Comments on: Preventing Surgical Infections http://www.leinfections.com/antibiotics/preventing-surgical-infections/ Companion Blog Tue, 24 Jan 2012 22:13:36 +0000 hourly 1 http://wordpress.org/?v= By: Warren S. Joseph, DPM, FIDSA http://www.leinfections.com/antibiotics/preventing-surgical-infections/#comment-12 Warren S. Joseph, DPM, FIDSA Fri, 12 Mar 2010 20:09:09 +0000 http://www.leinfections.com/?p=246#comment-12 Thank for your the thoughtful question. Actually, your comment can be broken down in to TWO distinct questions. The first is the duration of antibiotic prophylaxis and the second would be the use of a cephalosporin vs. vancomycin. I think that the consensus is pretty clear that the appropriate duration of antibiotic prophylaxis should be shorter rather than longer. By far the most important dose is the one given BEFORE the surgical procedure. The "first rule" of prophy, as discussed in the Handbook, is that the level should be at its maximum at the time of initial incision. Pretty much all other subsequent doses are "icing on the cake"...up to a point. Most literature points to 24-48 hours of prophylaxis as being acceptable. Any more than that CAN lead to resistance development. A paper by Manian, et al, published in Clinical Infectious Diseases, April 2003 stated that "On multivariate analysis, only discharge to a long term care facility and duration of postoperative antibiotic treatment of >1 day were significantly associated with MRSA Surgical Site Infection". So, I would have to agree with your colleague on this one...sorry! As for the second question as to whether or not we should be using anti-MRSA prophy instead of just cefazolin, unfortunately there is little good literature or even consensus that I have seen published. I think that it is an entirely valid suggestion. IF you have a hospital where there is a high incidence of MRSA surgical site infection, then yes, I think it would be reasonable to consider prophy against this organism as opposed to just using a cephalosporin active against MSSA. If most of the surgical infections in your community are still MSSA, then I would hold off on the vancomycin prophylaxis. If anyone reading this is aware of any recent consensus document or clinical trials addressing this issue specifically, I would welcome your input! Thank for your the thoughtful question. Actually, your comment can be broken down in to TWO distinct questions. The first is the duration of antibiotic prophylaxis and the second would be the use of a cephalosporin vs. vancomycin. I think that the consensus is pretty clear that the appropriate duration of antibiotic prophylaxis should be shorter rather than longer. By far the most important dose is the one given BEFORE the surgical procedure. The “first rule” of prophy, as discussed in the Handbook, is that the level should be at its maximum at the time of initial incision. Pretty much all other subsequent doses are “icing on the cake”…up to a point. Most literature points to 24-48 hours of prophylaxis as being acceptable. Any more than that CAN lead to resistance development. A paper by Manian, et al, published in Clinical Infectious Diseases, April 2003 stated that “On multivariate analysis, only discharge to a long term care facility and duration of postoperative antibiotic treatment of >1 day were significantly associated with MRSA Surgical Site Infection”. So, I would have to agree with your colleague on this one…sorry!

As for the second question as to whether or not we should be using anti-MRSA prophy instead of just cefazolin, unfortunately there is little good literature or even consensus that I have seen published. I think that it is an entirely valid suggestion. IF you have a hospital where there is a high incidence of MRSA surgical site infection, then yes, I think it would be reasonable to consider prophy against this organism as opposed to just using a cephalosporin active against MSSA. If most of the surgical infections in your community are still MSSA, then I would hold off on the vancomycin prophylaxis. If anyone reading this is aware of any recent consensus document or clinical trials addressing this issue specifically, I would welcome your input!

]]> By: kaufmandoc http://www.leinfections.com/antibiotics/preventing-surgical-infections/#comment-11 kaufmandoc Thu, 11 Mar 2010 19:27:02 +0000 http://www.leinfections.com/?p=246#comment-11 Not a comment but a question: What is the general concensus regarding post operative oral antibiotics in patients receiving implants (screws, etc)? I routinely give a 7 day course of antibiotic coverage in these patients and was trained this way as well. I have been chastized by one of my colleagues for doing this with the opinion being that if the patient developed MRSA post operatively, my antibiotic course could be cited at the cause. I argue that if this were true, then rather than giving Ancef 1g pre-operatively (standard of care), Vancomycin 1g should be given to "prevent" post-operative MRSA. Is there a true standard of care regarding post-operative antibiotics and is there a potentially negative repercussion for doing so? Not a comment but a question:
What is the general concensus regarding post operative oral antibiotics in patients receiving implants (screws, etc)? I routinely give a 7 day course of antibiotic coverage in these patients and was trained this way as well. I have been chastized by one of my colleagues for doing this with the opinion being that if the patient developed MRSA post operatively, my antibiotic course could be cited at the cause. I argue that if this were true, then rather than giving Ancef 1g pre-operatively (standard of care), Vancomycin 1g should be given to “prevent” post-operative MRSA. Is there a true standard of care regarding post-operative antibiotics and is there a potentially negative repercussion for doing so?

]]> By: wsiegle http://www.leinfections.com/antibiotics/preventing-surgical-infections/#comment-10 wsiegle Thu, 28 Jan 2010 05:15:59 +0000 http://www.leinfections.com/?p=246#comment-10 in responce to the following "The rate of S. aureus infection was 3.4% in the treated group vs. 7.7% in the placebo group. Interestingly, ALL were methicillin susceptible (MSSA) so the study may, or may not be able to be extrapolated to MRSA carriage." In the treatment of the Pt's nasal mucosa I am assuming the method of infection transmission to be the aerosolization Staph. It may ,therefore, be prudent to compare the infection rates of treating a Pt's nares with simply employing the same surgical masks all others in the OR wear. In addition to finding out which method would be superior to controlling infection it could also give insight to the time frame in which a Pt carring Staph. could infect their surgical wound. in responce to the following “The rate of S. aureus infection was 3.4% in the treated group vs. 7.7% in the placebo group. Interestingly, ALL were methicillin susceptible (MSSA) so the study may, or may not be able to be extrapolated to MRSA carriage.”

In the treatment of the Pt’s nasal mucosa I am assuming the method of infection transmission to be the aerosolization Staph. It may ,therefore, be prudent to compare the infection rates of treating a Pt’s nares with simply employing the same surgical masks all others in the OR wear. In addition to finding out which method would be superior to controlling infection it could also give insight to the time frame in which a Pt carring Staph. could infect their surgical wound.

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