendectomy for uncomplicated appendicitis Recommended •Cefoxitin 2 g Agents & •Cefotetan 2 g Dosage •Cefazolin 2 g* + metronidazole Alternative agents in Patients with B-Lactam Allergy Strength of Evidence (accord. To procedure) 09 JAN 2014 •Clindamycin 900 mg or vancomycin + aminoglycoside*** or aztreonam 2 g or fluoroquinolone**** •Metronidazole 500 mg + aminoglycoside*** or fluoroquinolone**** A Antibiotic Prophylaxis in Surgery 35
  35. 35. Vascular Procedures Recommended Agents & Dosage Cefazolin 2 g* Alternative agents in Patients with B-Lactam Allergy Clindamycin 900 mg Vancomycin 15 mg/kg Strength of Evidence (accord. To procedure) 09 JAN 2014 A Antibiotic Prophylaxis in Surgery 36
  36. 36. Recommended Agents & Dosage Urologic procedure Lower tract instrumentation with risk factors for infection:•Fluoroquinolone (e.g. ciprofloxacin 400mg) •Trimethoprim-sulfamethoxazole •Cefazolin 2 g* Clean without entry into urinary tract:•Cefazolin 2 g*; addition of single dose of aminoglycoside may be recommended for placement of prosthetic material •If involving implanted prosthesis: Cefazolin 2 g* with or without aminoglycoside Cefazolin as dosed above with or without aztreonam 2g Ampicillin-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 material Clean-contaminated:•Cefazolin 2 g*+ metronidazole 500 mg •Cefoxitin 2 g LoE 09 JAN 2014 A Antibiotic Prophylaxis in Surgery 37
  37. 37. Alternative agents in Patients with B-Lactam Allergy Urologic procedures Lower tract instrumentation with risk factors for infection: •Aminoglycoside*** with or without clindamycin 900 mg Clean without entry into urinary tract: •Clindamycin 900 mg •Vancomycin 15 mg/kg •If involving implanted prosthesis, consider adding aminoglycoside*** or aztreonam 2 g to either regimen Clean with entry into urinary tract: •Fluoroquinolone**** •Aminoglycoside*** with or without clindamycin 900 mg Clean-contaminated: •Fluoroquinolone**** •Aminoglycoside*** + metronidazole 500 mg or clindamycin 900 mg LoE 09 JAN 2014 A Antibiotic Prophylaxis in Surgery 38
  38. 38. Orthopedic procedures Recommended Clean operations involving hand, Agents & knee, or foot and not involving Dosage 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* LoE 09 JAN 2014 C, A Antibiotic Prophylaxis in Surgery 39
  39. 39. Alternative agents in Patients with B-Lactam Allergy Orthopedic procedures Clean 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: •Clindamycin 900 mg •Vancomycin 15 mg/kg LoE 09 JAN 2014 A Antibiotic Prophylaxis in Surgery 40
  40. 40. Plastic surgery -Clean with risk factors or cleancontaminated Recommended Agents & Dosage •Cefazolin 2 g* •Ampicillin-sulbactam 3 g** Alternative agents in Patients with BLactam Allergy •Clindamycin 900 mg •Vancomycin 15 mg/kg Strength of Evidence (accord. To procedure) 09 JAN 2014 Antibiotic Prophylaxis in Surgery C 41
  41. 41. Excluded recommendations  The panel decided to exclude the recommendations related to:1. Cardiac Surgery Procedures (Separate CPG) 2. Organ Transplantation Procedures (not currently practiced in KSUMC) 09 JAN 2014 Antibiotic Prophylaxis in Surgery 42
  42. 42. Implementation Strategies & Tools TOOLS/ Resources:  Quick Reference Guides STRATEGIES  Dissemination Process (print/ e-/website) (Key Recommendations)  Local Clinical Champions.  Protocol  Standing Orders: Paper  Awareness raising/ training activities. OR CPOE: Integration into New HIS (e-SIHI) as CPOE (Power Plans or Power Charts)  Networking and linking with existing projects.  Patient Education Guide  Patients as champions for (in Ar/ Eng) change.  Clinical Audit tools/ Performance measures  Regular M & E. 09 JAN 2014 Antibiotic Prophylaxis in Surgery 43
  43. 43. Thank YOU all for listening 09 JAN 2014 Antibiotic Prophylaxis in Surgery 44

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