Preoperative Antibiotic Prophylaxis

Crader MF, Varacallo M.

Continuing Education Activity

Preoperative antibiotic prophylaxis is administering antibiotics before performing surgery to help decrease the risk of
postoperative infections. The evidence supporting routine preoperative use of prophylactic antibiotic administration continues
to grow. The routine administration of prophylactic antibiotics is standard in cases in which a patient will have an artificial
implant or foreign body implanted as part of the procedure, bone grafting procedures, and other surgeries with extensive
dissections and expectations for higher amounts of anticipated blood loss. This activity will highlight the rationale, timing,
agent selection, coverage, and monitoring pertinent for interprofessional team members involved in the administration of
preoperative antibiotic prophylaxis to patients.

Objectives:

Explain the rationale behind preoperative antibiotic prophylaxis.

Summarize the evidence for the timing of administration with preoperative antibiotic prophylaxis.
Review the follow-up monitoring necessary to determine the successful implementation of preoperative antibiotic
prophylaxis.
Outline interprofessional team strategies for improving care coordination and communication to advance
preoperative antibiotic prophylaxis, where it is indicated and improves patient outcomes.

Access free multiple choice questions on this topic.

Indications
Preoperative antibiotic prophylaxis is defined as administering antibiotics prior to performing surgery to help decrease the risk
of postoperative infections. The evidence supporting routine preoperative use of prophylactic antibiotic administration
continues to grow. A 2008 study highlights the effectiveness of its administration during total hip and knee replacement,
reducing the absolute risk of wound infection by over 80% compared to patients treated with no prophylaxis.[1] The routine
administration of prophylactic antibiotics is standard in cases where a patient will have an artificial implant or foreign body
implanted as part of the procedure, bone grafting procedures, and other surgeries with extensive dissections or expected high
blood loss.

The timing of antibiotic administration may vary, but the goal of administering preoperative systemic prophylactic antibiotics
is to have the concentration in the tissues at its highest at the start and during surgery.[2][3] The literature supports at least 30
minutes, but no greater than 60 minutes before the skin incision is made to the optimal timing for the preoperative
administration of most commonly used antibiotics.[4][5][2] Special consideration is given to ideal preoperative timing when
using a tourniquet, as the administration is least effective when the antibiotic is given after the application of a tourniquet.[6]

The most common organisms implicated as causes of surgical site infections include[7]:

Staphylococcus aureus
Staphylococcus epidermidis
Aerobic streptococci
Anaerobic cocci

Other organisms, such as Cutibacterium acnes, are characteristically isolated in the setting of postoperative infections
following shoulder surgery.

The preoperative antibiotic selection is generally based on the anatomic region undergoing the specific surgical procedure.
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 When determining appropriate antibiotic selection, the goal is to have achieved a relatively narrow spectrum of activity while
ensuring the most common organisms are targeted. Additionally, preoperative antibiotics are chosen based on many factors,
including cost, safety, ease of administration, pharmacokinetic profile, bacteriocidal activity, and hospital resistance patterns.
By addressing all of these factors during antibiotic selection, surgical site infections (SSIs) are minimized. In aggregate, SSIs
constitute a significant factor driving negative patient-reported outcomes and independent risk factors for increasing the
financial burden to the entire healthcare system.[8]

Cefazolin is used most often for surgical prophylaxis in patients with no history of beta-lactam allergy or of MRSA infection.
It is not used for surgical sites in which the most probable organisms are not covered by cefazolin alone (e.g., appendectomy,
colorectal).

In patients requiring only cefazolin for preoperative surgical prophylaxis, clindamycin or vancomycin are often used as
alternatives for those with significant allergies to the medication. Most patients with a beta-lactam allergy are able to tolerate
cefazolin. In the case of MRSA colonization, or select patients at high-risk for MRSA (i.e., patients residing in nursing homes,
patients with a history of MRSA infection, or patients with current positive MRSA colonization testing), vancomycin is the
alternative unless additional antibiotics are required for possible gram-negative or anaerobic organisms.[9] Multiple options
may be considered for patients requiring additional microbe coverage (e.g., colorectal), including cefazolin plus
metronidazole, cefoxitin, or ertapenem. Additional antibiotics are options based on specific surgical sites in addition to
hospital-specific and patient-specific antibiotic resistance.[10]

Weight-based dosing should be followed per standardized protocol, and administration should occur within 1 hour of skin
incision and continue 24 hours postoperatively. Furthermore, surgical durations of greater than 4 hours or estimated blood loss
over 1,500 mL necessitates repeat intraoperative dosing of antibiotics.[11] Weight-based guidelines include the following[12]:

Cefazolin: 2 g (3 g for weight >120 kg) — standard adult surgical prophylaxis guidelines
Vancomycin: 15 mg/kg

Wound Classifications [13]

Wound types can be classified as clean, clean-contaminated, contaminated, or dirty/infected, according to the Centers for
Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN). Clean wounds are not infected,
without inflammation, primarily closed, and do not include the organ systems outlined in a clean-contaminated wound. Clean-
contaminated wounds involve the respiratory, alimentary, genital, and urinary tract as long as the tract is entered without
unusual contamination. Contaminated wounds include open, fresh accidental wounds, including those with non-purulent
inflammation. Contaminated wounds also include procedures with significant breaks in sterile technique or gross spillage
from the gastrointestinal tract. Dirty or infected wounds are old traumatic wounds with devitalized tissue, existing clinical
infection, or perforated viscera. During clean procedures, skin florae such as coagulase-
negative staphylococci (e.g., Staphylococcus epidermidis or Staphylococcus aureus) are predominant pathogens in surgical
site infections. In clean-contaminated procedures, the most commonly found organisms causing surgical site infections are
skin flora, gram-negative rods, and Enterococci.[14]

Skin Preparation

Other preoperative actions include basic infection control strategies, instrument sterilization, and a patient's skin preparation
(e.g., methicillin-resistant Staphylococcus aureus [MRSA] decolonization, appropriate hair removal, skin antiseptic).
[15] Regarding the latter, it is commonly recommended that patients about to undergo surgery perform a combination of a
standard soap-and-water shower and chlorhexidine gluconate cloth wash before surgery. Murray et al. previously
demonstrated that the combined protocol resulted in a 3-fold reduction in colony count for coagulase-negative Staphylococcus
(CNS), a significant decrease in the rate of positive cultures for CNS and Corynebacterium, and a significant decrease in
overall bacterial burden compared to soap-and-water shower alone.[16]

MRSA screening via swabs of the anterior nares weeks before elective arthroplasty procedures and reflexively treating
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 patients based on culture results is generally institution-dependent. Positive MRSA culture results can be treated with either
2% mupirocin twice daily for five days preoperatively to the nares or 5% povidone-iodine solution to each nostril for 10
seconds per nostril, 1 hour prior to surgery, in addition to vancomycin administration at the time of surgery.[17][18]

Splenectomized Patients

Another area requiring special attention and consideration is infection prevention in patients with hyposplenism (or status post
splenectomy). Davies et al. provided updated guidelines for the prevention and treatment of infections in patients with
dysfunctional (or absent) splenic function:

Pneumococcal immunization
Haemophilus influenza type B vaccination
Meningococcal group C conjugate vaccination
Yearly influenza immunization
Lifelong prophylactic antibiotics (oral phenoxymethylpenicillin or erythromycin)

Mechanism of Action
Multiple antibiotic classes are recommended for use in preoperative antibiotic prophylaxis. The antibiotics utilized are
bactericidal instead of bacteriostatic. This means that any of the targeted organisms are killed instead of just preventing the
multiplication of further growth. It should be noted that certain antibiotics can exhibit bacteriostatic or bactericidal properties
depending on bacterial sensitivity and antibiotic concentration. For example, clindamycin is bacteriostatic at lower doses, but
at higher doses, it can exhibit bactericidal properties. In most surgeries, the intent is to ensure the bactericidal concentration
has been reached in the blood and tissues before incision.

Administration
The majority of preoperative prophylactic antibiotics are administered intravenously (IV). The initial timing of administration,
redosing, if applicable, duration of prophylactic therapy, and dosing in obese patients are important components in the
prevention of surgical site infections as well as antimicrobial stewardship.[19] Avoiding unnecessary use of antibiotics helps
diminish adverse effects and antibiotic resistance development. Antibiotics should be given within 30 to 60 minutes of a
surgical incision. Exceptions include vancomycin and levofloxacin, which require administration within 120 minutes of the
procedural incision due to longer administration times. If a patient is already receiving an antibiotic for another infection
before surgery and that agent is appropriate for surgical prophylaxis, an extra dose of the antibiotic can be administered within
60 minutes of the incision. If a patient is already receiving vancomycin and has renal failure, cefazolin should be considered
before surgery instead of an extra vancomycin dose.[20]

Redosing antibiotics is an important factor due to the half-life of the particular antibiotic used. Factors such as renal
dysfunction and extensive burns may impact the half-life of an antibiotic. Based on the antibiotics mentioned above, cefazolin
and cefoxitin would have to be administered more than once, depending on the length of the procedure. A perioperative dose
of cefazolin should be administered again four hours after the initial preoperative dose, while cefoxitin should be administered
again two hours later. Redosing antibiotics due to significant blood loss or dilution during surgery are other considerations
being studied at this time.

Unless there is a known infection, prophylactic antibiotics should be discontinued within 24 hours. There remains controversy
regarding the duration of therapy to 48 hours postoperatively following cardiothoracic surgery. Two meta-analyses compared
24 hours versus 48 hours as the cut-off in cardiac surgeries. They found a significant decrease in surgical site infections with
the extended duration, particularly in sternal infections. The most recent guidelines from the CDC state that additional
prophylactic antibiotics should not be administered after the surgical incision is closed in clean and clean-contaminated
procedures. Although there could be procedure-specific exceptions, this recommendation applies to patients with or without a
drain after the surgical site is closed.
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 The three antibiotics used in adult surgical prophylaxis, where weight-based dosing is recommended, are cefazolin,
vancomycin, and gentamicin. For patients receiving cefazolin, 2 g is the current recommended dose except for patients
weighing greater than or equal to 120 kg, who should receive 3 g. Some literature states that cefazolin 2 g should be sufficient
for a patient at any adult weight. Vancomycin is dosed at 15 mg/kg, and gentamicin is dosed at 5 mg/kg. Other commonly
used prophylactic antibiotic dosing regimens in adults are clindamycin 900 mg, cefoxitin 2 g, and ertapenem 1 g. All
prophylactic antibiotics for pediatrics are dosed based on milligrams per kilogram of body weight. Examples of pediatric
dosages include cefazolin 30 mg/kg and vancomycin 15 mg/kg. Pediatric surgical prophylaxis dosages should not exceed the
usual adult dose.

Adverse E!ects
Limiting the duration of all antibiotics is important since any antimicrobial usage can alter hospital and patient bacterial flora,
which can potentially lead to colonization, resistance, or Clostridium difficile. The judicious use of vancomycin must be
considered to mitigate the potentially increased risk of vancomycin-resistant enterococcus (VRE).

Contraindications
Beta-lactam antibiotics, including cephalosporins, are commonly used for surgical prophylaxis, so it is crucial to identify
when these antibiotics are contraindicated. If a patient has an immunoglobulin (IgE) mediated (i.e., type 1) allergy to
penicillin, then penicillins, cephalosporins, and carbapenems should not be administered. A type 1 reaction would be
considered anaphylaxis, urticaria, or bronchospasm that occurs 30 to 60 minutes following administration of the antibiotic.
Cephalosporins and carbapenems are considered safe in patients who have not had a type-1 reaction or exfoliative dermatitis
(e.g., Stevens-Johnson syndrome and toxic epidermal necrolysis). Obtaining a thorough allergy history from each patient is
vital to determine whether the patient's allergy is a real and significant allergy that would impact the usual preoperative
surgical prophylaxis.

Monitoring
Surgical site infections may occur for various reasons, including, but not limited to, incorrect antibiotic usage. When
considering antibiotic prophylaxis practices, the correct antibiotic dosage, timing of the initial dose, and timing of any
applicable redosing are major factors to review to ensure best practices are always followed. If an institution recommends a
specific antibiotic in surgery when additional antibiotics are options, monitoring should ensure no surgical site infections
occur due to increasing local resistance. One example could be that growing clindamycin resistance has translated to increased
surgical site infections in those receiving clindamycin due to a penicillin allergy. That information could lead an institution to
switch to vancomycin instead of clindamycin in that patient population. Antibiotic selection should also be reviewed to
avoid using antibiotics, resulting in new or worsening resistance patterns identified on the antibiogram. An institution may
choose to use cefoxitin instead of ertapenem in colorectal surgeries to avoid excessive usage of the carbapenem class when
applicable, especially if the institution has an escalating number of carbapenem-resistant organisms.[21]

Toxicity
No apparent toxicities are known with the recommended doses. This is partially due to the limited duration of antibiotic
exposure in surgical prophylaxis.

Enhancing Healthcare Team Outcomes

The comprehensive and consistent practice regarding the routine perioperative antibiotic prophylactic measures requires the
coordination of the entire perioperative interprofessional healthcare staff. This includes but is not limited to the entire
operating room and perioperative staff members (including surgical techs, perioperative-based nursing staff, floor nurses,
advanced practitioners, pharmacists, and all clinicians participating in the care of surgical patients). This interprofessional
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 approach will optimize antibiotic prophylaxis, minimize adverse events, and drive optimal patient outcomes. [Level 5]

Review Questions
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Comment on this article.

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Publication Details

Author Information and A"liations

Authors

Marsha F. Crader1; Matthew Varacallo2.

A"liations

1 Univ. of Arkansas for Medical Sciences

2 Penn Highlands Healthcare System

Publication History

Last Update: September 4, 2022.

Copyright
Copyright © 2022, StatPearls Publishing LLC.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) (
http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used
commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

Publisher

StatPearls Publishing, Treasure Island (FL)

NLM Citation

Crader MF, Varacallo M. Preoperative Antibiotic Prophylaxis. [Updated 2022 Sep 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing;
2022 Jan-.
: