Cefuroxime is recommended for surgical antibiotic prophylaxis due to its broad-spectrum antibacterial activity against common pathogens. It achieves high concentrations in serum and tissues. Studies show cefuroxime is effective in reducing surgical site infections for procedures like hysterectomy and maxillofacial surgery when administered preoperatively. It has advantages of twice daily dosing, oral and IV formulations, and safety. Cefuroxime's broad spectrum and tissue penetration make it suitable for preventing postoperative infections from most bacteria encountered during surgery.

1. Surgical Site Infections
– Role of Cefuroxime

2. SSIs: Magnitude of the
Problem
Surgical site infections:
• are the third most prevalent HCAI in hospital inpatients
• are present in 1% of hospital inpatients surveyed (2011)
• account for 1.4% of overall HCAI incidence in England
• developed in 10% of large bowel operation cases*
• are largely preventable.

3. Surgical Wound Classification
• Class 1 – Clean
– Uninfected operative wound, no inflammation
• Class II – Clean-Contaminated
– Alimentary tract (and others), under controlled conditions without
unusual contamination
• Class III – Contaminated
– Major breaks in sterile technique, eg, gross spillage from the
gastrointestinal tract
– Incisions encountering acute inflammation
• Class IV – Dirty-Infected
– Old traumatic wounds with dead tissue, infection, perforated
viscera
Mangram AJ et al. Am J Infect Control. 1999;27:97–134.

4. Risk Factors for SSI: The Patient
• Age
• Nutritional status
• Diabetes
• Nicotine use
• Obesity
• Coexistent infection
• Colonization
• Altered immune response
• Long preoperative stay

5. Risk Factors for SSI: Pre- and Intraoperative
• Inappropriate use of antimicrobial prophylaxis
• Infection at remote site not treated prior to surgery
• Shaving the site vs. clipping
• Long duration of surgery
• Improper skin preparation
• Improper surgical team hand antisepsis
• Environment of the room (ventilation, sterilization)
• Surgical attire and drapes
• Asepsis
• Surgical technique: hemostasis, sterile field

6. CDC recommendation to
prevent SSIs

7. Prevention Strategies: Core
Preoperative Measures
Administer antimicrobial prophylaxis in accordance with
evidence based standards and guidelines
– Administer within 1 hour prior to incision*
• 2hr for vancomycin and fluoroquinolones
– Select appropriate agents on basis of
• Surgical procedure
• Most common SSI pathogens for the procedure
• Published recommendations
*Fry DE. Surgical Site Infections and the Surgical Care Improvement Project (SCIP): Evolution of National Quality
Measures. Surg Infect 2008;9(6):579-84.

8. • Remote infections-whenever possible:
– Identify and treat before elective operation
– Postpone operation until infection has resolved
• Do not remove hair at the operative site unless it will interfere
with the operation; do not use razors
– If necessary, remove by clipping or by use of a depilatory
agent
Prevention Strategies: Core
Preoperative Measures

9. • Skin Prep
– Use appropriate antiseptic agent and technique for skin
preparation
• Maintain immediate postoperative normothermia*
• Colorectal surgery patients
– Mechanically prepare the colon (Enemas, cathartic agents)
– Administer non-absorbable oral antimicrobial agents in
divided doses on the day before the operation
*Fry DE. Surgical Site Infections and the Surgical Care Improvement Project (SCIP): Evolution of National Quality
Measures. Surg Infect 2008;9(6):579-84.
Prevention Strategies: Core
Preoperative Measures

10. • Operating Room (OR) Traffic
– Keep OR doors closed during surgery except as
needed for passage of equipment, personnel, and
the patient
Prevention Strategies: Core
Intra-operative Measures

11. • Surgical Wound Dressing
– Protect primary closure incisions with sterile dressing for 24-
48 hrs post-op
• Control blood glucose level during the immediate post-
operative period (cardiac)*
– Measure blood glucose level at 6AM on POD#1 and #2 with
procedure day = POD#0
– Maintain post-op blood glucose level at <200mg/dL
*Fry DE. Surgical Site Infections and the Surgical Care Improvement Project (SCIP):
Evolution of Nationaluality Measures. Surg Infect 2008;9(6):579-84.
Prevention Strategies: Core
Postoperative Measures

12. Antibiotic Prophylaxis (NICE)
– Give antibiotic prophylaxis before:
- clean surgery for the placement of a prosthesis or
implant
- clean-contaminated surgery
- contaminated surgery
– Do not routinely use for clean non-prosthetic
uncomplicated surgery
– Use local antibiotic formulary and consider adverse
effects
– Consider prophylaxis on starting anaesthesia, or
earlier for operations using a tourniquet

13. Other Recommendation Sources
• American Society of Health-System Pharmacists
• Infectious Diseases Society of America
• The Hospital Infection Control Practices Advisory
Committee
• Medical Letter
• Surgical Infection Society
• Sanford Guide to Antimicrobial Therapy 2003
Bratzler DW. Available at:
http://www.medqic.org/scip/pdf/spkrnotesSIP_to_SCIP_101205.ppt. Accessed May
26, 2006.

14. Antimicrobial Requirements
• Active against most likely aerobes and anaerobes1,2
• Appropriate dosage and timing for adequate
concentration at wound site1,2
• Generally well tolerated1
• Administer for shortest effective period to minimize
adverse effects, cost, and resistance1
1. American Society of Health-System Pharmacists. Am J Health-Syst Pharm
1999;56:1839–1888.
2. Song et al. Br J Surg 1998;85:1232–1241.

15. Common Principles
Ideally, an antimicrobial agent for surgical prophylaxis should
1. Prevent SSI,
2. Prevent ssi-related morbidity and mortality,
3. Reduce the duration and cost of health care (when the costs
associated with the management of SSI are considered, the
cost-effectiveness of prophylaxis becomes evident),
4. Produce no adverse effects, and
5. Have no adverse consequences for the microbial flora of the
patient or the hospital

16. Ideal antimicrobial agent
1. To achieve these goals, an antimicrobial agent should be
1. Active against the pathogens most likely to
contaminate the surgical site,
2. Given in an appropriate dosage and at time that
ensures adequate serum and tissue concentrations
during the period of potential contamination,
3. Safe, and
4. Administered for the shortest effective period to
minimize adverse effects, the development of
resistance, and costs.

17. Cefuroxime is a second generation Cephalosporin,
highly stable to most ß-lactamases, both Penicillinases
and Cephalosporinases of gram positive and gram
negative bacteria
Description

18.  Aerobic Gram-Positive Microorganisms:
 Staphylococcus aureus
 Streptococcus pneumoniae
 Streptococcus pyogenes
 Aerobic Gram-Negative Microorganisms:
 Escherichia coli
 Haemophilus influenzae (including beta-lactamase–producing
strains)
 Haemophilus parainfluenzae
 Klebsiella pneumoniae
 Moraxella catarrhalis (including beta-lactamase–producing strains)
 Neisseria gonorrhoeae (including beta-lactamase-producing strains
 Spirochetes:
 Borrelia burgdorferi
Sensitive Organisms

19.  Cefuroxime is subsequently distributed throughout the
extracellular fluids. The axetil moiety is metabolized to
acetaldehyde and acetic acid.
 Absorption of the tablet is greater when taken after food
(absolute bioavailability of Cefuroxime Axetil tablets increases
from 37% to 52%).
 Cefuroxime is excreted unchanged in the urine; in adults,
approximately 50% of the administered dose is recovered in the
urine within 12 hours.
Pharmacokinetics

20. Tissue concentration during preoperative use
After giving 1.5 gm injection of cefuroxime 40 mins before surgical
incision achieved the concentration of antibiotics 14 times higher than
MICs of S. Aureus and S. Epidermis and 7 times higher than MICs of E.
coli.

21. Antibiotic prophylaxis for hysterectomy, a prospective
cohort study: cefuroxime, metronidazole, or both?
• Study was conducted in fifty-three hospitals in Finland.
A total of 5279 women undergoing hysterectomy for
benign indications were selected and given either
cefuroxime or metronidazole or both.
• In this study, cefuroxime appeared to be effective in
prophylaxis against infections. Metronidazole appeared
to be ineffective, with no additional risk-reductive
effect when combined with cefuroxime.

22. Suitability of cefuroxime for perioperative antibiotic
prophylaxis in maxillofacial surgical procedures
• Serum and tissue samples were taken, to determine the
intraoperative cefuroxime concentration, from 40
patients who had been given 1.5 g cefuroxime i.v. during
maxillofacial surgery.
• Maximum serum levels averaging 80 mg/l were
measured within 30 min of administration. Average
levels of 1–3 mg/kg were still measurable after 4 h. No
postoperative wound infection was seen under
prophylaxis with cefuroxime.
• Cefuroxime is suitable for perioperative prophylaxis
during maxillofacial surgical procedures because of its
favourable kinetics and broad spectrum of action.

23. Cefuroxime as antibiotic prophylaxis in CABG
surgery
• To determine the efficacy of cefuroxime as a
prophylactic agent against infection.
• The study enrolled 1232 adult patients (age )16
years who underwent isolated CABG surgery with
the use of extracorporeal circulation within two
periods.
• All these surgical procedures were performed by
the same three surgical teams. General anesthesia
was provided by the same three teams according to
a set protocol.

24. Results

25. Advantages:
 Broad-spectrum antibiotic - Cefuroxime has bactericidal activity
against a wide range of common pathogens, including many beta-
lactamase producing strains. It has good stability to bacterial beta-
lactamase, and consequently is active against many ampicillin-
resistant or amoxicillin-resistant strains.
 Wide tissue distribution - Widely distributed in the body into most
tissues and fluids including gallbladder, liver, kidney, bone, uterus,
ovary, sputum, bile, and peritoneal, pleural, and synovial fluids
 Most active cephalosporin for beta-lactamase-producing
Haemophilus influenzae, organism that causes respiratory tract
infections such as otitis media, bronchitis and sinusitis.
Cefuroxime "pros" and "cons”

26.  Less gastrointestinal side effects - Cefuroxime axetil produces
fewer gastrointestinal side effects than some other widely used
antibiotics (e.g. Augmentin, cefixime).
 Safe for use in children - Safety and effectiveness of cefuroxime
axetil have been established for children aged 3 months to 12 years.
 Pregnancy category B.
Ease of use - twice daily dosing.
 Available in oral and I.V. formulations.
Cefuroxime "pros" and "cons”