P J S S\ / o l .6 1 ,N o .

2 , A p r i l - J u n e2,0 0 6

PJss
iilf;liliiiilff
The Philippine College of Surgeons Evidence-Eased Clinical Practice Guidelines
on Antimicrobial Frophylaxis for Surgical Frocedures

D o r n i n g oS . B o n g a l aJ r . , M . D . , F . P . C . S . ; A l e x A . E r a s m o ,M . D . , F . P . C . S . ;
Mario M. PanaliganM , .D., F.F.C.S;
, . D . , F . P . S . M . I . D ,F . P . C . P . ;A n t o n i o A . A n : r s t a c i o M
R e n a t oR . M o n t e n e g r o ,M . D . , F . P . C . S ; A n t h o n y R . F e r e z ,M . D . , F . P . C " S .a n d
M a i t a T h e r e s aP . R i g o r , M . D . , F . P . C . S .

Starter Statement r o l e i n t h e c o n c e p t i o na r t c ld e s i g no f t h e s t t r c l yt,h e

s n c li n t e r p r e t a t i oonf c l a t aa n c tl l r e
c o l l e c t i o n a, r r a l y s i a
SLrrgical siteinf-ection is quitecolt'lt11otl anclhaswide d r a f t i n ga n d r e v i s i o ror f t l r e t n a n u s c r i p t .
socioeconorlic consequellces. andthus,it is necessary to
r e e x a m i r r tel t e p r a c t i c eo f a n t i m i c r o b i a pl r o p h y l a x i s ExecutiveSurnrnary
e s p e c i a l lrl v' i t ht h e c o n t i n u e c l i v e r s i t iyr ra r r t i r r r i c r o b i a l
prophylaxisnrethodsofferedto patientsby indiviclLral T h e c l i n i c a lq L r e s t i o nasc l c l r e s s b e yd t l r eg t r i c l e l i n e s
s u r g e o n sA.l t l r o L r gt hl r et o t a le l i n r i r t a t i oor fr s u r g i c asl i t e z r r e1 ) I s a n t i t t t i c r o b i apl r o p h y l a x i sr e c o t t . t t t t e r t cf ol er c l
infectionis not possible,a reductionin the irrfectionrate
t h e s u l g i c a l p r o c e d u r e ?a n c l 2 ) l i a n t i n r i c r o b i a l
t o a m i n i n r alle v e lw i l l l e s L r li tn c o t t s i d e r a bbl ee l r e f i t isn
p r o p h y l a x i iss r e c o t n n t e n d eFcol lt h ep r o c e c l u rw e ,l r a ti s /
telnrs of botlr patientcotnfort and nteclicalresottrces
a r et h ea p p r o p r i a taen t i n irc r o b i a | / s . c l o s e / a
s n c dl LtI'atiort
tused. It is theleforehopedthat sut'geous rvill recognize
o f p r o p h y l a x i sT ? l r e s eg u i c l e l i n easc l d l c stsl t e n e e c[l o r '
tlresholtcornings regardingthe eff-ects of tlany typesof
p r o p h y l a x i fso r o p e r a t i o n isr t v o l v i n gt l r eh e a cal t t crlr e c l < ,
interventious harrded clowtrfrorrrgettet'atiott to gertelation.
b r e a s tg, l o i r rh e r n i ag, z r s t r oLcrlo c l e r rbailI,i a r v c, o I o r e c t z i l .
some of rvhich have no proven efTicacy.and insteacl
t l r o r a c i c a n c l c a r cilo v a s c iltz t r , o t ' t h o p eiccl. t t r o l o g i c .
L r t i l i zteh et r e sat v a i l a b l e v i d e n c teo i m p r o v et l r eq L r a l i t y
andto facilitatecost-effective rueurosurgica I a'nclobstetl'icanclgvnecoIogic sttlgcry.
of theirclinical.lLrclgrnerrts
lrealthcare. S i g n i f i c a nLt l p d a t ef sr " o r trhr ep r e v i o L tvse l s i o no l ' t l t e
T h e e v i d e n c eb r o u g h tf o r w a r d i u t h e s eg u i d e i i n e s g L r i d e l r n ei nsc l u c l e t h e c l e v e l o p n t eonft g u i c l e l i t t ef o sr
i n s t o n e c Iean'an c[c I eatr-cotrtant i natecl o ttco I og i c heacl a lt cl n ecl<
s h o u l d ,h o w e v e r n, o t b e l o o k e do n a s r , v r i t t e n
s uf gery. r,i cleo-ass i stecltlroracoscop i c surgery,vascr-t Iat'
b u t r a t h e r a s r e c o n . u r e n d a t i o tbt sa s e d o l t c r t r t ' e t r t l y
s u r g e f y . s p i r r a l s u r g e r ) ' . c e s a r e a n c e
l l i r r e t ' r a
, trcl
a v a i l a b l e a d n r r s s i b l es t L t c l i e so t t a n t i m i c l o b i a l
p r o p h y l a x i sT. h e r e c o r r n t e u d a t i o tst hs o ul d a l s o b e g y n e c o l o g i sc L r f g e r yT.h e g L r i c l e l i r t lei ls< e w i s f
e o c t t s ecl
the
r l o d e r l a t e db y p a t i e n t s 'p r e F e t ' e n c easn d s c l c i e t a l o n t l i e p r e v e n t i o no f s L r r g i c asl i t e i nf e c t i o r ta s
c i r c u n s t a n c eass p a r t o f t h e m o s t i m p o l t a n te m p a t h i c s i g n i f i c a n t e n d - p o i n w
t h e n e v a l t r a t i n tgh c 'e t f i c a c yo f
a p p r o a c hb ) ,t h e s t l r g e o n . a d r ni n i s t e rni g p r o p h y l a c t i ac n t it r ri c r o bi a l s s in c ct' hi s i s
T h e P h i l i p p i r rCeo l l e g eo f S u r g e o r rwso u l d l i l < et o t h e m a i no L l t c o n roef c o t r c e r n[ o r s t t r g e o n s .
a c l i n o u , l e c l gt let e a s s i s t a n c o e f o L r rf r i e n c l sf r o n r t h e A s e a r c ho f p L r b l i c a t i o tur s' a s c a r r i e crl l t t t t t s i t l ga
p h a r m a c e u t i c ai n l c l u s t r y .[ t s h o u l d b e e r n p l r a s i z e d .s e n s i t i v es e a r c hs t r a t e g yc o n r b i r t i r t M g E S H a r r cl l ' e e -
h o w e v e rt,h a t t h c : i t ' a s s i s t a t w t caes p u r e l ya n d s o l e l y t e x ts e a r c l t e T
s l
. r i s s t f a t e g i
y r r c l t r d ea d n e x t e t i s i vsce a r c h
t e c h n i c ailn c h a r a c t e rt l' t, r o u g ht h e r e t r i e v aol f f i r l l - t e x t o f t h e f o l l o w i r r gc l a t a b a s e s :
a r t i c l e st l r a tw e r e i d e n t i f i e db y t h e T e c h n i c a W l olkirrg l . M e d l i r r e( 1 9 6 6t o p r e s e n t )
GloLrpaftera systentatic literaturesearch.They had no 2 . C o c h r a n eL i b r a r y( 2 0 0 4 )

66
 A n t i m i c r o b i a lP r o p h y l a x i sf o r S u r g i c a lP r o c e d u r e s 67

3. HealthResearchanclDevelopnteltt Networl< Panali-ean, MD, FPSMID,FPCP,AntonioA. Arrastasio.

(HERDIN) MD, FPCS,RenatoR. Montenegro, MD, FPCS,Anthony
4 . P h i l i p p i n Jeo u n r aol f S u r g i c aSl p e c i a l t i e s R. Perez,MD. FPCSand Maita TlreresaP. Rigor,MD.
C D - R O M ( 1 9 1 9t o 1 9 9 9 )a n d h a n ds e a r c h e s FPCS.
flom 2000 to oresent TbeTeclrnicalWorkingGrouppreparedtheevidence-
basedrepoftbasedon the articlesretrievedandappraised.
Frorr the searchresults.the technicalworkirrggroup After evalr-ration and validity appraisal, 47 articleswere
chosenand usedto answertlreclinicalqllestious.
selectecl releruant articlesfbr firll-text retrievalr"rsing tlre
TheTechuicalWorkingGroup togethelwith theparre I
N o m i n a lG r o u pt e c h n i q u eT.h e E v i d e n c e - B a s C e dl i n i c a l
of expertsreviewedthe interim repoft at the Bayauihan
Practice CLridelines for AntibioticProphylaxis in Elective
Hall,UnitedLaboratories, Inc.(LINILAB)in Mandalr.ryorrg
SurgicalProcedures rvhich was preparedin 2001 was
CityonNovenber27,2004.ThemodifiedDelphitechnique
reviervedtogetherwith the prirnaryliteraturebetweenthe
was tlren used to deterntinethe degree of colrsensr-rs
clateof thosepreviousgLridelines Lrpto 2004.Retrieved
regardi ng the recommendations.
studiesrverethenassessed fbr eligibilityaccordingto the
Thenrenrbers ofthe expertpanelr.l,ere; Drs.Dorringo
criteriasetby thegLrideline developers. The nrethodologic
S.B o n g a l a . l r . ,
A n t o ni o L . A n a s t a c i oM. a r i oM . P a n a l i g a n ,
qualitiesof the studieswere appraisedby at leasttwo
Alex A. Erasmo,RenatoR. Montenegro, MaitaTlreresa P.
inclepenclen r et v i e w e r su s i r r g a q L r a l i t ya s s e s s r r e r l t
Rigoraud AnthonyR. Perez.The invitedntembelswele
instrurment developecl by the PhilippineCardiovascular'Drs.Gr"racla pe V i I IanLreva
Ir"r and R i cardoM. Manalastas.lr.
Research GroLrp, as usedirrtlre previoLrs editionof these (POGSrepresentatives) andDrs. IsaacDavidE. Anrpil ll
guidelirres.' and RaymundoJoa.qr-rirr F. Erese(ResearchCourmittee
The clinical evidencewas rateclaccor"ding to the representatives). Otherexpeftpanelistscantefi'oll Metro
assessnlent systemof tlie InfectioLrs DiseaseSocietyof Manilahospitalsrepreserrted by Drs. EdgardoR. Cortez.
America:as usedin the flrst eclitionof tlresegLridelines.iJoseAntonioM Salud,Artulo S.DelaPeiia,MaximinoDy
R. Efgar,FranciscoY. Arcellana Jr., Rey MelchorF.
L e v e lI - E v i d e n c eo b t a i n e df r o r r a t l e a s t o n e Santos, l(im Shi C. Tan,ReynaldoSinamban, Dominador
properlydesigned randomized controlled M. ChiongJr'.,LeonardoL. CLraand JesusV. Valencia:
t l i a l o r n r e t a - a n a l y s iosf r a n d o m i z e d Drs.EdwinM. ConzagaandElvisL. Bediafrom Southern
controlledtrials TagalogChapter; Dr.JoseC. BLrgayorrgJr. fromCordillera
Levelll - Evidence obtainedfrom at leastonewell- ChapterlDr.Vitus S.Hobayanfi'orrCentralLuzon Chapter;
designecl controlledstLrcly withoutproper Dr, Stephen S.Siguanfi"omCebLr-Eastern VisayasChapter;
randomizatiorr, fi'omcolrortor case-contro I D r s .M a x i m oH , S i m b u l a Jn r .a r r dA l e x E L . C e i l i l l o f l o n r
arralyticstudies (preferablyfrolrr one Northern Mindanao Chapter.Drs. .lasonL. Letranancl
center),fi"ornrl ultip le t i me-series, or fronr DennisP. Serrano(PUA representatives), Drs.EnricoP.
d r a n r a t i c r e s u l t s i n u n c o n t r o l l e d R a g a z a a n d H e r r n o g e n e sJ . M o n r o y ( P C R C S
expelirlents representatives), Drs.AnclresD. BorrorleoandErlily H.
LevelIII - Evideuce obtained fi'ourexpeftconrurittee Tanchuling(POA representatirzes). Drs. Willy L. Lopez
reports ol opirrionsof respected atrtholities andLouieC. Racelis (AFN representatives), Drs,Napoleon
o n t h e b a s i so f c l i n i c a l e x o e r i e n c o e r De Guznran, Emrrranuel SanPedroandAntouioB. Rarnos
descriotivestLrcl i es. (TCVS representatives), Drs.AlbertoB. Roxas,Mark R.
Kho,lda MalieT. Lirn,andOrl i no C. B isqLrera Jr'..( Cancer
TheTechnicalWorkingGroLrpwascomposed of the Cornnritteerepresentati ves)
rurerrbers of tlre PCS Conrmitteeon Surgicallnfectiorr: The strengthof recomrrrendations for theguidelines
D o r n i n g oS . B o n g a l aJ r . , M D , F P C S - C l r a i r ,A l e x P . was categorized accordingto the level of agreenrent of
E r a s r l o , M D , F P C S - R e g e n t - i r r - C l r a r gM ea, r i o M . t h e p a n e lo f e x p e r t sa f t e ra v o t e b y t h e p a r t i c i p a r r t s :

PCSC.onrnrittcconStrrgica|]nf.ections,I999.200'
p r o c e d L r r ePsh. i l i p. l S L r r gS p e c2 0 0 2 : 5 7 ( 4 ) : I 3 5 -1 6 1 .
 2006
PJSSVot.61,No.2, APril-June'
68

CategoryA - Recommendation was approvedby An alternativeregitneuis cefazolinI gramIV single

consensLts of at least75 perceritof the mLrlti- d o s e .( l I I - A )
sectoralexPertPanel 6. A n t i m i c r o b i apl r o p h y l a x i si s r e c o m m e n d ef do r t h e
Category B - Recommendationwas soruewhat f o l l o w i n g o p e n b i l i a r y p r o c e d u r e sC: h o l e c y s t e c -
controversialand did not meetconsensus t o m y , S p h i n c t e r o t o r r i yC l r o l e c y s t e c t o t r tpyl u s
C a t e g o r y C - R e c o r n m e n d a t i o uc a u s e d r e a l sphincterotorny, Choledoclroenterostomy
disagreernent among membersof the expert ( C h oIe d o c h o d u o c l eons t o t l y , C h oI e d o c l r oudo d e -
panel uostonry,plr-rsphi ncterotonry,C hoIedochojej ltrros-
tor-ny), C hoIecystojej u nostonry,Cottrmonb i Ie d Lrct
Summaryof Guidelines e x p l o r a t i o n( l - A )
T h e r e c o t n m r e n daendt i r l i c r o b i afl o r p r o p h y l a x i s
l. A n t i n i i c r o b i a lp r o p h y l a x i si s r e c o m m e n d e df o r in open biliary sllrgeryis cefazolinI gram IV
electiveclean-contaminated oncologicheadandneck s i n g l ed o s e .( l - A )
surgery.(I-A) An alternativeregimenis cefuroximeI'5 grarnsIV
The recomtnended antimicrobialsfor prophylaxis s i n g l ed o s e (. l - A )
i n e l e c t i v ec l e a r r - c o n t a m i n a ot endc o l o g i ch e a da n d
neck surgery a r e c l i n d a m y c i n 3 0 0 n r g I V p r e - 7 . A r r t i m i c r o b i a lp r o p h y l a x i s i s N O T r o L r t i n e l y
recorrnrerrdecl fo r Iaparoscop i c choIecystecto my i n
operativelytherr300 mg IV every 8 hoLrrsfor 24
hours in conibinatiorrwith -eentarnicin 1.7 mg/l<g/ l o w - r i s kp a t i e n t s(.l - A )
dose IV pre-operativelytlien l'7 tt'tglkgldose IV
every 8 hoursfor 24 liours.(l-A) 8 . A n t i m i c r o b i a l p r o p h y l a x i s i s r e c o r n t n e n c l ef odr
T'hearninoglycoside may ltoweverbe administered c o l o r e c t aol p e r a t i o n s( .l - A )
a s a s i r r g l ed o s e .( l l l - A ) T h e r e c o n r n e n d e dt ' e g i m e nf o r p r o p h y l a x i si n
colorectalsttrgerycottsistsof an orally-adnr inistered
2. Antimicrobial prophylaxisis NOT roLrtinely antimicrobial combirred with a parenteral
recorntrrended for clean head and neck procedures a n t i m i c r o b i a l . T h e r e c o l l l m e n c l e do r a l l y -
such as thyroidectomy. parotidectomyand n 0 0m g
a d m i n i s t e r eadn t i m i c r o b i ai ls c i p r o f l o x a c i 5
s u b m a n d i b u l agrl a n de x c i s i o n (. l I - A ) for 3 dosesire-operatively.(l-A)
The reconrtnendea d n t i m i c r o b i a l sf o r s y s t e m i c
3 . A n t i i m i c r o b i a lp r o p h y l a x i si s N O T r o u t i n e l y p r o p h y l a x i sa. r e A m o x y c i l l i n - c l a v u l a n iacc i d 1 . 2
reconrurended for breastsurgery.(l-A) g r a r n sl V s i n g l e d o s e A m p i c i l l i n - s u l b a c t a1r .n5
g r a n r sI V s i n g l ed o s eC e f o x i t i n2 g r a n r sI V s i n g l e
4. Antimicrobial prophylaxisis NOT routirrely d o s eC e f a z o l i n2 g r a r n sT V p l L r sM e t r o n i c l a z o5l e0 0
recourmeuded for electivegroinherniasurgeryusittg m g I V s i n g l ed o s e( l - A )
p r i r n a r yt i s s u er e p a i r .( l - A )
Arrtimicrobial prophylaxisis likewiseNOT roirtinely 9 . A r r t i m i c r o b i a lp r o p h y l a x i si s r e c o m t n e r r d efdo r
for electivegroinherniasurgeryusirrg thoracic uotr-card iovascltlar procedr-rres. ( I -A )
recotnmetrded
m e s hr e p a i r . ( l - A ) T h er e c o m n t e r r d e adn t i r n i c r o b i af ol r p r o p h y l a x i isn
thoracicnort-cardiovascular sllrgeryis cefazolinI
5 . A n t i m i c r o b i a l p r o p h y l a x i s i s r e c o r n r l e n d e df o r g r a ml V s i n g { e d o s e (
. l - A )
electivegastricarrddtrodenalsurgery.(l-A)
T h e r e c o r r r t n e n daendt i r n i c r o b i af ol r p r o p h y l a x i isn 1 0 . A n t i n r i c r o b i a lp r o p l r y l a x i si s r e c o t n n r e n d efdo r
e l e c t i v eg a s t r o d u o d e nsaul r g e r yi s c e f t t r o x i t n e1 . 5 v i d e o - a s s i s t etdh o r a c o s c o p i cs t r r g e r y( V A T S ) .
g r a m sI V s i n g l ed o s e .( l l - A )
(rr-A)
A n t i m i c r o b i aP
l r o p h y l a x i sf o r S u r g i c a lP r o c e d u r e s 69

Tlrerecommended antirnicrobi als for vi deo-assisted Alternativeregimensare: Cephalexirr500 mg per

thoracoscop ic surgeryareArnpici I Iin-suI bactarnI .5 orern TID for 3 doses (l-A) FluoroqLrinolone
g r a r x sI V s i n g l ed o s eA m o x y c i l l i n - c l a v u l a n a
i cc i d (Ciprofloxacin,Ofloxacin, Levofloxacin)400 rng
2.4 grans IV singledose (II-A) IV every 12 hoursfor 3 days(lll-A)

l 1 A n t i r r r i c r o b i apl r o p h y l a x i si s r e c o m m e n d e df o r 1 5 .A n t i r n i c r o b i apl r o p h y l a x i iss r e c o n r m e n d ei nds p i n e

cardiacsurgery.(l-A) o p e r a t i o u ss r - r c ha s l a m i n e c t o m i e sf,u s i o n s a n d
T h e r e c o m r n e n d eadn t im i c r o b i a sl f o r p r o p h y l a x i s
d i s c e c t o m i e s( l.- A )
in cardiacsurgeryare Cefazolin I grarn IV pre-
The recommended antinricrobialfor prophylaxisin
opelativelythen I grarn IV every 8 hours for 48
spine surgeryis cefazolin I grarrrIV single dose
h o u r s C e f u r o x i m e1 . 5 g r a m s I V p r e - o p e r a t i v e l y
(I-A)
t h e n 1 . 5 g r a m sI V e v e r y l 2 h o r " r r fso r 4 8 l r o u r s
(I-A) An alternativeregimenis oxacillin I gram IV pre-
operativelythen 500 nrg IV every 6 lroursfor' 24
1 2 . A n t i n r i c r o b i apl r o p h y l a x i si s r e c o m m e n d e df o r Irours.(l-A)
peripheralvascular surgery.(l-A)
The recommended antirnicrobialfor prophylaxisin 1 6 . A n t i n r i c r o b i a lp r o p h y l a x i si s r e c o m r n e n d efdo r
peripheralvascularsLrrgeryis cefazolirrI gram IV c e r e b r o s p i n af llu i d s h u n t i n gp r o c e d u r e s( l.- A )
pre-operatively therrI grarnIV every6 hoursfor24 T h e r e c o m r r e n d e ad n t i r n i c r o b i a lfso r p r o p h y l a x i s
h o L r r s( .l - A ) i n C S F s h u n t i n gp r o c e d u r easr eC l o x a c i l l i nI g r a r r r
A n a l t e r n a t i v ree g i m e ni s c e f u r o x i r n e1 . 5g r a r n sI V IV pre-operatively then I granrIV every6 hoursfor
pre-operatively then 1.5 gramsIV everyB hoursfor 24 hoursOxacillin I gramIV pre-operativelythen I
2 4 h o L r r s( l. - A ) gram IV every 6 hours for 24 lrours (l-A)
If the patienthas a pre-operativestay of at least3
13. Ant i m icrobi al prophyIaxis i s recomrnended for total d a y s ,t h e a d d i t i o no f g e n t a m i c i n 2 4 0r n g I V s i n g l e
joirrt replacementsurg'rryand electivefixation of doseto eitlrerof the previor"rsly listed regirnensis
closedlorrgbonefractures.(l-A) recornmended. (lII-A)
The recornrnended antirlicrobialfor prophylaxisin
totaljoint replacement sLrrgery andelectivefixation 17. Antimicrobial prophylaxis is recommendedfor
of closedlong bonefi'acturesis cefazolinI grarnIV craniotomy.(l-A)
pre-operatively therrI gramIV every8 hoursfor24
The recomnlendedantirnicrobialsfor prophylaxis
h o u r s (. l - A )
i n c r a n i o t o r l y a r e C l o x a c i l l i n 1 g r a r r tI V p r e -
Alternative r e g i m e na s r e :C e f u r o x i t l eI . 5 g r a m sI V
operativelytheu I grarn IV every 6 hours for 24
pre-operativelythen 750nrg lV every8 hoursfor24
h o u r sO x a c i l l i n 1 g r a m I V p r e - o p e r a t i v e tl h
y en 1
l r o u r s o r C e f t r i a x o n e2 g r a m s I V s i n g l e d o s e
granrIV every 6 hours for 24 hours (l-A)
(I-A)
If the patienthas a pre-operativestay of at least3
1 4 . A r r t i r n i c r o b i apl r o p h y l a x i si s r e c o n r n r e n d efdo r days,the additionof gentamicin240 rng IV single
transurethralresectionof the prostateto prevent doseto either of the previor-rsly Iistedregirnensis
p o s t o p e r a t i vbea c t e r i u r i aa n d c l i n i c a l s e p t i c e m i a . recomrrrended. (llI-A)
(I-A)
The recomnrended antimicrobialfor prophylaxisin 18.Antimicrobialprophylaxisis recontntended for both
transnrethralresection of the prostate is electiveand emergeucycesareansections.(l-A)
ciprofloxacin500rngtabletper oremBiD for 3 days The recommendedantirnicrobialsfor prophylaxis
(I-A) i n c e s a r e a ns e c t i o n sa r e A r n p i c i l l i n 2 g r a m s I V
10 P J S SV o l . 6 1 , N o . 2 , A p l i l - J u r r e2, 0 0 6

s i n g l ed o s ep r e - o p e r a t i v e ol yr a f l e r c o r d c l a n r p i u g a c l ni rni s t e r i n gp r o p h y l a c t i a c n t it r i c r o b i a l s in c et hi s i s
Cefazolin2 grams lV singledose pre-opelatively or" the main outconreof concern for surgeons.
atier cord clamping (l-A)
T h e f o l l o w i n gg e n e r a pl r i n c i p l e si n a n t i r t t i c r o b i a l
1 9 . A n t i r r r i c r o b i apl r o p h y l a x i si s r e c o u r r r r e n d ef odr p r o p h y l a x i sw e r e u s e c la s t h e b a s i sf b r c h o o s i n gt l r e
a b d o m i n ahl y s t e r e c t o r n(yl .- A ) a p p r o p r i a taen t i t r i o t i c /i ns t h i sa r t i c l e :
T h er e c o n i r n e n d e adn t i n r i c r o b i af bl r p r o p h y l a x i isn l . T h ec h o i c eo f t h ea n t i r n i c r o b i sahl o L r lLcrle[ - r a s e c l o n
a b d o r r r i n ahl y s t e r e c t o u riys c e f a z o l i n I g r a r r il V the paranretersof efll cacy,epi dcrni c.l Iogyo1'ex pectecl
s i n g l ed o s e . ( l - A ) p a t h o g e r r l,o c a l r e s i s t a n c ep a t t e r n s ,s a f e t y a t n c l
a d v e r s er e a c t i o n sc,o s t a n c a l vailability.
Introduction 2 . T l r ec h o s e na n t i m i c r o b i af lo r p r o p h y l a x issl r o L l lbcel
a d n r i r r i s t e r ewdi t h i r r2 h o u r sb e f o l et l t es t a r to f t h e
S u r g i c a l s i t e i r r l ' e c t i o ni s a p o s t o p e r a t i v e proceclu re.
ct-rnrp I icationwh iclrresults i n signi ficarrtrnorbidity ancl 3 . T h e a c l r n i t r i s t e r edcols e o f t h e a r t t i t n i u ' o b i af lc r r '
n t o r t a l i t ay n dm a r k e d l yi n c r e a s ehso s p i t acl o s t sB . ecause p r o p h y l a x i s h o u l cnl o t b e l o w e rl'l t a t tt h e s t a r r c l a r c l
t h i s c o m p l i c a t i o ni s q L r i t ec o m n l o n a n c l h a s w i d e t l i e r a p e u t iccl o s eo f t h e d r u g .
s o c i o e c o r r o mci oc n s e q u e n c ei st w , a sd e e t t t e nd e c e s s a t ' y4 . I n u r o s t e l e c t i v e p r o c e cul r e s . s i n g l e c o l se
t o l e e x a r r r i ut eh e p r a c t i c eo f a r r t i n t i c r o b i aplr o p l r 1 , l 2 n 1 t a n t i n irc r o bi a l p r o p h yal x i s i s r e c o n i n i e n c l e c l .
e s p e c i a l lw y i t h t h ec o n t i n u e d i v e r s i t yi r ra n t i m i c r o b i a l 5 . 1 1 ' ap r o c e d u r el a s t sl o n g e rt h a r rt h e h a l f ' l i f ' eo l ' t h e
prophylaxisrlethodsofferedto patientsby incliviclual p l o p l r y l a c t iac n t i n t i c r o b i agl i v e n .a s e c o n ccll o s ei s
surgeons. ThesepracticegLridelines thereforeuseclttrore lecorrr mencled. Subsequentcloses i f ttecessaly shottlcl
s t r i n g e nct r i t e r i af c r r i n c l u s i o no f s c i e n t i f i ca l t i c l e si n b e g i v e na t i r t t e r v a l ns o t l o r t g e tr l t a t t t , v i c teh e h a l f - -
t l r e e v a l u a t i o no f a d n r i s s i b l e v i c l e n c ef o r t r e a t u r e n t l i [ eo f t h e c l r u g .
e f f i c a c y i n o r c l e l t o p r o r r r o t et h e i n t e g r a t i o na r t d 6 . T h e u s e o l ' a n t i n r i c r o b i a ;l r r o p h y l a x i iss t t o t z t
i n t e r p r e t a t i o no f v a l i c l , i n t p o r t a n ta n c l a p p l i c a b l e substitLrte for goocli nf'ectioucontt'o I practi ces,pfopel'
research-cleri veclevidence. p a t i e n tp r e p a l a t i o ng, o o d s u r g i c a lt e c h n i q u ea, n
T h e c l i n i c a lq u e s t i o n as d d r e s s e bd y t h e g u i c l e l i n e s a c l e q u a toep e r a t i n gl o o t n e n v i r o u l n e n ta, n c lg o o c l
a r e l ) i s a n t i m i c r o b i apl r o p h y l a x i sr e c o m r t t e n c l feodr cl i n ical-juclgnrerr t.
t h e s u r g i c a l p r o c e d u r e ,a n d 2 ) i f a n t i n r i c r " o b i a l" 7 . T h e f i r r a lc l e c i s i o rn^ e g a irrcrlgt l r eb e r r e l ' i a t st t dr i s l < s
prophylaxisis recornrrrended fbr the procedr,rre, rvhatis/ o f p r o p l r y l a x ifso r a r ri r r d i v i c l u awli l l d ep e r r coll t t l r e
arethe appropriate antirnicrobial/s, dose/saudduratiou p a t i e n t 'rsi s l <o f s u r g i c asl i t ei n f e c t i o nt,h ep o t e n t i a l
o f p r o p l r y l a x i sT? h e g L r i c l e l i n easd d r e s st h e t t e e df o r ' s e v e r i t y o f t h e c o l ' l s e q u e l l c eo sf s u r g i c a ls i t e
p r o p h y l a x ifso r o p e r a t i o nisr r v o l v i n gt h e h e a da n dn e c k , i n f e c t i o n t, h e e f f e c t i v e n e sosf p r o p l r y l a x i isr i t h a t
b r e a s tg, r o i nh e r n i ag, a s t r o d u o d e n a b li ,l i a r y .c o l o r e c t a l . operatiott,anclthc'consecluences of ;:rophylaxisl'or
t h o r a c i ca n d c a r d i o v a s c u l a o r ,r t h o p e c l i cu, r o l o g i c , t l r a tp a t i e r r t
n e u r o s u l g i c aaln do b s t e t r i ca n d g y n e c o l o g i sc u r g e r y .
S i g n i f i c a nut p d a t e fsi ' o r nt h ep r e v i o u sv e r s i o no f t h e ThesegLriclelines reflectcurrentl<nowleclge regarding
g u i d e l i n e si n c l u d et h e d e v e l o p m e not f g L r i d e l i n ef o s r ' a n t i r n i c r o b i aplr o p h y l a x i si t t s L r t ' g e a l yt t h e t i n r eo f i t s
c l e a na n dc l e a n - c o n t a r n i n a o t eudc o l o g i ch e a da n d n e c k p r e p a r a t i o nG . i v e n t l r e c l y n a r n i cn a t u f eo l ' s c i e r r t i f i c
surgery, video-ass isted thoracoscopic surgery,vascular' i n f o r r n a t i oann ctl e c h n ol o g y ,p e r i o ci cl r e vi e w ,u p c l a rt rig ,
s L r r g e r y s, p i n a l s L l r g e r y ,c e s a r e a r ld e l i v e l y a u d a r r dr e v i s i o na r e t o b e e x p ec t e c l .
- g y r r e c o l o gsiuc r g e r yT . h e g L r i d e l i n el si k e w i s ef o c u s e c l T h e s eg L r i c l e l i n ne rsa yn o t b e a p p r o p r i a tfeo r u s ei n
o n t h e p r e v e n t i o no f s u r g i c a l s i t e i n f e c t i o n a s t h e a l l c l i n i c a l s i t u a t i o n s .D e c i s i o r r st o f o l l o w t h e s e
significanteud-pointwhen evaluatiugtlre efficacy of r e c o m r n e n d a t i o n msu s t b e b a s e do n t h e p r o f e s s i o n a l
 Antimicrobial Prophylaxisfor SurgicalProcedures 7l

judgrnentof the surgeonand considerationof individual dateofthosepreviousguideli nesupto and including2004.

patientcircumstances and availableresoltrces. Retrievedstudieswere tlren assessedfor eligibility
accordingto the criteriaset by the guidelinedevelopers.
Methods The methodologicqualitiesof the studieswereappraised
by at least two iridependentreviewersusing a quality
The followingclinicalquestions wereaddressed by these assessmentinstrumentdevelopedby the Philippine
guidelines: CardiovascularResearch Group,asusedin thefirstedition
l. Is antimicrobialprophylaxisrecomrnendedfor the oftheseguidelines.i ParticLrlar attentionwasgivento study
surgicalprocedure? design, with greatestcredencegiven to randomized,
2. If antirnicrobialprophylaxisis recommended for the controlleddouble-blindstudiesandsystematic reviewsof
procedure,wltat isI are th e appropriateantim icrobials, properlydonerandomizedcontrolledtrials.
dose/sanddurationof prophylaxis? Tlie pertinentresultsof the selectedarticlesbasedon
the clinical questionswere sulnlnarizedand compared.
The followingsLrrgical procedures were includedirr Whenappropriateandwhererelevantdatawereavailatrle,
t h eg u i d e l i n e s : tlrerelativeor absoluterisks,risk differences,oddsratios
a. FleadandNeck Surgery and nunrberneededto treat (NNT) were conlputedarrd
b. BreastSurgery cornpared.
c. GroinHerniaSurgery EaclrguideIinewasratedusinga two-partrating system.
d. Gastroduodenal Surgery Roman numeralsI through III indicatethe "quality of
e. Biliary Surgery evidence"while the letters A through C indicate the
f. ColorectalSurgery "strengthof tlre recommendation. "
g. Thoracicand Cardiovascular Surgery The clinical evidencewas rated accordingto the
h. OrthopedicSurgery assessment systemof tlre InfectiousDiseaseSocietyof
i. UrologicSurgery America,asusedin thepreviouseditionoftheseguidelines.'
j Neurosurgery
k. Obstetricand GynecologicSurgery Level I- Evidence obtained from at least one
properlydesignedrandomizedcontrolled
A searchof publicationswas carried out using a trial or meta-analysisof randomized
controlledtrials
sensitivesearclrstrategycombining MESH and free-text
Level II pvidenceobtainedfrom at leastonewell-
searclres. This strategyinclLrded an extensivesearchofthe
designedcontrolledstLrdy withoutproper
followingdatabases:
randornization,fromcohortor case-control
I . Medline(1966to preserrt)
analytic studies(preferablyfrom one
2. Cochrane Library(2004)
center),frornrnLrltip Ie tinre-series,
or fi"om
3. HealthResearchand DevelopnrentNetwork dramatic results in uncontrolled
(Herdin)
experiments
4. PhilippineJournalof SurgicalSpecialties LevelIII - Evidenceobtainedfronrexpertcommittee
CD-ROM (1979to 1999)and handsearches reportsor opinionsofrespectedauthorities
frorn 2000 to nresent on the basis of clinical experienceor
descriptive studies
From tlre searchresults,the teclrnicalworking group
selectedrelevantarticlesfor full-text retrievalusingthe The TechnicalWorking Croup was conlposedof the
NorninalCroLrp Teclinique. The Evidence-Based Clinical following:
PracticeGLridelines for AntibioticProphylaxisin Elective DomingoS. BongalaJr., MD , FPCS- Chair
SurgicalProcedures which was preparedin 2001 was AlexA.Erasrno,MD,FPCS-Regent-in-Charge
reviewedtogetherwith the primaryliteraturebetweentlre Mario M. Panaligan,MD, FPSMID,FPCP

PCSClornmittee on SurgicalInfeotions,1999-2000. clinicalpracticeguidelinestbr antibioticprophylaxisin electivcsurgical

Evidence-based
p r o c e d u r ePsh. i l i pJ S L r r S
g p e c2 0 0 2 ;- 5 7 ( 4 )1: 3 5 - l 6 l
11 2006
PJSSVol. 61,No.2, APril-June'

Antonio A. Anastasio,MD, FPCS complicationsand costsassociated with an intervention.

RenatoR. Montenegro,MD, FPCS Therefore,an exactcorrelationdoesnot exist betweenthe
AnthonyR. Perez,MD. FPCS "quality of' evidence" and the "strengthof a
Maita TheresaP. Rigor, MD, FPCS recommendation. "

TheTechnicalWorkingGrouppreparedtheevidence- Operational Definitions

basedreportbasedon the articlesretrievedandappraised. Ant imicr obial Pr ophylaxis
After evaluationand validiiy appraisal,47 articleswere This was defined as the adrninistrationof a short-
chosenand usedto answerthe clinical questions.The courseof an anti-infectivedrr-rgin order to achievethe
TechnicalWorking Group then held severalmeetingsto followinggoals:
discusseach clinical question and the corresponding I Preventthe development of postoperative infectionat
)
evidence,formulate the initial recommeudationsand the surgicalsite,
thereafterreacha consensus utilizing the NorninalGroup 2) Prevent postoperativeinfectiorrsmorbidity and
technique.A consensus wasreachedafterhavingattained mortality,
at least70 percentagreementamongtlre rnembersof tlre 3) Haveno adverseconsequellces for themicrobialflora
TechnicalWorkingCroup. of the patientor the hosPital,and
TheTechnicalWorkingGrouptogetherwith thepanel 4) Reducethe dLrration anclcostof healthcare.
of expertsreviewedthe interim report at the Bayanihan
Hall,UnitedLaboratories, Inc.(UNILAB) in Mandaluyottg Surgical SiteInJection
r 7 , 2 0 0 4 ' E a c hc l i n i c a l
C i t y . P t r i l i p p i n eosn N o v e m b e 2 Tlieseguidelirres adoptedthe standarddefinitionof
question,the evidenceand the recolntnendations were wound infectionsas proposedby the Centet'for Disease
analyzedand the participantsgiven the opportunityto ControfandPreventionin I 992 andusedin thefirst edition
expresstheir opinionsand views. The rnodifiedDelphi of theseguideliries.i
techniquewas then used to determinethe degree of
consensus regard ing the recommendations' l) SuperficialIncisionalSrrrgicalSiteInfection
The strengthof recommendatioris forthe gtridelines - rnust occur wttltin 30 days after the operative
was categol'ized accordingto the level of agreementof procedure, mustinvolveorrlytlre skin or sttbcttta-
the panelofexpertsaftera votationby the participants: neoustissueof the incision,and at leastone of the
CategoryA - Recommendationwas approved by followingmust be Present:
corlsensus of at least 75 percent of the multi- a. PurulentdrainagefrorntlresLrperticial ittcision:
sectoralexpert panel b. Microorganisms isolated fiorrr an aseptically
C a t e g o r y B - R e c o m m e n d a t i o nw a s s o m e w l r a t obtainedcultLtre of flLridor tissttefiornthe
corrtroversiat and did llot lreet consenstls i sttperficial incisiorr;
C a t e g o r y C - R e c o m m e n d a t i o nc a u s e d r e a l c. At leastoneof the fbllowingsigrrsands)'nrptotlls
disagreenrent amongmenrbersof the expertpanel of infection-paitt or tenderttess, localizedswelling,
r e c l n e s so. r h e a t - a n d s u p e r f i c i a li n c i s i o ni s
The lettersA throLrghC are used to indicatethe deliberately openecl by thestrrgeott. ttnless culture
"strengthof recomtnendatiou" for or against the use of a o f i n ci s i o ni s n e g a t i v e .
particularoption. Detertninationof the "strengthof d. Diagnosisof sr,rperficial irtcisionalSSI by the
recomntetrdatiott" wasbasedon a consideration of several sltrgeolt or attertding physiciarr.
criteria,includingthe"qualityof evidence"asdetermined
by at leasttwo independent appraisersof the studiesused 2) DeepIrrcisional SLrrgical Site lnfectiorr
- rnust occur within 30 days after the operative
for tlre reconrmendation,potential for lrarm if an
interventioudid not take place,as well as the potential procedureif no implant is left in placeor withirr

p c s c o m n r i t t eoen s u r g i c a Il n f ' e c t i o n lsg, g g - 2 0 0 0E. v i d e n c e - b a scel idn i c a p g u i d e l i n efsb r a n t i b i o t i cp r o p h y l a x iisn e l e c t i v se L t r g i c a l

l ractice
2
p r o c e d u r ePsh. i l i p. l S u r gS p e c 0 0 2 :
5 7 ( 4 ) :I 3 5 - l6 l
Antimicrobial for SurgicalProcedures
Prophylaxis I3

1 year if irnplant is in place; the infection must Results

appearto be relatedto the operativeprocedure;the
Head and Neck Surgery
infectionmustinvolvedeepsofttissues(fascialand
m u s c l el a y e r so) f t h e i n c i s i o na; n da t l e a s to n eo f t h e A. Clean-ContaminatedHead and Neck Surgery
f o l l o w i r r gm u s tb e p r e s e n t :
l. I s a n t i r n i c r o b i a lp r o p h y l a x i sr e c o m m e n d e df o r
a. Purulentdrainagefrom the deepincisionbut not
electiveclean-contaminated oncolosicheadandneck
from tlreorgan/space componentof the strrgical
surgery?
sitel

b. A deepincisionthat spontaneously dehiscesor A n t i r n i c r o b i a lp r o p h y l a x i si s r e c o m m e t r d e fdo r

is deliberately opened by a surgeon wlren the electiveclean-contaminated oncologicheadand neck
t r r eo f t h e f o l l o w i n gs i g n so r
p a t i e nht a sa t l e a s o s u r g e r y(. C A T E G O R YA R E C O M M E N D A T I O N )
s y m p t o m sf:e v e r > 3 8 o Co r l o c a l i z e dp a i n o r
t e u d e r n e s su,nl e s s c u l t u r e o f t h e i n c i s i o r ri s Summary of Evidence
ruegative;
A randomizedplacebo-coritrolled trial (Dor, 1973)
c . A n a b s c e s so r o t l r e r e v i d e n c e o f i n f e c t i o n enrolling 102patientswas doneto detenninetheefficacy
i n v o l v i n gt h e d e e p i n c i s i o nt h a t i s f o u n d o n of the combinedcloxacillin-arnpicillin (2 gramsof each
direct examination,during reoperation,or by daity) comparedto placebo.There was a statistically
l r i s t o p a t l r o l o goi cr r a d i o l o g i c e x a m i n a t i o n ;
significantdifferericein infectionratesbetweentlretwo
g r o u p sw i t h 1 7 . 3 p e r c e n t( 9 o f 5 2 p a t i e r r t s i)n t h e
d . D i a g r r o s iosf a d e e pi r r c i s i o n aSl S Ib y a s L l r g e o r l
prophylaxisgrolrpand 36 percent( I 8 of 52 patients)in
o r a t t e n d i n gp h y s i c i a n .
t h e p l a c e b og r o u p d e v e l o p i n gi n f e c t i o n s( p < 0 . 0 5 ) .
(LEVEL I EVIDENCE)
3) Organ/Space SurgicalSite Infection A randomizeddoLrb le-blind placebo-contro I ledtrial
- must occr"rrwitlrin 30 days after the operative (Becker, 1979) enrolling 59 patientswho underwent
procedure i f n o i m p l a n ti s l e f t i n p l a c eo r w i t h i n h e a d a n d n e c k s u r g e r y f o r c a n c e r o f t h e L l p p e r
1 y e a r i f i r n p l a n ti s i n p l a c e ;t h e i n f e c t i o nm u s t aerodigestive tract was done to deternrinethe efTicacy
appearto be relatedto the operativeprocedure;the of cefazolin 500 mg IM for 24 hours comparedto
infectionmustinvolveany partof theanatotnyother placebo.Therewasa statisticallysigrrificantdifference
t l r a nt h e i n c i s i o no, p e n e do r m a n i p u l a t eddu r i n gt h e in infectionratesbetweentlre2 groupswith 3B percent
o p e r a t i v e p r o c e d u r e ;a l t d a t l e a s t o n e o f t h e (12,of 32 patieilts)in the cefazolingroupand87 percent
f o l l o w i n gm u s tb e p r e s e n t : ( 2 0 ' o f 2 3 p a t i e n t s )i n t h e p l a c e b og r o u p d e v e l o p i n g
<
a. Purulentdrainagefrom a drain that is placed i n f e c t i o n sf o r a n R R o f 0 . a 9 ( p 0 . 0 0 1 ) .( L E V E L I
througha stabwound into the organ/space; EVIDENCE)
A r a n d o m i z e dp l a c e b o - c o n t r o l l et d rial (Johnson,
b. Microorganisrnsisolated from an aseptically 1 9 8 4 )e n r o l l i n g8 7 p a t i e n t sw a s d o n et o d e t e r r n i nteh e
obtainedcultureof fluid or tissuein the organ/ e f f i c a c y o f t h e t h i r d g e n e r a t i o nc e p h a l o s p o r i r r s
space; cefoperazoneand cefotaximegiven for 24 hours as
comparedto placeboin preventirrgsurgicalsiteinf'ection.
c . A n a b s c e s so r o t h e r e v i d e n c e o f i n f e c t i o n
a s t a t i s t i c a l l ys i g n i f i c a n t d i f f e r e n c ei n
involvingtheorgan/space that is foundon d irect T h e r e w a s
infectionratesbetweenthe antimicrobialprophylaxis
examination,during reoperation,or by
and placebogroupswith 10 percentin the cefotaxime
histopathologic or radiologic examittation;
group, 9.4 percentin the cefoperazonegroup and 78
d . D i a g n o s i os f a d e e pi n c i s i o n aSl S Ib y a s u r g e o n p e r c e n ti n t h e p l a c e b og r o u p d e v e l o p i n gi n f e c t i o n s .
or attendingphysician. (LEVEL I EVIDENCE)
 74 P J S SV o l .6 1 ,N o .2 , A p r i l - J u n e , 2 0 0 6

2. What is/arethe appropriateantimicrobial/s,dose/s prophylaxisand25 percent( I 4 of 56 patients)of those

and duratiorrof propliylaxis? w h o r e c e i v e d5 d a y s o f a n t i m i c r o b i a lp r o p h y l a x i s
d e v e l o p i nign f e c t i o n(sp > 0 . 0 5 ) (. L E V E L I E V I D E N C E )
T h e r e c o m m e n d eadn t i m i c r o b i a l fso r p r o p h y l a x i s A r e t r o s p e c t i vset l r d y( R u b i n , 1 9 8 8 )e n r o l l i n g2 3
in electiveclean-contaminated oucologicheadandneck patientswlro developedbacteriaIsurgicalsiteinfection
surgeryareclindamycin300 mg IV pre-operatively then following headand neck oncologicsurgeryfoundtlrat
300 nrg IV every 8 hours for 24 hours in combination the most freqLrentlyisolatedorganismswere aerobic
with gentamicin1.7mg/kg/dose IV pre-operatively then gram-positive andgram-negative organisms whiclrwere
1 . 7 m g l k g / d o s eI V e v e r y 8 h o u r s f o r 2 4 l r o u r s . isolatedin 91 percentand the anaerobeswhich were
(CATEGORY A RECOMMENDATION) isolatedin 74 percent.Colorrizationwith Candidawas
seen in 48 percentof casesbut this was observedto
Summary of Evidence r e s o l v e w i t h o r . r ta n y s y s t e m i c a r r t i f u n g a lt h e r a p y .
A r a n d o m i z e dc o n t r o l l e d t r i a l ( J o h n s o n ,1 9 8 4 ) (LEVEL III EVIDENCE)
enrolling 107 patients r.vas doneto determinetheefficacy
o f c e f a z o l i rcro m p a r e d t o c l i n d a m y c i np l u sg e n t a n r i c i n B, Clean Heacl and h'eck Surgerv
in preverrting surgicalsiteinfections.After stratification
p r i o rt o r a n d o rirz a t i o nt o d i s t r i b u t e q u a l l yt l r ev a r i a b l e s 1 . I s a n t i r n i c r o b i aplr o p h y l a x i sr e c o m m e n c l ei nd c l e a n
that might irnpacton the developnrerrt of postoperative headand neck surgery?
infectiorrsacrossthe treatmentgroups,a statistically
significantreductionin theriskof infectiorrwasobserved A n t i m i c r o b i a lp r o p h y l a x i si s N O T r o u t i n e l y
a t n o n g p a t i e n t sr v h o r e c e i v e d c l i n d a m y c i n p l u s recofflnrencled for clearrlreadand neckoperatiorrs suclr
g e n t a m i c ie n i t h e ra s s i r r g l ed o s eo r n r u l t i p l ed o s e s( 7 % a s t h y r o i d e c t o m yp, a r o t i d e c t o m a y nd submandibular
and 4Yo, respectively)comparedwith patients who g l a n d e x c i s i o n . ( C A T E G O R Y A R E C O M M E N -
r e c e i v e dc e f a z o l i ne i t l r e ra s s i n g l e d o s e o r m u l t i p l e DATION)
doses(33% and 200/0,respectively).A postoperative
surgical site infection rate of 37 percent was noted Summary of Evidence
a r n o n gt h o s e w h o u n d e r w e n t f l a p r e c o n s t r u c t i o n .
(LEVEL I EVIDENCE) A r e t r o s p q c t i v se t u d y ( J o h r r s o n 1, 9 8 7 )e n r o l l i n g
A randomized double-bIind controlledtrialenrolIing 4 3 8 p a t i e n t s w h o u n d e r w e n t t h y r o i d e c t o n r y .
1l3 patientswas done to determinethe efficacy of p a r o t i d e c t o n ray n, d s u b m a n d i b u l agrl a n de x c i s i o nw a s
t i c a r c i l l i up l u sc l a v u l a n i ac c i dc o m p a r e tdo c l i n d a m y c i n dope. Eighty percentof thesepatientsdicl not receive
plLrs amikacingivenfor 24 hoLrrs. Therewasa statistically antib'ioticprophylaxis.Infectionscleveloped in orrly0.7
significantdifferencein infectionratesbetweenthetwo percent(3 patients)dr-rringthe one month follow-up
groLrpswitlr 36 percent (20 of 55 patients) in tlie periodafter surgerywith one of tliesepatientshaving
t i c a l c iI I i n - c l a v u
l a ni c a c i dg r o L l pa n d I 0 p e r c e n(t6 o f 58 r e c e i v e dp e r i - o p e r a t i v a e n t i r n i c r o b i apl r o p h y l a x i s .
p a t i e n t si )n t h ec I i n d a m y c i n - a n r i l < agcr ionu pd e v e I o p i n g ( L E V E L I I E V I D E N C E )
i n f e c t i o n s( p < 0 . 0 5 ) .( L E V E [ - I E V I D E N C E )
A r a n d o m i z e dc o n t r o l l e d t r i a l ( J o h n s o n ,1 9 8 6 ) Breast Surgery
e n r o l l i n g1 0 9p a t i e n t su n d e r g o i n g m a j o rc o n t a m i n a t e d
lread and neck surgery with flap reconstructionwas 1. Is antimicrobial prophylaxisrecommended for breast
doneto determinethe efficacy of cefoperazone2grams surgery?
IV givenfor either1 or 5 days.Tlrerewasno statistically
significarrtdifferenceirr postoperativeinfectionrates A n t i m i c r o b i a l p r o p h y l a x i si s N O T r o u t i n e l y
b e t w e e nt h e t w o g r o u p s with 18 p e r c e n t( 1 0 of 53 r e c o m m e n d e df o r b r e a s t s u r g e r y . ( C A T E G O R Y A
patients)ofthosewho receivedouedayof antimicrobial RECOMMENDATION)
Antimicrobial Prophylaxisfor SurgicalProcedures 75

Summary of Evidence likewiseNOT routinelyrecommendedfor electivegroin

lrernia surgery using mesh repair. (CATEGORY A
A randornized, double-blind placebo-control ledtrial
RECOMMENDATION)
(Platt, I 990) was doneto determinethe efficacy of pre-
operativecefonicidcomparedto placeboin preventing Summary of Evidence
surgicalsite infectionsin a mixed group of breastand
herniapatients.A subgroupof 606 patientsunderwent A meta-analysis of 5 randomizedcontrolledtrials
t h e f o l l o w i n g e l e c t i v e b r e a s t s u r g i c a l p r o c e d u r e s : on primary tissuerepair and 2 randomizedcontrolled
lumpectomy,local excision,or simple mastectomyin trialson meshrepair(Sanchez-Manuel, 2003)enrolling
54 percent, rnodified radicalmastectomy in 36 percent, 2,660 patientswas done to determinethe efficacy of
axillarylymphnodedissection in 4 percent,andreduction antimicrobialprophylaxiscomparedto placeboin the
rrrammoplasty in 6 percent. There was no statistically p r e v e n t i o n o f s u r g i c a l s i t e i n f e c t i o n a f t e r g r o i n
significantd ifferencebetweenthe 2 groups(p = 0.206) herniorrlraphy.There was no statisticallysignificant
with 5.61 percent(17 of 303 patients)in the cefonicid difference in the over-all surgical site infection rate
grolrp and 8.58 percent (26 of 303 patients) in the b e t w e e nt h e 2 g r o u p s( p : 0 . 1 4 )w i t h 3 . 0 8p e r c e n(t 4 0
p l a c e b og r o L r pd e v e l o p i r r gs u r g i c a l s i t e i n f e c t i o n s . of l,297 patients) in tlre prophylaxisgroup and 4.69
(LEVEL I EVIDENCE) percent(64 of 1,363 patients) in the control grolrp
A p r o s p e c t i v e ,r a n d o r n i z e d ,d o L r b l e - b l i n dt r i a l developingsurgicalsite infectionsfor an oddsratio of
( W a g m a n ,1 9 9 0 )e n r o l l i n g I l 8 p a t i e n t sw a s d o n e t o 0 . 6 1( 9 5 % C l : 0 . 3 2t o I . 1 7 ) .T h e a u t h o r sc o n c l u d e tdh a t
determine theefficacyof cefazolincomparedto placebo there was no evidencethat the use of prophylactic
in the preventionof surgical site infection in breast antimicrobialsreducedthe surgicalsite infectionrate
surgery.PatientsinclLrded in the stLrdywere thosewho after herniarepair.(LEVEL I EVIDENCE)
u n d e r w e n tt h e f o l l o w i n g e l e c t i v e b r e a s t s u r g i c a l Sr-rbgroup analysis of 5 randomizedtrials using
p r o c e d u r e s :t o t a l m a s t e c t o m yw i t h a x i l l a r y n o d e prirnarytissuerepair(Sanchez-Manuel, 2003)enrolling
dissectiorr 65 in percent, segmental mastectomy with 1,867patientsshowedthat there was no statistically
axillarynodedissectionin 29 percent,totalmastectomy significantdifference in surgical site infection rates
in 5 percent,and segrnentalmastectomyin I percent. betweenthe two groupswith 3.78 percent(35 of 924
Therewas no statisticallysignificant differencebetween patients)in the prophylaxisgroup and4.87 percent(46
t h e 2 g r o u p s( p : 0 . 7 2 ) w i t h 5 . 0 8 p e r c e n t( 3 o f 5 9 o f 9 4 3 p a t i e n t s ) i n t h e c o n t r o l g r o u p d e v e l o p i n g
patients)in thecefazolingroLrp and 8.47percent(5 of 59 infectionsfor,an odds ratio of 0.84 (95% Cl: 0.53 to
p a t i e n t si)r rt h e p l a c e b og r o u pd e v e l o p i n gs u r g i c a sl i t e 1 . 3 4 ) "( L E V E L I E V I D E N C E )
i n f e c t i o n s .T h e a u t l r o r sc o n c l u d e dt h a t t h e u s e o f Subgroupanalysis of 2 randomizedtrials using
prophylacticantibioticsdid not significantlyreducethe meslr repair (Sanchez-Manuel,2003) enrolling 793
i ncidenceof surgical sitei nfectionsafterbreastsurgery. patientsshowedthattherewasno statisticallysignificant
(LEVEL I EVIDENCE) difference in surgical site infection ratesbetweenthe
two groupswith 1.3 percent(5 of 373 patients)in the
Groin Hernia Surgery proplrylaxisgroup and4.2 percent(18 of 420 patients)
in the control group developinginfectionsfor an odds
l . I s a n t i r n i c r o b i ap l r o p h y l a x i sr e c o m m e u d e df o r r a t i o o f 0 . 2 8 ( 9 5 % C I : 0 . 0 2 t o 3 . 1 4 ) . ( L E V E L I
electivegroin herniasurgery? EVIDENCE)

A r r t i m i c r o b i a lp r o p h y l a x i s i s N O T r o u t i n e l y Gastric and Duodenal Surgery

recornmended for electivegroin lrerniasurgeryusing
primary tissue repair. (CATEGORY A l . I s a n t i m i c r o b i a lp r o p h y l a x i s r e c o m m e n d e df o r
RECOMMENDATION) Antimicrobial prophylaxisis electivegastro-duodenal surgery?
76 PJSSVol. 61,No.2, April-June,2006

Antimicrobial prophylaxis is recommendedfor An altemativeregimenis cefazolinI grarnIV singlJ

elective gastro-duodenalsurgery. (CATEGORY A dose(CATEGORY A RECOMMENDATION)
RECOMMENDATION)
Summary of Evidence
Summary of Evidence
Subgroupanalysisof 96 patientswho underwent
A prospective randomized double-blind trial (Stone, gastric surgery in a prospectiverandomizeddor-rble-
1 9 7 6 )e n r o l l i n g4 0 0 p a t i e n t sw a s d o n et o d e t e r m i n teh e blindtrial (Stone,1976)showedthat patientswho were
efficacy of antimicrobialprophylaxis in preventing given cefazolin i gram IM the eveningbeforesLrrgery,
surgicalsite infectionafter electivegastric,biliary and I gram[M orrcallto the operatingroom and I grarnlM
colonic surgery.Ninety-sixpatientsunderwentgastric on tlreeveningof the operationfor a total of 3 dosesor
operationsfor gastriccancer,gastriculcer or duodenal cefazolin I gram IM on call to the operatingroom, 1
ulcer.Therewasa statisticallysignificantdifferencein gramlM on the eveningof the operatiortand 1 granrIM
surgicalsite infectionratebetweenthe 2 groupswith 4 on the morningaftersurgeryfor a total of 3 doseshada
percentof thosewho were given cefazolin 1 gram IM
significantly lower surgical site infection rate of 4
either I hour or 8 to 12 hoLrrspreoperativelyand 19
percentcomparedto patientswho wereeitlrernot given
p e r c e n to f t l r o s e e i t h e r r r o t g i v e n a n t i m i c r o b i a l
a n t i m i c r o b i a losr i n w h o mt l r ea n t i m i c r o b i a l w asst a r t e d
p r o p h y l a x i so r i n w h o m a n t i b i o t i c s w e r e s t a r t e d
postoperatively who hada l9 percerrtinfectionrate.Tlre
postoperatively developinginfectionsfor an ARR of 15
ARR was l5 p e rcena t n d t l r e R e l a t i v eR i s k R e d u c t i o n
p e r c e n (t p : 0 . 0 a 6 ) (. L E V E L I E V I D E N C E )
= (LEVEL I EVIDENCE)
A p r o s p e c t i v rea n d o m i z e d o u b l e - b l i n dp, l a c e b o - w a s 7 9 p e r c e n (t p 0 . 0 4 6 ) .
c o n t r o l l e dt r i a l ( N i c h o l s ,1 9 8 2 )e n r o l l i n g3 9 p a t i e n t s A p r o s p e c t i v er a, u d o r n i z eccol n t r o I I e tdr i a l( M o r r i s .
was done to determinethe efficacy of antimicrobial 1 9 8 4 )e n r o l l i n g7 8 p a t i e n t su n d e r g o i r regl e c t i v eg a s t r i c
prophylaxisusingcefamandole 2 gramsIV administered slrrgery was doneto comparecefuroximeI .5 gramsIV
one hour preoperatively then I gram IV 4 hoLrrsand 8 s i n g l ed o s ew i t h r n e z c l o c i l l i n 2 g r a m sI V s i n g l ed o s e .
hoursafter incisioncomparedwith placebofor gastro- T h e r e w a s a s t a t i s t i c a l l ys i g n i f i c a n t d i f f e r e r r c ei n
duodenal operations performedbecause ofgastriccancer, infectiouratesbetweenthe two groups.',vith 2.5 percent
c h r o n i c o r b l e e d i n gg a s t r i c t t l c e r s ,a n d b l e e d i r r go r i n t l r e c e f u r o x i m e g r o r - r pa n d l 8 p e r c e n t i r r t l r e
o b s t r u c t i ndgu o d e n aul l c e r sA . l l p a t i e n t si n c l L r d ei dn t h e m e z c l o c i l l i n g r o l r pd e v el o p i n gi r r f e c t i o nfso r a nA R R o f
stLrdyhadclirricalfeaturesthat placedthem at high risk 1 5 . 5p e r c e n t(. L E V E L I I E V I D E N C E )
for the developmentof postoperativesurgical site Although studieshave shown that cefazolingiven
infection.The surgicalsite infectionrate of 5 percent intramuscu larly is efficacioLt s for prophyIaxis in gastro-
( I of 19 patients)in the cefamandole prophylaxisgroup duodenalsurgery,the expert panel believesthat it is
was significantlylower tlran the 35 percentinfection i n d p p r o p r i a tteo a d n r i n i s t etrh e a n t i m i c r o b i at lh r o u g h
rate(7 of 20 patients)in the placebogroupfcrran ARR t h i s r o u t eb e c a u s o e f t h e p a i n ,r i s l < sa t t di n c o n v eine n c e
o f 3 0 p e r c e r i ( 9 5 % C I : 2 . 3t o 5 7 . 1 % ) A . l t h o u g ht h et r i a l
t o t h e p a t i e r ritn h e r e n t l ya s s o c i a t ew dith intranrttsc'ular
w a s I i m i t e d b y t h e s m a l l s a r n p l es i z e , t h e a u t h o r s
i n j e c t i o r r sI t. w a st h e c o n s e t t s uosf t h e e x p e l tp a n e l t h a t
concIudedthat short-termantimicrobialprophylaxisis
c e f a z o l i n l g r a m l V s i n g l e d o s e i s a d e q u a t ef o r
effectivein preventing surgicalsiteinfectionsin patients
prophylaxis in gastro-duodenalsLrrgeryand thus a
u n d e r g o i r r gg a s t r o d u o d e n asl u r g e r y . ( L E V E L I l
EVIDENCE) s L r i t a b lael t e r n a t i v ree g i m e t t(.L E V E L I I I E V I D E N C E )

2. What is/arethe appropriateantirnicrobial/s, dose/s Biliary Surgery

and durationof prophylaxis?
A. Open Biliary Surgery
antirnicrobialfor
The recorrrrlended prophylaxisin
electivegastroduodenal surgeryis cefuroximeI .5 grams l . l s a n t i m i c r o b i a lp r o p h y l a x i s r e c o m t n e n d e fdo r
I V singledose(CATEGORY A RECOM MENDATION) biliary surgery?
 for SurgicalProcedures
Prophylaxis
Antimicrobial 77

A n t i m i c r o b i a lp r o p h y l a x i si s r e c o m m e n d e df o r c o n c o m i t a n t a l i m e n t a r y p r o c e d u r e s .T h e a u t h o r s
p a t i e n t sw h o w i l l u r r d e r g ot l i e f o l l o w i n g b i l i a r y concludedthatantimicrobialprophylaxisin biliarytract
procedures: surgeryis effectiveespeciallyin high risk patientsand
Cholecystectorny that theseresultsindicatethat this is evidenceagainst
Sphincterotomy tlre further use of no-treatmentcontrols. (LEVEL I
Cholecystectomy plus sphincterotomy EVIDENCE)
Choledochoenterostomy
2. dose/s,
What is/aretheappropriateantimicrobial/s,
(Choledochoduodenostomy,
and durationof prophylaxis?
CIroledochoduodenostomy plus sphincterotomy,
Choledochojejunostomy) The recommended antirnicrobialfor proplrylaxisin
C hoIecystoje.iunostomy biliary surgery is cefazoliri I gratn IV single close.
C o m m o nb i l e d u c t e x p l o r a t i o n (CATECORY A RECOMMENDATION)
(CATEGORY A RECOMMENDATION) An alternativeregirnenis cefitroxime1.5gramslV
s i r r g l ed o s e .( C A T E G O R YA R E C O M M E N D A T I O N )
Summary of Evidence
Summary of Evidence
A meta-analysis of 60 randomizedcontrolledtrials
(Meijer, 1990) for operationson the gallbladderand Subgroua pnalysio s f I I r a n d o m i z etdr i a l se n r o l l i n g
c o m l n o n b i l e d r r c t , i n c l u d i n g c h o l e c y s t e c t o m y , I , 1 2 8 p a t i e n t si n a m e t a - a n a l y s i(sM e i . i e r ,1 9 9 0 )w a s
e x p l o r a t i o n o f t h e c o n l m o n b i l e d u c t a n d done to evaluatethe effectivenessof first generation
choledochoenterostomy was done to determinethe cephalosporins comparedwith secondorthirdgeneration
efficacyof antimicrobialprophylaxisfor open biliary ceplialosporins for prophylaxisin biliarysurgery.There
sLrrgery. A subgroup of 42 trials in the meta-analysis was no statistically significantdiffererrcein strrgical
enrollirig 4,129 patientscomparedthe surgical site site infection rates between the two groups with a
infection rates amoltg patients given prophylactic cornrnonpercentage differenceof 0.5 percent(95% Cl:
- 1 . 5%to2.5 o / o )
a n dp o o l e do d d sr a t i oo f I . l 8 ( 9 5 % C l :
a n t i m i c r o b i a l sw i t h a c o n t r o l g r o u p n o t g i v e n
Tlie resultsshoweda significantlylower 0 . 6 9 t o 2 . 0 0 ,p > 0 . 0 5 ) .( L E V E L I E V I D E N C E )
antimicrobials.
surgicalsite infection rate of 2.1 percent in the S u b g r o u p
a n a l y s i so f I 5 r a n d o mi z e dt r i a l se n r ol l i r r g
prophylaxisgroupcomparedto the 15 percentirrfection 1,226 patients in a meta-analysis(Mei.ier,1990)rvas
doneto evaluate effectiveness
tlre of a singledoseof a
rate in the control group for an over-all percentage
prophyIactic antimicrobialcomparedwith rnultipledose
d iffererrceof 9 percent(.95%CI: 7 %oto 11 %) in favor
regimensfor propliylaxisin biliary surgery.Therewas
o f a n t i b i o t i cp r o p h y l a x i sa, p o o l e do d d s r a t i o o f 0 . 3 0
no statisticallysignificant differencein surgicalsite
( 9 5 % C l : 0 . 2 3 t o 0 . 3 8 )a n d a n N N T o f 1 1 . S u b g r o u p
infectionratesbetweenthe two groupswith a commol.l
analysisfor the two factors that appearedto lrave a percentage
differenceof 0.4 percent(95 % Cl: - I . | %oto
significanteffecton the percentage differencesshowed
1. 9 % ) a n da p o o l e do d d sr a t i oo f 0 . 8 ( 9 5 % C I : 0 . 4I t o
a significantlystrongerprotectiveeffect of prophylaxis 1 . 5 7 , p> 0 . 0 5 ) ,( L E V E L I E V I D E N C E )
f o r h i g h r i s k p a t i e n t sw l i i l e t h e t i r n i n g o f w o u n d A randornized double-blind multicentertrial (Meijer,
inspection rnarkedly influenced the treatment effect 1993) enrolling 1,004 patientswas doneto comparethe
reported.Patientswho were labeledas high risk were efficacy of a single pre-operativedose of cefuroxime
those who had acuteclrolecystitiswithin 4 weeks of a g a i n s tm u l t i p l e d o s e so f t h e s a m e a n t i m i c r o b i a il r r
sLrrgery,emergencycholecystectomy,common dltct p r e v e n t i n gs u r g i c a l s i t e i n f e c t i o n s .T h e r e w a s r t o
stone or ductal exploration,jaundice at the time of statisticallysignificantdifferencein majorsurgicalsite
sLrrgery, ageover60years,previousbiliarytractsurgery, infectionratesbetweenthe two groupswith 3.8 percent
rnorbidobesity,non-visualization of the gallbladderon in tlre singledosegroup and4.6 percentin the rnultiple
oral c h o l e c y s t o g r a p h y d
, i a b e t e s m e l l i t u s , a n d dose group developinginfectionsfor an ARR of 0.8
18 P J S SV o l .6 1 ,N o .2 , A p r i l - J u n e , 2 0 0 6

p e r c e n (t 9 5 % C l : - 1 . 7t o 3 . 3 ; p : 0 . 5 2 ) . T h e a u t h o r s t l r e r i s k o f d e v e l o p i u gs u r g i c a ls i t e i n f e c t i o n si n l o w -
concludedthat there is no significant advantageto risk patients undergoingelective laparoscopic
g i v i n gr n u l t i p l ed o s ep r o p h y l a x i cs o m p a r e d
with single cholecystectorny is modestar,d doesnotj ustifyclinically
doseprophylaxisin biliary operationsto preventpost- t h e u s e o f p r o p l r y l a c t i ca n t i m i c r o b i a l s (. L E V E L I
operativeincisionalsurgicalsite irrfections.(LEVEL I EVTDENCE)
EVIDENCE) A meta-analysis of 6 randonrizedcontrolledtrials
(Catarci, 2004) enrolling 974 low-risk patients
B. LaparoscopicCholecystectomy u n d e r g o igne l e c t i v el a p a r o s c oi p cclrolecystectom wya s
doneto assess whetherantinricrobialprophylaxis reduces
l . l s a n t i n i i c r o b i a lp r o p h y l a x i sr e c o r n n t e n d e fdo r t h e r i s k o f d e v e l o p i n g s u r g i c a sl i t ei n f e c t i o n a
s nclother
laparoscopic cholecystectomy? s e p t i c c o r n p l i c a t i o n s
c o u r p a r e dt o p l a c e b oo r u o
a n t i b i o t i c s .T l r e r e w a s n o s t a t i s t i c a l l y s i g n i f i c a n t
A n t i m i c r o b i a l p r o p l r y l a x i s i s N O T r o u t i n e l y differencein cumulativesurgical site infection rates
recommended for laparoscopic cholecystectonty in low- b e t w e e n t h e t w o g r o u p s w i t h 2 . 1 p e r c e n t i r r t h e
risl<patients.(CATEGORY A RECOMMENDATION) prophylaxisgroLrpand2.9 percentin the controlgroup
d e v e l o p i n gs L r r g i c asli t e i n f e c t i o n sf o r a p o o l e do d d s
Summaryof Bvidence r a t i oo f 0 . 8( 9 5 % C I : 0 . 3 6t o 1 . 8 6 p ; = 0 . 6 3 )T . h e r ew a s
l i k e w i s en o s t a t i s t i c a l l ys i g n i f i c a n td i f f e r e n c ei n t h e
A meta-analysis of 5 randomizedcontrolledtrials cumulatived istantinfectionratesbetweenthetwo groups
( A l - G h n a n i e m2, 0 0 3 ) e n r o l l i n g8 9 9 l o w - r i s kp a t i e n t s with 0.7percentin the prophylaxisgroupand L5 percent
undergoing electivelaparoscopic cliolecystectomy was in the controlgroupdevelopirrginfectionsfor a pooled
:
doneto assess whetherantimicrobialprophylaxisusing o d d sr a t i oo f 0 . 8 2( 9 5 % C l : 0 . 18 t o I . 9 0 ;p 0 . 3 7 ) .T h e
o n et o t h r e ed o s e so f c e p h a l o s p o r i nr se d u c e tsh e r i s ho f authorsconcludedthattlrerewasno needto giveroutine
d e v e l o p i n gs L r r g i c asl i t e i n f e c t i o r r sa n d o t h e r s e p t i c a n t i m i c r o b i a l p r o p h y l a x i s f o r l o w - r i s k p a t i e n t s
c o m p l i c a t i o n s u c h a s r e s p i r a t o r ya n d u r i n a r y t r a c t L r n d e r g o i nl g a p a r o s c o p icch o l e c y s t e c t o r n(yL.E V E L I
infectiorrcomparedto placeboor no arrtibiotics.Low- EVIDENCE)
risl<patientswere defined as those who did not have It was tlre consensusof the expert panel that
acutecholecystitis, a recenthistoryof acutecholecystitis, antirnicrobial prophylaxis shoLrldNOT be roLrtirrely
conlmonbi le d LrctcalcLrl j
i, aundice,i mmunesuppress ion recommended flor laparoscopic cholecystectomy in low-
o r p r o s t h e t i ci m p l a n t s . T h e r e w a s n o s t a t i s t i c a l l y risk patients because ofthe currently avai lable evidence.
significantd ifferencein incisionalsurgicalsiteinfection The expertsIi kewiseagreed[roweverthat antirnicrobiaIs
ratesbetweenthe two groupswith 1.5 percentin the m a y b e a d m i n i s t e r ew d h e n s p e c i f i cc l i n i c a ls i t u a t i o n s
proplrylaxisgrolrpand2.2 percentin the controlgroLrp are'presentwhich may increasethe patient'srisk of
d e v e l o p i n gi n c i s i o n a sl u r g i c a ls i t e i n f e c t i o n sf o r a n developinga surgical site infection. Factorssuch as
o d d sr a t i oo f 0 . 6 8( 9 5 % C l : 0 . 2 4 t o1 . 9 1 p ; = 0 . 5 ) . T h e r e patientimmunocompetence andotherco-morbid medical
wasalsono statisticallysignificantdifferencein organ/ conditions,the surgeon'sexperience,tlre lengthof tlre
space surgical site infection rates between the two operativeprocedure,and the stateof the hospitaland
g r o u p sw i t h 0 . 1 9p e r c e n it n t h e p r o p h y l a x i sg r o u pa n d o p e r a t i n gr o o m e n v i r o n r n e nat n d e q u i p r n e n itn t h e
0.27 percentin the control group developingmajor clinicalsettingshoLr ld beconsideredin decidingwhetlrer
infectionsfor an odds ratio of 0.93 (95% Cl: 0.06 to t o a d m i n i s t e r o r t o w i t h h o l dg i v i n g a n t i m i c r o b i a lfso r
1 4 . 9 1 ;p = l ) . T h e r e w a s n o s t a t i s t i c a l l ys i g n i f i c a n t p r o p h y l a x i s(.L E V E L I I I E V I D E N C E )
differerice in distant infection rates between the two
groupswith 0.8 per cent in tlre proplrylaxisgroup and Colorectal Surgery
1 . 6p e r c e n it r rt h e c o n t r o lg r o u pd e v e l o p i n gi n f e c t i o n s
f b r a n o d d sr a t i oo f 0 . 5 ( 9 5 % C I : 0 . 1 4t o I . 7 8 ;p = 0 . 3 ) . L I s a n t i r n i c r o b i a lp r o p h y l a x i sr e c o m m e n d e df o r
Tlre autlrorsconcludedthat the observedreductionin colorectalsr-rrgery?
 Antimicrobial
Prophylaxis
for SurgicalProcedures 79

A n t i m i c r o b i a l p r o p h y l a x i si s r e c o m m e n d e df o r f o r a n A R R o f 6 . 7 p e r c e n t( 9 5 % C l : 2 . 3 t o 1 1 . l % ;
e l e c t i v e c o l o r e c t a l p r o c e d u r e s .( C A T E G O R Y A p <0.01). In the 9 trialsfrom I 976 onwards, themortality
RECOMMENDATION) rateof 3 .4 percent(15 of 443patients)in theprophylaxis
group was significantly lower comparedto the 8.7
Summary of Evidence percentmortalityrate(34of 390 patients)in the control
group for an ARR of 5.3 percent(950/o CI: I .9 to 8.7 o/o:
A meta-analysis of 26 randomizedcontrolledtrials p < 0.01).The pooledmortality rateof 3.9 percent(36
( B a u n r ,1 9 8 1 )p u b l i s h e df r o m I 9 6 5 t o 1 9 8 0e n r o l l i n g o f 9 12 p a t i e r r t s )i n t h e p r o p h y l a x i s g r o u p w a s
2,052 patientswas done to detennine the efficacy of significantlylowercomparedto the9.7 percentrate(64
v a r i o u s a n t i m i c r o b i a lr e g i m e n sf o r p r o p h y l a x i si n of 657 patients)in the control groupfor an ARR of 5.8
colorectalsurgery conrparedto no antimicrobial in percent.(LEVEL I EVIDENCE)
p r e v e n t i n gs u r g i c a I s i t e i r r f e c t i o n s( 2 6 t r i a l s ) a n d A meta-analysis of I 47 randomizedcontrolledtrials
o p e r a t i v em o r t a l i t y( 1 7 t r i a l s ) .O r a l b o w e l - s t e r i l i z i n g( S o n g , i 9 9 8 ) r v a s d o n e t o a s s e s st h e e f f i c a c y o f
r e g i m e n s w e r e u s e d i n f i v e t r i a l s , p a r e n t e r a l antimicrobialprophylaxisin the preventionof sLrrgical
a n t i m i c r o b i a lisn l 3 t r i a l s ,t o p i c a la g e n t si n o n e t r i a l , siteinfectionin patientsr-rndergoing
colorectalsLlrgery.
a n d c o m b i n a t i o nosf t h e s ei n 7 t r i a l s . I n t h e l 2 t r i a l s For,rrtrials
irrclLrded irr the meta-analysis whiclr were
through 1975,the sr"rrgical site iufectiou rate of 21.8
p u b l i s h e ds i n c e 1 9 8 4 t h a t c o m p a r e dp a t i e r r t sg i v e r r
percent(199 of 475 patients)in the prophylaxisgroLrp
antirnicrobialprophylaxiswith a no treatrnentcontrol
was significantlylower conrparedto the 35.7 percent
groupconsistentlyshowedthatthesurgicaI site i nfectiorr
r a t e( 1 3 8 o f 3 8 7 p a t i e n t s )i n t h e c o n t r o lg r o u p f o r a n
A R R o f I 3 . 9 p e r c e n t ( 9 5 %C l : 7 . 9 t o 1 9 . 9% ; p < 0 . 0 1 ) r a t e o f 1 3 p e r c e n t i n t h e p r o p h y l a x i s g r o l r p w a s
andanNNT of 8. In the I 4 trialsfrom 1976onwards,the significantlyIowertlranthe 40 percentinfectionrate in
s L r r g i c asli t e i n f e c t i o nr a t eo f 1 6 . 3p e r c e n t( 9 1 o f 5 5 8 tlrecontrolgroupfor an ARR of 27 percentandan odds
p a t i e n t s )i n t h e p r o p h y l a x i sg r o u p w a s s i g n i f i c a n t l y r a t i o o f 4 . 0 8 ( 9 5 % C l : 2 . 3 3 t o 7 . 1 3 ) . T h e a u t h o r s
lower conrparedto the 4 I .9 percentrate ( 199 of 415 c o n c l u d e tdh a ta n t i m i c r o b i apl r o p h y l a x i iss e f f e c t i v ei n
patients)in thecontroI groLrp for an ARR of 25.6percent t h e p r e v e n t i o no f s u r g i c a ls i t e i n f e c t i o ni n c o l o r e c t a l
( 9 5 %C I : 1 9 . 6t o 3 1. 6 % ; p < 0 . 0 1 ) T . h e p o o l e ds u r g i c a l sLrrgery. (LEVEL I EVIDENCE)
siteinf.ection rateof I 9.2 percent (229 of 1, I 90 patients)
i n t l r e p r o p h y l a x i sg r o u p w a s s i g n i f i c a n t l y l o w e r 2. {lrat is/arethe appropriateantimicrobial/s, dose/s,
conrpared to the 39.1 percerrtrale(337 of 862 patients) arr"il'dr-rrati on of prophylaxi s?
i n t h e c o n t r o lg r o L r pf o l a n A R R o f 1 9 . 9p e rc e n t .T h e
a u t h o r sc o n c l u d e dt h a t a n t i m i c r o b i apl r o p l r y l a x i ws as T h e r e c o m m e n d e dr e g i m e n f o r p r o p l r y l a x i si n
effectivein preventing sLrrgical site infectionsand that colorectalslrrgeryconsistsof an orally-adnrinistered
a n y f u r t h e r t r i a l s o n a r r t i u r i c r o b i apl r o p h y l a x i s i n
antiniicrobialcombinedwith a parenteral antirni crobial.
colorectalsurgeryshoLrldernploya previouslyproven
Therecommended orally-adrnin isteredantirnicrobial
standardinsteadof no treatrnerltcolttrols.(LEVEL I
is ciprofloxacin500 mg for 3 doses,startedtheday prior
EVIDENCE)
to (CATEGORY A RECOMMENDATION)
Seventeen randonrized trials in the meta-analysis surgery.
(Baum,1981)alsocomparedthe mortalityratesbetweerr T h e r e c o n t m e n d e da n t i r n i c r o b i a l sf o r s y s t e m i c
the prophylaxisgroup and the no treatmentcontrol p r o p h y l a x i sa r e a m o x y c i l l i n - c l a v u l a nai c i d 1 . 2g r a m s
grolrp.In the B trialsthrouglt1975, tlremortalityrateof I V s i n g l ed o s eA m p i c i l i n - s r , r l b a c t1a.m 5g r a m sl V s i n g l e
4.5 percent(21 of 469patients)i n the prophylaxis group dose Cefoxitin 2 grarnslV single dose Cefazolin 2
was significantlylower comparedto the I 1.2 percent g r a m sI V s i n g l ed o s ep l L r sM e t r o r r i d a z o l5e0 0 m g I V
nrortalityrate(30 of 267 patients)in the controlgroup s i n g l ed o s e( C A T E G O R Y A R E C O M M E N D A T I O N )
80 PJSSVol. 61,No.2, April-June,2006

Summary of Evidence p < 0 . 0 0 1 )a l l f a v o r e dt h e c o r n b i n e d o r a l p l r . rssy s t e m i c

antimicrobialprophylaxis group. The authorconcltrded
A meta-analysis (Song,1998)was doneto compare thattheuseofcombinedoralandsystemicantirnicrobials
severaI d iffe rentairtimi crobial regirnensfor prophylaxis f o r p r o p h y l a x i s w a s s u p e r i o r t o u s i n g s y s t e mi c
in colorectalsLrrgery i nclLrdin g amoxiciI lin-clavulanic antirnicrobials alonein preventing surgicalsiteinfections
a c i d . a m p i c i l l i n - s r - r l b a c t acme,f o x i t i n . i n t i p e r t e n r ,i r re l e c t i v ec o l o r e c t asl u r g e r y . ( L E VEI- I EVIDENCE)
c e f a z o il n p l Lsr m e t r o n i d a z o l e ,c e f u r o x i m e p l u s O f t h e o r a l l ya d m i n i s t e r eadn t i m i c r o b i a u l ss e di n
m e t r o n i d a z o l eg, e n t a r n i c i np l L r sm e t r o n i d a z o l eo r t l r et r i a l s ,o r r l yc i p r o f l o x a c i u i s c u r r e n t l ya v a i l a b l e i r rt h e
c l i n d a m y c i n ,a n d c i p r o f l o x a c i np l u s m e t r o n i d a z o l e . local market so this was recomrnended bv the expert
Therewas r1osignificantdifferencein the surgicalsite p a n el .
infectionratesbetweenthe variousproplrylacticagents
but regimenssuclrasmetronidazole alone,doxycycline Thoracic and Cardiovascular Surgery
a l o n e , p i p e r a c i l l i na l o n e a n d o r a l n e o m y c i np l u s
erytlrromycinalonegiven the day beforethe operatiott A. Thoracic Non-CardiovascularSurgery
appearedto be inadeqLrate. (LEVEL I EVIDENCE)
S e v e n t e erna n d o m i z e dt r i a l s i n t h e m e t a - a n a l y s i s l . I s a n t i m i c r o b i a pl r o p h y l a x i sr e c o n r m e r r d ef odr
( S o n g ,I 9 9 8 )e n r o Il i n g 2 , 4 5 0p a t i e n t cs o n r p a r eadsi n g l e t h o r a c i cn o n - c a r ido v a s c u larsurgery?
d o s e r e g i u r e na d m i r r i s t e r e dp r e o p e r a t i v e l yw i t h a
m u l t i p l e - d o sree g i m e nu s i n gt h e s a m ea n t i m i c r o b i aol r A r r t i r n i c r o b i apl l o p h y l a x i s i s r e c o m n r e n d e fdo r
a c o m b i n a t i o no f a n t i r n i c r o b i a l sN. o n e o f t h e t r i a l s t h o r a ci c r t o n - c a ri do v a s c lua r p r o c e d u r e (sC . ATEGORY
found a significantdiffereucein surgicalsite infection A R E C O M M E N D A T I O N )
r a t e sb e t w e e a n s i n g l ed o s ea n da m u l t i p l e - d o sree g i r n e n
w i t h a p o o l e do d d sl a t i oo f L l 7 ( 9 5 % C l : 0 . 9 t o 1 . 5 3 ) . S u m m a r y o f E v i d e n c e
( t , E V E LI E V I D E N C E )
S i x r a n d o n r i z etdr i a l s i n t h e m e t a - a n a l y s (i sS o n g , A r a n d o r inz e dd o u b l e - bi n l ctl r i a l ( A z n a r ,
l d c o r r t r ol e
I 9 9 B )e n r o l l i n g5 5 1 p a t i e n t s
c o m p a r e a
d f i r s t - g e n e r a t i o r r s r r r d e r ignogt l r o r a c isct r f g e r y
19 9 I ) e n r o l l i n g1 2 7p a t i e n t L
c e p h a l o s p o r i nw i t h a s e c o n d -o r t h i r d - g e n e r a t i o t t was done to evaluatethe effectivenessof cefazolinI
c e p h a l o s p o r fi o n r p r o p h y l a x i sN. o n e o f t h e t r i a l sf o r . r n d g r a mI V s i n g l e ' d o sper e o p e r a t i v ecl yo m p a r etdo p l a c e b o
a statisticallysignificant difference in surgical site i n p r e v e r r t i n gs u r g i c a ls i t e i n f e c t i o r r T . lre irrcisional
infectionratesbetweentlre two groupswith a pooled s u r g i c a ls i t e i n f e c t i o nr a t e o f 1 . 5 p e r c e n t( l o f 7 0
o d d s r a t i o o f 1 . 0 7( 9 5 % C l : 0 . 5 4 t o 2 . 1 2 ) .( L E V E L I p a t i e n t si)n t h e c e f a z o l i ng r o L r p w a ss i g n i f i c a n t l lyo w e r
EVIDENCE) t h a nt h e 14 p e r c e nitn f e c t i o nr a t e( 8 o f 5 7 p a t i e n t si )n t h e
A r r e t a - a n a l y soi sf l 3 r a n d o r n i z ecdo n t r o l l e dt r i a l s p l a c e b og r o u pf o r a r e l a t i v er i s l io f 3 . 2 1( 9 5 %C l : I . 5 t o
(Lewis. 2002) enrolling 2,065 patietttswas done to 1 1 . 5 )a n d a n A R R o f 1 2 . 5 .T h e a u t l r o r sc o r r c l u d etcl rl a t
determinethe efficacyof systernic prophylaxiscompared a s i n g l ep r e o p e r a t i vcel o s eo f c e f a z o l i ni s e f f e c t i v ei n
to combinedoralandsystemicprophylaxisfor colorectal r e d r - r c i nt hge r a t eo f i n c i s i o n asl u r g i c asl i t ei n f e c t i o n isn
sLlrgery in preventingsurgicalsiteirrfections. The orally non-card iacthoracicprocedures. (LEV EL I EV I D ENCE)
a d m i r r i s t e r eadn t i m i c r o b i a l Ls r s e di n t h e v a r i o r - rt sr i a l s
i n c l u d e d r l e o l r y c i n - e r y t h r o m y c i u , n e o n t y c i l t - 2 . W h a ti s / a r et h ea p p r o p r i a taen t i m i c r o b i a l /ds o , se/s,
n r e t r o n i d a z o l er ,r e o m y c i u - t i n i d a z o l ek .a n a m y c i n - a n d d u r a t i o no f p r o p h y l a x i s ' ?
n r e t r o n i d a z oal e n dc i p r o f l o x a c i nT.h e u r r w e i g h t em de a n
r i s k d i f f e r e n c ei n t h e r a t eo f s u r g i c a sl i t e i n f e c t i o n so f T h e r e c o m n r e u c l eacnl t i n r i c r o b i aflo r p l o p h y l a x i s
0 . 6 9 ( 9 5 % C I : 0 . 3 9 t o 0 . 9 9 ) ,t l r e w e i g h t e dm e a nr i s k iu thoracicnon-carcliovascrtlar sLrrgeryis cefazolin I
diff-ererro cef 0.56 ( 9 5 % C l : 0 . 2 6 1 o0.86; p < 0 . 0 1 )a t t d g r a m l V single dose. (CATEGORY A
t h es u n r m a rrye l a t i v er i s ko f 0 .5 1 ( 95 % C L :0 . 2 4t o 0 .7 8 ; RECOMMENDATION)
 8l
Antimicrobial Prophylaxisfor SurgicalProcedures

Summary of Evidence therewasno statisticallysignificarrtd ifferencebetween

tlretwo groupswith 6.47percentof thosewho underwent
A randornized doLrble-blind controlledtrial (Aznar, wedgeresectionand6.28percentof thosewho ttnderweut
199 I ) enroll ing127patientsLrndergoing thoracicsurgery biopsyonly developingirifection.The two groupslrad
o/o;
was doue to evaluatethe effectivenessof cefazolin 1 similar surgical site irrfectionrates (2.8 % vs 1
o / o p; : N S ) , a n d
gramlV singledosepreoperatively comparedto placebo p : N S ) , p n e u m o n i a( 2 . 8 % v s 3 . 4
p r e v e n t i l r gs L r r g i c asl i t e i n f e c t i o n .T h e i n c i s i o n a l :
e m p y e m a( 0 . 7% v s 2 Y o :p N S ) A t n o n gt h ea s s e s s e d
iu
sr-rrgical site irrfectiorl rate of 1'5 percent (1 of 70 irifectionrisk parameters,all FEVI < 70 percentof
patieuts)in the cefazolin group was sigrrificarrtly lower expected wasobservedmuclturorefrequentlyin infected
patients) in the oh.
tharithe l4 percetttinfectionr:ate (8 of 57 patientstlran in non-infectedpatients(58 % vs 25
placebogroupfor a relativerisk of 3 .27 (95% CI: 1.5 to p < 0 . 0 5 ) b y m u l t i v a r i a t e a n a l y s i s .( L E V E L I l
I 1.5)and an ARR of 12.5.Tlre authorscoriclLrded that EVIDENCE)
a singlepreoperative doseof cefazolin is effectivein
reclucing therateof incisionalsr-rrgical site infectiottsin ' 2. What is/arethe appropriateantirlicrobial/s'dose/s.
non-carcliac thoracicprocedures. (LEVEL I EVIDENCE) a u dd u r a t i o no f p r o p h y l a x i s ?
A r a n c i o m i z eddo u b l e - b l i n d c o n t r o l l e dt r i a l ( O l a l < ,
1 9 9 1 )e n r o l l i n g2 0 8 p a t i e n t sw a s d o n et o c o n r p a r e the The recomntended antirl icrobi als fo r v ideo-ass i sted
efficacy of one doseversussix dosesof cefazolinas t h o r a c o s c o p iscu r g e r ya r e : A m p i c i l l i n - s L r l b a c t a1r.n5
prophylaxisin generalthoracicsurgery' Therewas no gramsIV singledose (CATEGORY A RECOMMEN-
statisticallysigrrificant drfferencein the rateof surgical DATION) and Amoxycillin-clavr'rlanic acid 2.4 grans
site infections betweerf the two groLlps with no infections
IV singledose(CATEGORYA RECOMMENDATION)
occurring i r r t h e s i r r g l e - d o s g
e r o u p and only two
infectionsoccurring irr tlre six-dose group (95% CI:
S u m m a r yo f E v i d e n c e
- 0 . 0 0 8t o 0 . 0 4 8 ) .T h e a L r t h o rcso n c l u d e d t h a tg i v i n gs i x
doses of cefazolin does not confer any clinically In a cohortstLrdy(Rovera,2003),8 percentdid not
irnportantbenefit beyondthat obtainedfrorn a single
receiveprophylaxisdue to suspectedor established
dosefor prophylaxisof sLrrgical siteinfectionin elective
(LEVEL I EVIDENCE) antibioticallergy.Short-termantibioticprophylaxis was
generalthoracic surgery.
g i v e n u s i n ge i t h e ra m p i c i l l i n - s u l b a c t a lm . 5 g r a m so r
arrioxic i I I i n-cla'luI an ic acid 2.2 grams ad m in isteredasa
B. Video-AssistedThoracoscopicSurgery (VATS)
s i n g l eI V d o s ea t i n d L r c t i oonf a n e s t h e s i aT. h e o v e r - a l l
l. I s a n t i m i c r o b i a lp r o p h y l a x i s r e c o n r t r l e n d efdo r rateof postoperativeinfectionswas 4'9 percent( I 7 of
video-assiste t hdo r a c o s c o p iscu r g e r y( V A T S ) ? 3 4 6 p a t i e n t sw) i t h a l l i n f e c t e dp a t i e n t cs o m i n gf r o mt h e
groupgivenprophylaxis. Thetotal trumberof i nf-ection s
for
A r r t i u r i c r o b i apl r o p h y l a x i si s r e c o m t n e n d e d occurringin groLrp A (6.47%) and in group B (6.28%)
v i c l e o - a s s i s t e tdh o r a c o s c o p i c s L r r g e r y ( V A T S )' wasnot significantlyd ifferent.GroupsA andB showed
(CATEGORY A RECOMMENDATTON) s f s L r r g i c asli t e i n f e c t i o n( 2 . 8 % v s
s i r n i l a ri n c i d e n c e o
=
lo/o;p NS), pneumonia(2.8Y0vs 3.4o/o; p = N S), and
Summary of Bvidence enlpyema(0J% vs 2%o', p : NS). All postoperative
infections were treated sr:ccessfirlly with arrtirnicrobial
cohortstLrdy
A prospective (Rovera,2003)enrolling
therapy and surgical drainage as appropriate'
346 patientswas done to determineand cotnparethe mortality was nil in both groups. The
Postoperative
incidencearrdtypes of infectionsoccurringafter two
postoperativestay was longer for the irrfectedpatierits
differentVATS procedures:lung wedgeresectionand patients(8 +
or rnediastinalmassesand to identify (13 + 7 clays)as comparedto non-itrl'ected
biopsyof pleLrral
the predictivevalue of infection risk parameters'The 6 clays)bLrtthe differencewas not statisticallysignificant'
overallpostoperative infectionrate was 4.9 percentbut (LEVEL II EVIDENCE)
 82 P J S SV o l .6 1 ,N o .2 , A p r i l - J u n e2,0 0 6

C. Cardiac Surgery significantdifferencebetweenthe cefazolilrgroupand

the cefamandole or cefuroximegroupwhen sternaland
l.I s a n t i m i c r o b i a lp r o p h y l a x i s r e c o m m e n d e df o r legwound infectionsiteswere analyzedseparately. The
cardiacsurgery? summaryoddsratio of I .58 (95% Cl: 1.03to 2.45) after
A n t i n i i c r o b i a lp r o p h y l a x i si s r e c o m m e n d e df o r analysisof tlre cornbinedsternaland leg inf-ection rates
cardiac surgery. (CATEGORY A RECOM- howeversuggests thatdespitethegenerallylow 5 percent
MENDATION) surgicalsite infectionrate in the cefazoliugroup,there
is a furtherreductionin infectionratesto approximately
Summary of Evidence 3 percentwith the use of tlre secondgeneration
c e p h a l o s p o r i r (r L
s .E V E L I E V I D E N C E )
Subgroupanalysisof for-rrplacebo-controlled trials A r a n d o n r i z e dd o u b l e - b l i n d c o n t r o l l e d t r i a l
i n a m e t a - a n a l y s(iK s r e t e ra n d W o o d s ,1 9 9 2 )e n r o l l i n g ( T o w n s e r r d1,9 9 3 )e n r o l l i n gI , 6 4 1p a t i e n t ws a sd o n et o
405 patientswas done to determinethe efficacy of comparetlre efficacy of cef'amandole. cefazolinand
a n t i m i c r o b i a l p r o p h y l a x i s f o r c a r d i a c s L r r g e r ya s cefuroxinrein preventingsLlrgicalsite irrfectionsafler
compared to placebo. Therewasa statistically significant cardiacsurgery.There was no statisticallysigrrificant
reductionin the sLrrgical site infectionrate in the group differerrcein surgical site infectiou rates among the
given antimicrobialprophylaxiswith a summaryodds t l r r e eg r o u p s( p = 0 , 9 2 ) w i t h 8 . 4 p e r c e n t( 4 6 o f 5 4 9
ratioof 4.96(95% Cl:2.06to9.72).Tliis corresponds to patients)in the cefamarrdole groLrp,8.4 percent(46 of
a s i g r r i f i c a nr e
t d L r c t i oi n t h e s u r g i c a l s i t ei n f e c t i o nr a t e 547 patients)in the cefazolingroup,and 9 pelcent(49
l'ronrabout20 -25 percentin theplacebogroupcompared o f 5 4 5 p a t i e n t s )i r r t h e c e f u r o x i m eg r o L l pd e v e l o p i n g
t o t h e4 - 5 p e r c e nrta t ei n t h ea n t i t n i c r o b i apl r o p h y l a x i s irrfections.In addition,tlrere was also no significant
g r o u p .( L E V E L I E V I D E N C E ) differencewith respectto the sitesof irrfectiotrs andthe
depth of tissue involvementamong the three groups.
2. What is/arethe appropriateantimicrobial/s,
dose/s, (LEVELI EVIDENCE)
and durationof prophylaxis? A meta-arralysis of four randomizedcontrolledtrials
(l(riaras,2000) was done to evaluatetlre effect of a
T h e r e c o m m e r r d eadn t i r n i c r o b i a lfso r p r o p h y l a x i s r e d u c t i o ui n t h e d u r a t i o no f p r o p h y l a c t i ac n t i m i c r o b i a l
i n c a r d i a c s u r g e r ya r e C e f a z o l i n l g r a r n I V p r e - r e g i m e n s i n m a j o r c a r d i o v a s c u l a rs u r g e r y o n
operativelythen I gram IV every 8 hours for 48 lrours postoperative i nfectioLts colrrp I ications.A randomized
(CATEGORY A RECOMMENDATION) a n d trial errrolling569 patientswas doneto cot'npare a long
CefuroximeI .5gramsIV pre-operatively then I .5 grams d u r a t i o ror f p r o p h y l a x i sL r s i n g c e f a z o l i n5 0 0 r n gI V p e r
I V e v e r y 8 h o u r s f o r 4 8 h o u r s ( C A T E G O R Y A d a y f o r 4 d a y s w i t h a s h o r t d u r a t i o no f a n t i b i o t i c
RECOMMENDATION) adririnistration r-rsing cefuroxime1.5granrsIV per day
f o r 2 d a y s . T h e r e w a s n o s t a t i s t i c a l l ys i g n i f i c a n t
Surnmary of Evidence differencebetweentlre two groltpswith a 2.5 percent
surgicalsite infectionrateand 5.7 percent30-daytotal
Subgroupanalysisof six randomizedtrials in a infectionrate in the cefazolingroup and a 1.1percent
meta-ana lysis (KreterandWoods, 1992) eriroI I ingZ,630 surgicalsite infectionrateand 5.3 percent30-daytotal
patientswas doneto comparethe efficacy of tlre first- infection rate in the cefuroxime group. (LEVEL I
generatiorrcephalosporincefazolin with the second E V I D E N C E )
generationcephalosporins cefamandoleor cefuroxime A r a n d o m i z ecdo n t r o l l e d t r i a le n r o l l i n g8 8 3p a t i e r r t s
for prophylaxisof surgical site infection in cardiac wasdonetocompareceftriaxone2 gramsIV singledose
surgery.The total surgicalsite infectionratesranged with cefazolin500 mg IV every6 hoursfor I day.There
from 2.5 percentto 16.7percentfor tl-recefazolingroup was no statisticallysignificantdifferencebetweenthe
and from 0 percentto 13.5percentin the cefamandole- two groupswith a 0.4percenttotalsLrrgical siteinfection
or cefuroxime-treated patients.Tlrerewasno statisticaI ly rate and 5 percent30-day total infection rate in the
 Antimicrobial Prophylaxisfor Surgical Procedures 83

ceftriaxonegroupanda I .3 percentsurgicalsiteinfection groin incisionand whetherthe routeof administration

rate and 4.5 percent30-day total infection rate in the was important.The incidenceof groin wound infection
cefazolingroup. (LEVEL I EVIDENCE) was 24.5 percent (13 of 53 patients) in the no
A r a r r d o m i z e dc o n t r o l l e d t r i a l e n r o l l i n g 1 , 0 0 9 antimicrobialgroup,5.9 percent(3 of 5l patients)in the
patientswas done to conrparecefuroxime 3 grams IV combinedtopical plus intravenouscephradinegroup,
singledosewitlrthecombinationof amoxicillin2 grams while no infectionsoccurredin the topical cephradine
IV every8 hoursfor 4 daysplus netihnycin150 mg IV group of 46 patientsand tlre intravenouscephradine
every l2 hours for 4 days.There was no statistically groupof 55 patients.Comparingsurgicalsite infection
significantdifferencebetweenthetwo groupswith a I .2 ratesby incisionsite betweenthe use of antirnicrobial
percenttotal sLrrgical siteinfectionrate and5.7 percent prophylaxisand no antimicrobials,the incidenceof
groin and abdominal incision infections were
30-daytotal infectionratein the cefuroximegroupand
s i g n i f i c a n t l yl o w e r i n t h e p r o p h y l a x i sg r o u p a t 1 . 8
a 0.6 percentsurgicalsite irifectionrateand 5.6 percent
percent(3 of I 69 incisions)and 0 percent(0 of 3 I
30-day total infection rate irr the cefazolin groLrp.
incisions)respectively comparedwith tlrecorresponding
(LEVEL I EVIDENCE)
groin infectionrateof 22.6 percent(14 of 62 incisions)
A randornized controlledtrial was doneto compare
and abdominalincision infectionrate of 22.2 percent
cefuroximewith ceftriaxoneboth of which were given (2
of 9 incisions)in the no antinricrobialgroLrp. There
for 48 hours,The total postoperative infectionratewas wasno statisticallysignificantdifferencein leg incision
5.2 percent(range4.5 % to 5.7 %) but there was no infectionrateswith a I .0 percentrate(3 of286 incisions)
statisticallysignificant difference in infectiorr rates in the prophylaxisgroup comparedwith none(0 of 77
betweentheantimicrobialregirnens. Despitethevarying i n c i s i o n s )i n t h e n o a n t i m i c r o b i apl r o p h y l a x i sg r o u p .
forms and durationof antimicrobialproplrylaxis,the (LEVEL I EVIDENCE)
total surgicalsite infectionrate in the meta-analysis of
2,970 patientswas 1.1 percentand there was a trend 2. What is/arethe appropriateantimicrobial/s, dose/s,
generallyin favor of the shorterregimen.(LEVEL I and durationof prophylaxis?
EVIDENCE)
AlthoLr glrvariousantim icrobial regimens havebeen The recommended antirnicrobialfor prophylaxisin
shown to be equally efficacious for proplrylaxis in periplreral vascular sLlrgery is cefazolinI granrIV pre-
cardiac procedures,cefazolin and cefuroxirnewere operativelytlren'l grarl IV every6 hoursfor 24 hours.
recornrrrended by the membersof tlre expertpanel. (CATEGORY A RECOMMENDATION)
,I.5
An alternativeregimenis cefuroxirle grarnsIV
D . V a s c u l a rS u r g e r y pre-Qperatively then 1,5 grams IV every 8 hoursfor24
hours.(CATEGORY A RECOMMENDATION)
l . I s a n t i m i c r o b i a lp r o p h y l a x i sr e c o m r n e n d e d for
peripheralvascularsurgery? Summary of Evidence

A n t i r n i c r o b i a lp r o p h y l a x i si s r e c o m m e n d e df o r A prospectiverandonrizedstudy (Edwards,1992)
p e r i p h e r a l v a s c n l a r s L r r g e r y .( C A T E G O R Y A enrolling559 patientswas done to determinewhether
RECOMMENDATION) the incidenceof vascular sr-rrgical site infectionsin
p a t i e n t sL r n d e r g o i n a g b d o r n i n a la o r t i c a n d l o w e r
S u m m a r yo f E v i d e n c e extremityperipheralvascularsr"rrgical procedurescan
be redLrcedby administeringa more beta-lactamase-
A p r o s p e c t i vbel i n d e dr a n d o m i z e tdr i a l ( P i t t , 1 9 8 0 ) s t a b l ec e p h a l o s p o r i nl i k e c e f u r o x i m e1 . 5 g r a m s I V
enrolling217 patientswas done to determinewhether preoperative Iy, 750 mg IV every3 hours duri ng operation
l so u l d r e d u c et h e i n c i d e n c e and750 mg IV every6 hoursfor 24 hourspostoperatively
p r o p h y l a c t iacn t i m i c r o b i a w
of infection in peripheralvascularprocedureswith a ascomparedto cefazolinI grarnIV preoperatively, 500
84 2006
PJSSVot.61,No.2, April-June,

mg every4 hoursduringoperation,and 1 gramevery6 a n t i m i c r o b i a l s i n p a t i e n t s u n d e r g o i n gs u r g i c a l

hours postoperativelyfor 24 hottrs.Tlie study showed management of hip or otlrerlorrgbonefracturesreduces
that tlrere was lto statisticallysignificant difference the incidenceof surgicalsiteandotherhospital-acqtrired
betweenthe two groups with 2.6 percent (7 of 272 infectionsS . u b g r o u pa n a l y s i so f s e v e t lt r i a l s w l r i c h
patients)in the cefuroximegroup and 1.0percent(3 of compareda siugle pre-operativedose of a parenteral
287 patients)in the cefazolirrgroup developingdeep antibiotic with placeboor tro treatruentslrorvedthat
i n c i s i o n a l s u r g i c a l si irtref e c t i o n( sp = 0 . 2 ) .T h ea u t h o r s
s i n g l e d o s e a n t i m i c r o b i apl r o p l r y l a x i s i g n i f i c a n t l y
c o n c l u d e dt h a t a l t h o u g h t h e d i f f e r e r r c ew a s n o t reducedthe rate of sLrperficial sLrrgicalsite irrfections
statisticallysignificant,the trend in infection rates with arr R R o f 0 . 6 9 ( 9 5 % C I : 0 . 5 0 t o 0 . 9 5 )a n d d e e p
suggeststhat at tlre dosesused in the study, cefazolin w
s u r g i c asl i t ei n f e c t i o n s i t h a n R R o f 0 . 4 0( 9 5 % C l : 0 . 2 4
providesmoreeffectiveperi-operative prophylaxisthan t o 0 . 6 7 ) .T e n t r i a l s w h i c h c o n r p a r e cal p r e - o p e r a t i v e
cefuroxime. (LEVEL I EVIDENCE) d o s ep l u s2 o r m o r ep o s t o p e r a t i vdeo s e sw i t h p l a c e b o r
A r a n d o n r i z e dt r i a l ( H a l l , 1 9 9 8 ) e n r o l l i n g 3 0 2 n o t r e a t m e n ts h o w e dt h a t t h e u s e o f r n u l t i p l ed o s e
p a t i e n t sw a sd o n et o c o m p a r et h e i n c i d e r r coef s u r g i c a l a n t i r n i c r o b i apl r o p h y l a x i sa l s o s i g n i l ' i c a n t l yr e d r r c e d
the rateof sLrperficial
s i t e i n f e c t i o n a f t e r v a s c u l a rs l l r g e r y f o l l o w i r r g t h e surgicalsiteirrl'ectiorrs witlt an RR
o f 0 . 4 8( 9 5 % C l : 0 . 2 8t o 0 . 8 1 5 )a r r dd e e ps u r g i c asl i t e
a d r n i n i s t r a t i oonf t i c a r c i l l i n3 . 0 g r a r l s / c l a v u l a n a0t e.I
grarrrIV either as a single pre-operativedose or as a s i t h a r rR R o f 0 . 3 6 ( 9 5 % C l : 0 . 2 1t o 0 . 6 5 ) '
i r i f e c t i o nw
multiple-doseregirnenat 6 hourly intervalsafter the (LEVEL I EVIDENCE)
initial dosefor a maximum of 20 doses'There was a A m e t a - a n a l y soi sf 15 r a n d o m i z e cdo n t r o l l e dt r i a l s
(SoLrthr,vetl-Keely,
s t a t i s t i c a l l sy i g n i f i c a n dt i f f e r e n c ei n t h e i n c i d e n c eo f 2004) enrolling 2,417 patientswas
s u r g i c asl i t ei n f e c t i o n b d o n e t o e v a l u a t et h e e f f e c t i v e n e s os f a n t i r n i c r o b i a l
s e t w e e nt h e t w o g r o l l p sw i t h l 8
p e r c e n(t2 8o f 15 3 p a t i e n t si)n t h es i n g l ed o s eg r o u pa n d s l r o h a c sl t r r g i c ailn t e r v e n t i o n
p r o p h y l a x i fso r p a t i e r l t w
l 0 p e r c e n (t 1 5 o f 1 4 9 p a t i e n t s i)n t h e n r u l t i p l ed o s e after a proxinialfenloralft'acture.Otttcontesmeasured
g r o u p d e v e l o p i n gi n f e c t i o n sf o r a r e l a t i v er i s k o f 2 . 0
incILrded sLrrgicaI siteinf-ectiorts, ttrinarytt'actittfection,
( 9 5 Y "C l : - 1 . 0 2t o 3 . 9 2 ) .T h e a u t h o r sc o n c l u d e dt h a t a a n dr n o r t a l i t yO. f t h e t e nt r i a l si r r c l L r d ewdh i c hs o u g h t t o
mr-rltip le-doseratlrerthana singledoseregimenprovides determine whether antinricrobial prophylaxis
optirnalprophylaxisagainstsurgicalsite infectionfor s i g n i f i c a n t l yr e d u c e do v e r - a l l s L r r g i c asl i t e i n f e c t i o n
p a t i e n t su n d e r g o i n gv a s c u l a r s u r g e r y . ( L E V E L I rateswhencomparedwith placebo,threestr'rdies showed
EVIDENCE) a s t a t i s t i c a l l y ' s i g n i f i c a nbt e r r e f i tf o r t h e u s e o f
a n t i m i c r o b i a l sf i,v e s t u d i e ss h o w e da t r e n di t t f a v o ro 1 '
0rthopeclic Surgery a n t i b i o t i c s ,a n d t w o s t u d i e s f a v o r e d p l a c e b o 'T h e
cour.bJ rredresultsshoweda slllnlllaryoddsratioof 0.55
1. ls antitnicrobial prophylaxisrecolnmended for total ( 9 5 % C l : 0 . 3 5 t o 0 . 8 5 )f a v o r i r r gt l r eu s eo f p r o p h y l a c t i c
(LEVEL I EVIDENCE)
-ioint replacetnentarrd elective fixation of closed a r r t i m i c r o b i a l s .
long bone fractures?
2 . W h a ti s / a r et h ea p p r o p r i a taen t i r n i c r o b i a l /dso. s e / s ,
ArrtirnicrobiaI prophyIaxis is recommended for totaI a n dd L r r a t i oor rf p r o p h y l a x i s ?
-iointreplacetnent surgeryandelectivefixatiorrof closed
l o r rg b on e fractures. (CATEGO RY A T h e r e c o m m e n d eadn t ir l i c r o bi a l f b r p r o p h yl a xi s i n
RECOMMENDATION) total joint replacemetrt surgeryand electivefixationo1'
closed long bone fractures is cefazolin I gram IV pre-
operativelytlten 'l grarn lV every 8 lroursfbr 24 lrours
S u m m a r yo f E v i d e n c e
( C A T E G O R YA R E C O M M E N D A T I O N )
A rneta-analysis of 22 randomized controlled trials
( G i l l e s p i e2, 0 0 4 )e n r o l l i n g8 , 3 0 7p a t i e n t sw a s d o n et o Alternativeregimensare:
t h e n7 5 0 m g
determinewhetlrerthe prophylacticadtninistrationof C e f u r o x i m e1 . 5g r a m s[ V p r e - o p e r a t i v e l y
Antimicrobial Prophylaxisfor Surgical Procedures 85

lV every 8 lrours for 24 hours (CATEGORY A SLrbgroLrp analysisof two trials in tlremeta-analysis
RECOMMEN DATION) (Gilfespie,2004)wlrichcomparedthe useof prophylaxis
Ceftriaxone2 grams IV single dose (CATEGORY A l i m i t e d t o 2 4 h o u r s o r l e s s w i t h l o n g e r p e r i o d so f
R E C O M M E ND A T I O N ) a n t i m i c r o b i a l a d r n i n i s t r a t i o nd i d n o t s h o w a n y
statisticallysignificant difference between the two
Summary of Evidence regimensin termsof superficialsurgicalsite inf-ection
rateswith a n R R o f 0 . 5 7( 9 5 % C l : 0 . l 7 t o 1 . 9 3 ) a ndde e p
Sr-rbgroup analysisof two trials in a meta-analysis s u r g i c a l s i t ien f e c t i o nr a t e sw i t h a n R R o f L l 0 ( 9 5 %C l :
(Gillespie2 , 0 0 4 )w h i c l r c o m p a r e da s i n g l ed o s eo f a 0 . 2 2t o 5 . 3 4 ) .( L E V E L I E V I D E N C E )
s h o r t a c t i n ga r r t i n r i c r o b i a wli t h m L r l t i p l ed o s e so f t h e
s a n l e a g e n t f o r p r o p h y l a x i ss h o w e d a s t a t i s t i c a l l y Urologic Surgery
significantdiff'erencefavorirrgrlLrltipledoses in the
preventionof superficialsLrrgicalsite infection rates A. Transurethral Resectionof the Prostate
r.vitlran RR of 4.82 (95% CI: L08 to 21.61) and deep
surgicalsiteinfectiortrateswith an RR of 7.89(95%CI: l . I s a n t i m i c r o b i a lp r o p l r y l a x i sr e c o n t m e r t d etdb r
1 . 0 1t o 6 1 . 9 8 )(.L E V E L I E V I D E N C E ) transurethral resectionof the prostate?
S L r b g r o Larnpa l y s i so f t h r e et r i a l si n a m e t a - a n a l y s i s
(Gillespie2 , 0 0 4 )r v h i c hc o n t p a r e da s i n g l ed o s eo f a A n t i r n i c r o b i a lp r o p h y l a x i si s r e c o m t n e n d e fdo r
l o n g a c t i n ga n t i m i c r o b i awl i t l r r n u l t i p l ed o s e so f o t h e r t r a n s u r e t h r a lr e s e c t i o n o f t h e p r o s t a t et o p r e v e n t
a n t i u r i c r o b i aw l si t h s h o r t e rh a l f - l i v e sd i d n o t s h o wa n y p o s t o p e r a t i v e b a c t e r i u r i aa n d c l i n i c a l s e p t i c e m i a .
s t a t i s t i c a l l ys i g n i f i c a n td i f f e r e r r c eb e t w e e nt h e t w o ( C A T E G O R YA R E C O M M E N D A T I O N )
r e g i n r e nisn t e r m so f s u p e r f i c i asl u r g i c a sl i t e i n f e c t i o n
r a t e sw i t h a n R Ro f 1 . 0 1( 9 5 % C l : 0 . 3 5t o 2 . 9 3 )a n dd e e p S u m m a r y o f E v i d e n c e
sLrrgica s il t ei n f e c t i o nr a t e sw i t h a n R R o f 0 . 5 7( 9 5 % C I :
0 . 2 0t o 1 . 6 4 )T. h e a u t h o r sc o n c l u d e d t h a tt h e e f f e c to f a c o n t r o l l e ct rl i a l s
A m e t a - a n a l y soi sf 3 2 r a n d o t r i z e d
s i n g l ed o s ei s s i r n i l a tr o t h a to f m u l t i - d o s e isf t h e a g e r i t (Berry, 2002) enrolling 4.260 patientswas done to
r-rsep d l o v i d e st i s s u el e v e l s e x c e e d i n gt h e m i n i m t t m determinetlie efficacyof antimicrobialprophylaxisin
i n h i b i t o r yc o r t c e n t r a t i oorvl e r a l 2 - h o u r p e r i o d .I f t h e preventi ng postoperati ve bacteri uria i n tnetturtdergo i ng
a n t i b i o t i cc h o s e nh a s a s h o r t - h a l fl i f ' ew h i c h r r a y r l o t pri nrary treatment
transurethral prbstatic resection.The
allowmittittrumirrhibitol')/ concentratiotts to beexceeded
e n d p o i r r to f b a c t e r i u r i aw a s d e f i n e di n t h e s t u d i e sa s
t h r o L r g l i o tuht e p e r i o dl j ' o mi n c i s i o nt o w o u n dc l o s u r e ,
g r o r , v t hb e t w e . e n1 0 4 a n d 1 0 7 p e r n r l b e t w e e n
t h eu s eo f r n u l t i p l e d o s er e g i r r r e nnsl a yb ed o n e .( L E V E L
pos{operative days 2 and 5. Eight trials in tlre meta-
I EVIDENCE)
analysie s r r r o l l i r r 1g , 9 7 9p a t i e n t lsi k e w i s ee x a r l i n e dt h e
A r a n d o m i z e dd o u b l e - b l i n dn t u l t i c e n t e rt r i a l
efficacy of antirnicrobialprophylaxis in preventing
( M a u e r h a nI,9 9 4 )e n r o l l i n g1 , 35 4 p a t i e n t sw a sd o n et o
postoperative septicernia.This secondaryoutcomeof
c o m p a r ec e f u r o x i n t e1 . 5 g r a r n s I V p r e - o p e r a t i v e l y
c l i n i c a l l y a p p a r e n ts e p s i sw a s d e f i n e d b y o b . i e c t i v e
follr:wedby 750 rng every 8 hours for a total of three
followed parameters such as persistenttemperaturegreaterthan
closes with cefazolinI granrIV preoperatively
3 B . 5 o Cr,i g o r sa n de l e v a t e d C - r e a c t i v pe r o t e i n(.L E V E L
b y I g r a n rl V e v e r ye i g h th o t t r sf o l ' a t o t a lo f n i n ed o s e s
in patierrts Lrndergoirrgtotal hip or kneejointarthroplasty. I E V I D E N C E )
weredoneat two to threenronths The nreta-analysis of 32 trials slrowedthat the
Follow-Lrp assessnleltts
combined bacteriuria event ratewassignificantlylower
and one year afterthe procedure.An intention-to-treat
a t 9 . 1 p e r c e n (
t 2 { 3 o f 2 , 3 4 6p a t i e n t s w ) i t h t h e u s eo f
a r r a l y s i sd i d n o t s h o r v a n y s t a t i s t i c a l l ys i g n i f i c a n t
as compared to the26 percent
differencein the strlgicalsite infection ratesbetween prophylacticantirnicrobials
p a t i e n t s e) v e n tr a t e i n t l r e l a c e b oo r n o
p
the two groupswith 3 percentin the cefut'oximegroLrp ( 4 9 7 o f 1 , 9 1 4
risk of bacteriuriairr
a n c l 3 p e r c e n t i r r t h e c e f a z o l i n g r o u p d e v e l o p i n g agentcontrol groLrp.The relative
a l l t r i a l s w a s 0 . 3 5 w i t h R R o f 6 5 p e r c e n t ( 9 5 0C/ Io: - 5 5
i n f ' e c t i o n (sL. E V E L I E V I D E N C E )
 86 P J S SV o l .6 1 ,N o .2 , A p r i l - J u n e2,0 0 6

to -72).On tlreotlierhand.the subsetof 8 trials slrowed p < 0 . 0 1 ) .C e p h a l o s p o r itnr i a l s i r t v o l v e d6 7 p e r c e r rot f

that the combinedclirricalsepticeuria episoderatewas t l r et o t a ls t L r dpy a r t i c i p a n t(s2 , 8 1 4o f 4 , 2 6 0p a t i e n t sa)n d
l i k e w i s es i g n i f i c a n t l yl o w e r a t 0 . 7 p e r c e n (t 9 o f 1 . 2 2 9
c o n r b i n etdh e ys h o r v e a d 6 6 p e r c e r rrte l a t i v ed e c r e a sier r
r i s k ( 9 5 % c l l : - 5 7 t o - 7 3 . p < 0 . 0 1 ) .N i t r o f u r a n r o i n .
p a t i e n t sw) i t h t h e u s eo f p r o p h y l a c t i ac n t i r n i c r o b i a al ss
conrparedto the 4.4 percent(33 of 750 patients)event p e ni ci l l i n a n dB - p e ni c i l l i nd i d r r o ts i g ni f i c a n t l yc l e c r e a s e
ratein the placeboor uo agentcoutrolgroupfor a RRR t l r er i s k o f b a c t e r i u r i a l t l r o L r gthl r ep o i r r te s t i n r a t ef so r
of 77percent(95% C I : 5 5 t o - 8 8 ) .T h e r e s u l t ss h o wt l r a t
e a c h c l a s s w e r e i n t h e d i r e c t i o no f d e c r e a s e d risk.
i f I , 0 0 0 p a t i e n t sw i t h s t e r i l e u r i n e w e r e g i v e n (LEVEL I EVIDENCE)
p r o p h y l a c t i ca n t i m i c r o b i a l sb, a c t e r i u r i aw o L r l db e A m e t a - a n a l y soi sf 3 2 r a n d o m i z e cdo n t r o l l e dt r i a l s
a v o i d e di n 1 7 5w h i l e s e p t i c e n r iwa o u l d b e p r e v e n t e idn ( B e r r y , 2 0 0 2e) n r o I I i n g 4 . 2 6p0a t i e r r tasl s oa n a l y z etdh e
9 to 20. Tlreresults of the meta-analysis thereforeshow difTerenttreatrnent duratiorrs usedin thetrialsby dividing
t h a ta n t i mi c r o b i a l p r o p h y l a x i s them into 3 groups.Basedon the dose regirtterts
i s e f f e c t i v ei n d e c r e aisn g Lrse-cl,
the rate of postoperative thedLrrations
b a c t e r i u r i aa n d c l i n i c a l wereclassifiedaseitlrersingledose cc'rurse
s e p t i c e m i a( L. EVEL I EVIDENCE) (predonr inantlyantibioticadnrin isteredpreoperatively).
slrort-course (moretlranoneantibioticdoseadministered
2. What is/arethe appropriateantirnicrobial/s,dose/s, within 72 hoLrrs of surgeryor until catlteterrerttoval), or
a n d d u r a t i o no f p r o p l r y l a x i s ? e x t e n d e dc o l u ' s e( n r u l t i p l ea n t i b i o t i cc l o s e se x t e n d i n g
beyond 72 hours fronr the tirre of tlre procedureor
T h e r e c o n r m e n d eadn t i m i c r o b i af lo r p r o p h y l a x i si n b e y o r r dc a t h e t e rw i t h d r a w a l ) .A n a l y s i s o f a l l t l i a l s
transurethral resectionof the prostateis ciprofloxacin indicatedthat extendedcourseprotocolsdecreased tlte
500 mg tabletper orernBID for 72 hours(CATEGORY incidenceof bacteriuriaby 72 percent(95% Cl: -42 to
A RECOMMENDATION) -87), short-colrrse protocols decreased it by 68 percent
(95% Cl: -56 to -77) andsi ng Ie doseprotocoIs decreased
A Iternative r e g i m e n sa r e : i t b y 5 7 p e r c e n(t9 5 % C I : - 4 I t o - 6 8 ) .S L r b g r o uapn a l y s i s
C e p l r a l e x i n5 0 0 m g p e r o r e m T I D f o r 3 d o s e s o f c e p h a l o s p o r i n - b a s e dt l i a l s w i t h s i g n i f i c a n t
(CATEGORY A RECOMMENDATTON) h e t e r o g e n e i ti yn c l u d i n -7u s i n g l ec l o s e1. 2 s h o r t - c o u r s e
F l u o r o q u i n o l o n e ( C i p r o f l o x a c i r r , O f l o x a c i n , ancl I extendeclcoursereginrensshor,l'ed RRR of 82
Levofloxacin)400 rng IV every l2 hours for 72 hoLrrs p e r c e n (t 9 5 % Q l : 3 7 t o - 9 5 , p < 0 . 0 1 )f o r t h e e x t e r r d e d
(CATECORY A RECOMMENDATTON) coursereginren, RRR of 71 percent(95% Cl: -63 to
7 7 , p < 0 . 0 1 )f o r t h es h o r tc o u r s ep r o t o c o l sa n d R R R o f
S u m m a r yo f E v i d e n c e 5 2 , p e r c e n(t9 5 0 / C o l : - 38 t o - 6 2 , p < 0 . 0 1) f o r t h e s i n g l e
d o s t ' ' p r o t o c o l sT. h e n r e t a - a n a l y s issh o w e d t h a t a
A m e t a - a n a l y soi sf 3 2 r a n d o m i z e cd o n t r o l l e dt r i a l s significantbacteriuria RRRwasaclrievecl by alltreatrttent
( Berry. 2002)errro I ling 4,260 patients also analyzedthe d u r a t i o np r o t o c o l s(.L E V E L I E V I D E N C E )
a n t i m i c r o b i acll a s s eus s e di n t h et r i a l sb y d i v i d i n gt h e m A l t h o L r g ho n l y c 1 r - r i n o l o nseusc h a s c i p r o f l o x a c i r t
into 9 groups. The risk of bacteriuriawas significantly and fleroxacinwere used in tlre trials includedirr the
decreased by aminoglycosides with RRR of 55 percent nreta-analysis, the expertpanelbelievesthat the Lrseof
(95% CI:0 to -80,p: 0.051). co-trirnoxazole with RRR o t h e r q L r i n o l o nwe hs i c ha r er l r o r er e a d i l ya v a i l a b l e inthe
o f 6 4 p e r c e n t( 9 5 % C l : - 4 t o - 8 7 , p = 0 . 0 4 1 ) .f i r s t local settirrgmay be sLritablealternativeregirnerrs if
g e n e r a t i o nc e p h a l o s p o r i n w i t l r RRR of 66 percent used parenterally for a slrort-colrrse of abor,rt 72 hours
(95% Cl: -36 to -82, p < 0.0 | ), second generation considering thatthefl uoroquinolonesasa c lassgavethe
c e p h a l o s p o rw i ni t h R R R o f 6 3 p e r c e n(t 9 5 % C I : - 2 8 t o h i g h e s tr e l a t i v e r i s k r e d u c t i o no f 9 2 p e r c e n tw h e n
-8 I , p < 0.01). tlrird generatiorr cephalosporin with RRR c o m p a r e dt o p l a c e b o R . andomized c o u t r o l l e dt r i a l st o
o f 6 7 p e r c e n t( 9 5 % oC l : - 5 5 to - 7 6 , p < 0 . 0 1 ) , a n d evaluatethe efficacyof the other quinolones shoulclbe
quinolonewith RRR of 92 percent(95ohCI: -75 to -98, donein the future.(LEVEL III EVIDENCE)
 Antimicrobial
Prophylaxis
for SurgicalProcedures 81

Neurosurgery smallertreatmenteffectsfor antimicrobialr"rse with arr

odds ratio of 0.30, tlrerewas no evidenceof different
A. Spinal Surgery treatmenteffects witlr tlre inclusion of grarn-rregative
coverageover gram-positive coveragealone(oddsratio
I . Is antinricrobialprophylaxis recorlmende d for spirral o f 0 . 5 4 . p : 0 . 5 ) . T h e a r - r t h o rf sa i l e d t o i d e n t i f ya n y
surgery? additionalbenefitwhenantimicrobialcoverage incIuded
Antimicrobialprophylaxisis recommended in spinal gram-negative organisnrs. One trial (Rubinstein,I994)
o p e r a t i o n ss u c l r a s l a m i n e c t o r l i e s ,f u s i o n s , a n d usedcefazolinsingledosewhile anothertrial (Redjian.
d i scectonr ies.(CATEGORY A RECOMMENDATION) 1990) utilized oxacillin for 24 hours as prophylaxis.
(LEVEL I EVIDENCE)
Summary of Evidence Four randornized trials in a meta-analysis (Barker,
A meta-analysis of 6 randomizedcontrolledtrials 2002) used only pre-operative and intra-operative dosirig
(Barl<er,2002) enrolling 843 patients was done to w h i l e t w o t r i a l s u s e d a d d i t i o n a p
l o s t o p e r a t i vdeo s i r r g
d e t e r m i n ew h e t h e r a n t i mi c r o b i a l p r o p h y l a x i s w a s for 12 to 24 hours. There was no evidence of different
beneficialfor spinaloperationsdespitethe prevailing treatmenteffects witli the different dosing periods
low infectionratewithout pre-operative antibiotics.In a l t h o u g h t h e t r i a l s L l s i n g p o s t o p e r a t i v ed o s i n g
the antibiotic prophylaxis group, 2.2 percent( I 0 of 451 demonstratedslightly smaller treatmenteffects for
patients)developed sr"rrgical siteinfectionscomparedto a n t i b i o t i cL r s e ( o d d sr a t i oo f 0 . 5 2v e r s u s0 . 3 4 ,p = 0 . 9 6 ) .
5.9 percent(23 of 392 patients)in the pooledcontrol The authors failed to identify any additiorralbenefit
armsof thetrials.Tlrerarrdom-effects pooledodds-ratio whenmr"rltiple-dose regimerrs wereusedasconrpared to
o f 0 . 3 7( 9 5 % C l : 0 . I 7 t o 0 . 7 8 ;p < 0 . 0 1 )d e r n o n s t r a t e ds i n g l e - d o sree g i n r e n s( .L E V E L I E V I D E N C E )
s t a t i s t i c a l l y s i g n i f i c a r r te v i d e n c e o f e f f i c a c y f o r
antirnicrobial prophylaxis. It alsodemonstrated a pooled B. CSF Shunts
risk difference of 2.9 percent favoring the use of
prophylacticantinricrobials. l . I s a n t i m i c r o b i a lp r o p h y l a x i sr e c o m m e n d e df o r
A meta-analysis of 6 norr-
ranclom izedtrialssirnilarlydemonstrated lowerinfection cerebrospiua f llu i d s h u n t i n gp r o c e d u r e s ?
rates among autibiotic-treated patientswith an odds
ratioof 0 .22(95% CI: 0 . I 5 to 0.33 , p < 0 .00 I ). (LEV EL A n t i m i c r o b i a l p r o p h y l a x i s i s r e c o m m e n d e cf ol r
I EVIDENCE) c e r e b r o s p i n fal lL l i ds h u n t i n gp i o c e d u r e s( C
. ATECORY
A RECOMMENDATION)
2. Whatis/arethe appropriate antimicrobial/s,
dose/s,
of proplrylaxis?
and clLrration Sum:rparyof Eviclence

T h e r e c o m m e n d eadn t i m i c r o b i af lo r p r o p h y l a x i isn A m e t a - a n a l y so i sf 9 r a n d o m i z e d c o n t r o l l e dt r i a l s
s p i n a l s u r g e r yi s c e f a z o l i n I g r a m l V s i n g l e d o s e ( H a i n e s ,I 9 9 4 ) e n r o l l i n g 1 , 0 4 4p a t i e r r t w s a s d o r r et o
( C A T E G O R YA R E C O M M E N D A T I O N ) d e t e r m i n teh e e f f i c a c yo f a n t i n r i c r o b i aplr o p h y l a x ifsb r
A n a l t e r n a t i v ree g i n r e ni s o x a c i l l i n I g r a ml V p r e - cerebrosp i ualfl u iclshuntoperations. OnestLrdy appearecl
operativelythen 500 mg IV every6 hoursfor 24 houls. t o s h o w a h i g h e r i n f e c t i o nr a t e i n t h e a n t i r n i c r o b i a l
( C A T E C O R YA R E C O M M E N D A T T O N ) prophylaxisgroup tlran tlre placebogroup, 3 studies
showedessentiallyno effect for pLophylaxis. 3 studies
S u m m a r yo f E v i d e n c e s h o w e ds t a t i s t i c a l liyn s i g ni f i c a n t r e n d sf a v o r i r r gl o w e r
infectionratesin the antimicrobial-treated group,and2
Threerandomized (Barker,
trials in a meta-analysis studiesshowedstatistically si gni ficanteffectsfavoling
2002) r-rsedantibioticswith both granr-positiveand the antirni crobi aI-treatedgroup. I n the anti b i ot i c-treatecj
gram-negative coveragewlrile three randomizedtrials g r o u p s ,7 . 2 p e r c e n t( 3 7 o f 5 1 7 p a t i e n t s )d e v e l o p e d
usedgram-positive coveragealone.Althoughthe trials surgicalsite irrfectiollscolxparedto12.9percent(68 of
with granr-negativecoveragedemonstratedslightly 527 patients)in the pooled control arms of the trials.
88 PJSSVol. 61,No.2, April-June,2006

The estimatedpooledodds-ratioof 0.48 (95% CI:0.31 hoursin one trial and for 36 hours in anothertrial, and
to 0.73;p = 0.001)demonstrated statisticallysignificant o x a c i l l i r rf o r 2 4 h o u r s .( L E V E L I E V I D E N C E )
evidence of efficacy for antimicrobial prophylaxis.
(LEVEL I EVIDENCE) C. Craniotomy
A meta-analysis of 12 randomizedcontrolledtrials
( L a n g l e y , 1 9 9 3 ) e n r o l l i n g 1 , 3 5 9 p a t i e n t sl i k e w i s e 1 . I s a n t i m i c r o b i a lp r o p h y l a x i s r e c o m m e n d e df o r
d e m o n s t r a t e dt h a t a n t i m i c r o b i a l p r o p h y l a x i s f o r craniotomy?
c e r e b r o s p i n a fl l u i d s l r u n t o p e r a t i o n ss i g n i f i c a n t l y
A r r t i r n i c r o b i apl r o p l i y l a x i s i s r e c o n r m e r r d ef d
or
reducedthe infectionratewith a Mantel-Haenszel risk
c r a r r i o t o m y( C. A T E G O R YA R E C O M M E N D A T I O N )
ratio of 0.52 (95% CI: 0.37 to 0.73,p: 0.0002).
(LEVEL I EVIDENCE)
S u m m a r yo f E v i d e n c e
2. What is/arethe appropriatearrtimicrobial/s, dose/s, A m e t a - a n a l y s oi sf 8 r a n d o m i z e d c o n t r o l l e dt r i a l s
arrddr,rration of proplrylaxis? (Barker, 1994) enrolling 2,074 patientswas done to
determine t h e e f f i c a c yo f a n t i m i c r o b i apl r o p h y l a x i isn
The recommended antirnicrobialsfor prophylaxis p r e v e n t i n gs u r g i c a sl i t e i n f e c t i o na n d m e n i r r g i t ias f t e r
in CSF shuntingprocedures are: Cloxacillin 1 grarnIV craniotomyand whetherenoughrandomizedstudieson
pre-operativelytherr I gram IV every 6 hours for 24 a n t i r n i c r o b i a p l r o p h y l a x i sh a v e b e e n p e r f o r m e dt o
hours (CATEGORY A RECOMMENDATION) answerthe questioncorrfidently.The cumulativeodds
Oxacillin 1 gram lV pre-operativelythen 1 gram IV r a t i o o f 4 . 2 ( 9 9 . 9 % C l : 1 . 9 t o 9 . 2 ; p < 3 x l 0 - 8 )
e v e r y 6 h o u r s f o r 2 4 h o u r s ( C A T E G O R Y A d e n r o n s t r a t e ds t a t i s t i c a l l y s i g n i f i c a r r te v i d e n c eo f
RECOMMENDATION) efficacyfor anti rnicrobi al prophylaxis. The cLrm ulative
treatmenteffect usingdifferences-in-proportion of 6.2
If thepatierrthasa pre-operative stayof at least3 days, p e r c e n(t9 9 . 9 % C I :3 t o I 0 ; p < 4 x I 0 - 8 l)i h e w i s ef a v o r e d
theadditionof gentamicin240 mg IV singledoseto either t h e u s eo f p r o p h y l a c t i ac n t i n r i c r o b i a l s .
of the previonsly listed regirrrensis recommended. T o d e t e r r n i n et l r e m i n i m u m n u m b e r o f s t u d i e s
(CATEGORY A RECOMMENDATION) r e q u i r e da f t e r w h i c h t h e q u e s t i o no f a n t i m i c r o b i a l
prophylaxis fdr craniotomyshoLrld lravebeenconsidered
S u m m a r yo f E v i d e n c e c l o s e dt,l r ec u n r u l a t i vner e t a - a n a l y suessi r i gp < 0 . 0 0 1a s
the definitionof statisticalsignificanceshowedthatthe
A meta-analysis of 9 randomizedcontrolledtrials
sti,pulated levelwas aclrievedin 1987afteronly 3 trials
(Hairres,1994) enrollirig 1,044 patientswas done to
L r s i ntgh eo d d sr a t i on i e t h o do r i n 1 9 8 8a f t e ro n l y 5 t r i a l s
determinethe efficacyof antimicrobialprophylaxisfor n-proportiorrs method.Theauthors
usingtlred ifference-i
cerebrospina f l lr - r i d
s h u n to p e r a t i o n sl n
. t h e a n t i b i o t i c - c o n c l u d e d t l r a t t h e r e i s a n a d v a n t a g et o u s i r r g
treatedgroups,7 .2percent(31of5 17 patients)developed antimicrobialsfor prophylaxisin craniotornyand that
surgicalsite infectionscomparedto12.9percent(68 of f u t u r e s t L r d i e ss l r o u l d c o m p a r e p r o p o s e d n e w
527 patients)in the pooled control arms of tlre trials. a n t i r n i c r o b i a lr e g i m e n sw i t l r o n e o f t h o s e a l r e a d y
The estimatedpooledodds-ratiosof 0.48(95% Cl: 0.31 demonstratedto be effective and not with placebo.
to 0.73;p : 0.001) demonstrated statisticallysignificant (LEVEL I EVIDENCE)
evidenceof efficacyfor antirnicrobialprophylaxis.The
a r r t i m i c r o b i a l su s e d i n t h e m e t a - a n a l y s i si n c l u d e d 2. What is/aretlreappropriateantirnicrobial/s, doseis,
g e n t a n r i c ipnl u sc l o x a c i l l i nf o r 6 h o u r s c, e p h a l o t h ifno r a n d d L r r a t i oor rf p r o p h y l a x i s ?
24 hours in one trial and for 72 hours in anothertrial.
methicillinfor 20 hoursin one trial and for 72 hor"rrs in T h e r e c o m m e n d eadn t i r n i c r o b i a lfso r p r o p h y l a x i s
anothertrial, trimethoprim-sulfamethoxazole for l6 in craniotomyare:CloxacillinI grarnIV pre-operatively
Antimicrobial Prophylaxisfor SurgicalProcedures 89

tlren1 gramlV every6 hoursfor24 hours(CATEGORY of postoperat i ve i nfecti ous comp I i cati ons aftercesarean
A RECOMMENDATION) sectionirr the popLrlation at lowestrisk in favor of the
Oxacillin I grani IV pre-operativelythen I gran-rIV use of prophylactic antibiotics. Antimicrobial
every 6 hours for 24 lrours (CATEGORY A prophylaxiscauseda statistically si gnifi cantreduction
RECOMMENDATION) in postoperative feverwith RR of 0.25(95% C1,0.14to
If the patienthas a pre-operativestay of at least 3 0.44),endometritiswith RR of 0.05 (95% Cl,0.0l to
days,the additionof gentamicin240mg IV singledose 0.38)and surgicalsite infectionwith RR of 0.59 (95%
to either of tlre previously listed regimens is C 1 , 0 . 2 4t o 1 . 4 5 ) .( L E V E L I E V I D E N C E )
r e c o m m e n d e d . ( C A T E G O R YA R E C O M M E N - A m e t a - a n a l y soi sf 5 1 r a n d o m i z e cdo n t r o l l e dt r i a l s
DATTON) ( S r n a i l la n d H o f m e y r , 1 9 9 9 ) w a s d o n e t o c o m p a r e
antibioticprophylaxiswitlr no treatmentin bothelective
Summary of Evidence a n d n o n - e l e c t i v ec e s a r e a ns e c t i o n s .T h e u s e o f
prophylacticantibioticspriorto cesarean sectionreduced
A rneta-analysis of 8 randomizedcontrolledtrials the incidenceof complicationssecondaryto infection
(Barker, 1994) enrolling 2,074 patientswas done to witli the reductionirr risk for endometritisfound to be
determinethe efficacyof antimicrobialprophylaxisfor sirnilaracrosstlre variouspatierrtgroups.Tlre relative
craniotomyin preventingsr,rrgicalsite irifectionand r i s k f o r e n d o m e t r i t iw s a s 0 . 38 ( 9 5 % C l : 0 . 2 2- 0 , 6 4 )f o r
r n e n i n g i t i sT.h ec u m u l a t i v eo d d sr a t i oo f 4 . 2( 9 9 . 9 % C l : the 9,805 patientswlro underwentelective cesarean
1.9 to9.2;p < 3 x I 0-8)demonstrated significantevidence
s e c t i o nR , R o f 0 . 3 9( 9 5 % C I : 0 . 3 4- 0 . 4 6 )f o r t h e2 , 1 3 2
of efficacyfor antimicrobial prophylaxis. Thecumulative
patientswho underwentemergencycesareatt section,
treatmenteffectusingdifferences-in-proportion of 6.2
a n d R R o f 0 . 3 9( 9 5 % C I : 0 . 3I - 0 . 4 3 )f o r a l l t h e | 1 , 9 3 7
percent(99.9%CI: 3 to 10;p < 4 x l0-8)likewisefavored
patientswho underwentcesareansection,The relative
the use of prophylactic antimicrobials. The
risk for surgicalsite infectionwas 0.73(95% Cl:0.53 -
antimicrobialsused in the trials in the meta-analysis
0.99) for tlte 2,015 patientswho underwentelective
i n c l L r d ecdl i n d a m y c i sni n g l ed o s e c, e f o t i a ms i n g l ed o s e ,
cesareansection,RR of 0.36 (95% CI: 0.26 - 0.51) for
vancomycin singledose,cefazolinplusgentamiciri single
the 2,780patientswho underwentemergencycesareall
d o s e , v a n c o m y c i np l u s g e n t a m i c i t t s i n g l e d o s e ,
s e c t i o na, n dR R o f 0 . 4 1( 9 5 % C l : 0 . 2 9- 0 . 4 3 )f o r a l l t l r e
p i p e r a c i l l i nf o r 3 d o s e s ,c l o x a c i l l i nf o r 4 d o s e s ,a n d
1 1 , 14 2 p a t i e n t s w h o u r r d e r w e n tc e s a r e a ns e c t i o n .
oxacillin for 6 doses.(LEVEL I EVIDENCE)
(LEVEL I EVIDENCE)

Obstetric and GynecologicSurgery

dose/s,
2. What is/aretheappropriateantimicrobial/s,
zinddurationof prophylaxis?
I. CesareanSection

The recommendedantimicrobialsfor prophylaxis

1 . I s a n t i m i c r o b i a lp r o p h y l a x i sr e c o m m e n d e df o r
cesarean section? in cesareandeliveryare: Ampicillin 2 gramsIV single
dosepre-operativelyor after cord clampingCefazolin2
Antimi crobial prophylaxis i s recommended for both grams IV single dose pre-operativelyor after cord
electiveandemergency cesarean sectiotl.(CATEGORY clamping (CATEGORY A RECOMMENDATION)
A RECOMMENDATION)
Summary of Evidence
Summary of Evidence
A meta-analysis of 51 randomizedcontrolledtrials
A meta-analysis of 7 randomizedcontrolledtrials (Smaill and Hofmeyr,2002) was done to comparetlre
(Chemlow,2001)wasdoneto determinethe efficacyof di fferentantirni crobials givenfor prophyIaxi s i u cesareatr
antimicrobialprophylaxisfor electivecesarean . he efficacy of ampicillin irr preventing
section' s e c t i o t t s T
significantreductionin tlie risk p o s t o p e r a t i v ei r i f e c t i o n s w a s s i m i l a r t o t h e f i r s t -
Therewasa statistically
 90 PJSSVol. 61,No.2, April-June,2006

g e n e r a t i o cne p h a l o s p o r i nwsi t h O R o f 1 . 2 7( 9 5 % C l : morbidityrates(definedas a tenrperature above37.9'C

0.84 - 1.93) and to the second- or third-generation on 2 occasionsafterthe first24 hoLrrspost-surgery) with
c e p h a l o s p o r i nwsi t h O R o f 0 . 8 3( 9 5 % C I : 0 . 5 4- 1 . 2 6 ) . 1 5 . 6p e r c e n itn t h e p r o p h y l a x i sg r o u pa n d 2 5 . l p e r c e n t
The first-generatiorr cephalosporins were likewise as of tlrose who did not receive arrtibioticprophylaxis
e f f i c a c i o u s a s t h e s e c o n d - o r t h i r d - g e r - r e r a t i o nd e v e l o p i n gf e b r i l em o r b i d i t yf o r O R o f 0 . 5 5( 9 5 % C l :
c e p h a l o s p o r i nwsi t h O R o f 1 . 2 1( 9 5 % C l 0 . 9 ' l- 1 . 5 l ) . 0 . 4- 0 . 7 ;p < 0 . 0 0 0 1 )(.L E V E L I E V I D E N C E )
(LEVEL I EVIDENCE)
Subgroupanalysisoftrials comparingmLrltipledose 2. What is/arethe appropriateantinricrobial/s,dose/s,
with singledoseregimenshowedthat a multiple dose and durationof prophylaxis?
regimenfor prophylaxisoffered no additionalbenefit
o v e r a s i n g l ed o s er e g i m e nw i t h O R o f 0 . 9 2( 9 5 % C l : T h e r e c o m r n e r r da en d t i m i c r o b i af lo r p r o p h y l a x iisn
0 . 7 0- r . 2 3 )(.L E V E Lr E V T D E N C E ) a b d o m i n ahl y s t e r e c t o miys c e f a z o l i r Ir g r a mI V s i n g l e
d o s e .( C A T E G O R YA R E C O M M E N D A T I O N )
B. Abdominal Hysterectomy
Summary of Evidence
l . I s a n t i r n i c r o b i a pl r o p h y l a x i sr e c o m m e n d e df o r
abdominalhysterectomy? A m e t a - a n a l y soi sf 2 5 r a n d o m i z e cdo n t r o l l e d trials
(Mittendorf,1993) enrolling3,604patientswasdoneto
A n t i r n i c r o b i a lp r o p h y l a x i si s r e c o m m e r r d e fdo r analyzethed i fferent antirnicrobiaIs usedby perforrrri ng
a b d o m i n a l h y s t e r e c t o m y . ( C A T E G O R Y A separate rneta-analyses for eaclrantibiotic.Therewasa
RECOMMENDATION) statisticallysignificantdifferencein tlre postoperative
i n f e c t i o nr a t e sw i t h 2 l . l p e r c e u o t f t h o s ew h o d i d n o t
Summary of Evidence receiveantibioticprophylaxiscomparedto I 1.4 percent
( 7 0 o f 6 1 5 p a t i e n t s )f o r t h o s e g i v e n c e f a z o l i n
A m e t a - a n a l y soi sf 2 5 r a n d o m i z e cd o n t r o l l e dt r i a l s ( p = 0 . 0 0 0 21) , 6 . 3p e r c e n(t 1 7 o f 2 6 9 p a t i e n t sf)o r t h o s e
( M i t t e n d o r f1 , 9 9 3 )e n r o l l i n g3 , 6 0 4p a t i e n t w
s a sd o n et o g i v e nm e t r o r r i d a z o(l p e : 0 . 0 1 5 ) ,a r r d5 . 0 p e r c e n(t 5 o f
d e t e r m i n ew h e t h e rt h e u s eo f p r e o p e r a t i v ae n t i b i o t i c s 10 I p a t i e n t s )f o r t h o s e w h o r e c e i v e dt i n i d a z o l e
preventedseriouspostoperativeinfectionsassociated ( p = 0 . 0 3 4 ) .( L E V E L I E V I D E N C E )
witli total abdominal hysterectomyas comparedto A meta-aflalysis (Tanos, 1994)evaluatedthe three
placebo.Therewasa statisticallysignificantdifference generations of cephalosporins.The infectionratewas
irrpostoperative infectionratesbetweenthe two groups 10.8percentfor thosewho receiveda first generation
w i t h 9 . 0 p e r c e n (t 1 6 6 o f 1 , 8 3 6p a t i e n t s a ) m o n gt h o s e c e p l r a l o s p o r i n c o n t r a stto 2 3 . 1 p e r c e nat m o n gt h o s e
wlro receivedantibioticproplrylaxisand 21.1 percent w h o d i d n o t r e c e i v ea n t i b i o t i cp r o p h y l a x i fso r a r rO R o f
( 3 7 3o f i , 7 6 8p a t i e n t sa) m o n gt h o s ew h o d i d n o tr e c e i v e 0 . 3 5( 9 5 % C I : 0 . 2t o 0 . 5 ; p < 0 . 0 0 0 1 )T. h e i n f e c t i o nr a t e
antibioticprophylaxisdevelopinginfectionsforan RRR w a s 9 . 7 p e r c e n t f o r t h o s e w h o r e c e i v e da s e c o n d
o f 1 2 . 1 p e r c e n(t p. = 0 . 0 0 0 0 1 )(.L E V E L I E V I D E N C E ) generationcephalosporinin contrastto 26.'7percent
A nreta-analysis of l7 randomizedcontrolledtrials a m o n g t h o s w e h o d i d n o t r e c e i v ea n t i b i o t i cp r o p h y l a x i s
(Tanos, 1994) enrolling 2,752 patientswas done to f o r a n O R o f 0 . 2 9( 9 5 % C l : 0 . 2 t o 0 . 6 ; p < 0 . 0 0 0 2 )T. h e
d e t e r m i n e t h e e f f e c t i v e n e s so f c e p h a l o s p o r i n si n infectionratewas 7.4 percentfor thosewho receiveda
p r e v e n t i n gi n f e c t i o L r sc o m p l i c a t i o n sa f t e r e l e c t i v e thirdgeneration ceplralosporin in contrastto23.4percent
a b d o m i n a lh y s t e r e c t o m yT. h e r e w a s a s t a t i s t i c a l l y a n r o n gt h o s ew h o d i d n o t r e c e i v ea n t i b i o t i cp r o p h y l a x i s
significantdifferenceirr postoperativeinfection rates f o r O R o f 0 . 2 6 ( 9 5 % C l : 0 . 2 t o 0 . 4 ; p < 0 . 0 0 0 1 ) .
with 9.8 percentin the prophylaxisgrolrp and 23.4 Multivariateanalysisslrowedno advantage forthenewer
percentin theno prophylaxisgroupdevelopinginfections a n d m o r e e x p e n s i v e s e c o n d a n d t h i r d g e n e r a t i o r r
f o r O R o f 0 . 3 5( 9 5 % C l : 0 . 3 - 0 . 4 ; p = 0 . 0 0 0 1 ) T . h e r e c e p h a l o s p o r i ns st u d i e dA. s i n g l ed o s ew a ss i g n i f i c a n t l y
was a statistically significant difference in febrile moreefficientconrpared to mLrltiplecloseprophylaxisin
 Antimicrobial Prophylaxisfor Surgical Procedures 9l

preventingi n f e c t i o nw i t h O R o f 0 . 3 7( p : 0 . 0 0 0 1 ) . T h e 2 . M e i j e r W S , S c h r n i t zP I , . l e e k e.l1 M . e t a a n a l y s io s f r a n d o n r i z e dc o n t r o l l e d
c l i n i c a l t r i a l s o f a n t i b i o t i c p r o p h y l a x i s i n b i l i a r y t r a c t s u r g e r y .B r . l
intravenousroute was significantly superior to the
Surg 1990;77:283-290.
intramuscular routeof administrationwith OR of 0.66
(p < 0.005).(LEVEL I EVIDENCE) Lrparoscopic Cholecystectorny
l. A l - G h n a n i e m R , B e n j a m i n I S . P a t e l A C . M e t a - a n a l y s i ss u g g e s t s
a n t i b i o t i cp r o p l r y l a x i si s n o t w a r r a n t e di n l o w - r i s k p a t i e n t su n d e r g o i n g
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