Transcript Antibiotic prophylaxis

Perioperative Antimicrobial Prophylaxis
Dr. R. Sherkat
Isfahan University of Medical Sciences
Surgical wound infections
 Surgical wound infections are the second most common healthcare-associated
infection
 Although usually localized to the incision site, surgical wound infections can
also extend into adjacent deeper structures; thus, the term surgical wound
infection has now been replaced with the more suitable name, surgical site
infection (SSI)
 CDC has developed criteria for defining SSIs, which have become the national
standard and are widely used by surveillance and surgical personnel
 These criteria define SSIs as:
 Infections related to the operative procedure that occur at or near the surgical
incision (incisional or organ/space) within 30 days of an operative procedure
 or within one year if an implant is left in place
 Among surgical patients, SSIs are the most common nosocomial infection,
accounting for 38 percent of nosocomial infections
 It is estimated that SSIs develop in 2 to 5 percent of the more than 30 million
patients undergoing surgical procedures each year (ie, one out of every 24
patients who have inpatient surgery in the United States has a postoperative SSI)
 The cost of SSIs is substantial
DETERMINANTS AND PATHOPHYSIOLOGY
 Whether a wound infection occurs after surgery
depends on a complex interaction between the
following:
(I) Patient-related factors (e.g., host immunity,
nutritional status, the presence or absence of diabetes)
(2) Procedure-related factors (e.g., implantation of
foreign bodies, degree of trauma to the host tissues)
(3) Microbial factors (tissue adherence and invasion)
(4) Perioperative antimicrobial prophylaxis
Sources of Wound Bacteria
 Although numerous sources of bacterial contamination of surgical
wounds have been described, it is virtually impossible to identify with
certainty the source(s) and route(s) of contamination
 The direct inoculation of a patient's endogenous flora at the time of
surgery is believed to be the most common mechanism; however, others
undoubtedly occur
 Transmission from contaminated surgical instruments or surgical
material
 Hematogenous seeding from preexisting infection of a nonwound site
 Contamination from either the skin, mucous membranes, or clothing of
operating room staff
 A combination of them, have all been implicated as potential sources of
microbial contamination
GENERAL PRINCIPLES in the prevention of SSIs
 The most important factors are meticulous operative techniques and
timely administration of effective preoperative antibiotics
 A number of interventions have been used over the years to reduce
the risk of SSIs, including :
 Preoperative showering with antimicrobial soaps
 Preoperative application of antiseptics to the skin of the patient
 Washing and gloving of the surgeon's hands
 Use of sterile drapes
 Use of gowns and masks by operating room personnel
 Most of these interventions were developed to reduce contact with
flora from the hands, hair, scalp, nares, and oropharynx of hospital
personnel, which were believed to be potential sources of
microorganisms causing SSIs
ANTIMICROBIAL PROPHYLAXIS
 The goal of antimicrobial prophylaxis is to prevent SSI by reducing the
burden of microorganisms at the surgical site during the operative
procedure
 The efficacy of antibiotic prophylaxis for reducing surgical SSI has been
clearly established
 Preoperative antibiotics are warranted:
 if there is a high risk of infection or
 if there is high risk of deleterious outcomes should infection develop at
the surgical site
(such in the setting of immune compromise, cardiac surgery, and/or
implantation of a foreign device)
 Patients who receive prophylactic antibiotics within one to two hours
before the initial incision have lower rates of SSI than patients who receive
antibiotics sooner or later than this window
 Antimicrobial therapy administered in the setting of contaminated wounds
is not considered prophylactic; in such cases a therapeutic course of
antimicrobial therapy is warranted
 Errors in selection or dose of prophylactic antimicrobials are common
Timing of prophylaxis
 Antimicrobial therapy should be administered within
60 minutes prior to the surgery to ensure adequate
drug tissue levels at the time of initial incision (or
within 120 minutes if vancomycin or a fluoroquinolone
is used)
 This practice also reduces the likelihood of antibioticassociated reactions at the time of induction of
anesthesia
 If the 60 minute window for prophylaxis has past,
administration of antimicrobial therapy 30 to 60
minutes prior to surgery appears to be more effective
than administration immediately before surgery
Repeat dosing
 For procedures lasting less than four hours, a single repeat dose of
intravenous antimicrobials is appropriate
 Repeat dosing is indicated every one to two half-lives of the drug in patients
with normal renal function
 for procedures lasting more than four hours
 or in the setting of major blood loss
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Cefazolin every two to five hours, cefoxitin every two to three
hours, cefuroxime every three to four hours,ampicillin/sulbactam every two to
four hours, vancomycin every 6 to 12 hours, clindamycin every three to six
hours, and metronidazole every six to eight hours
 Antibiotic concentration >MIC pathogen at the time of incision and throughout
the procedure
 In general, repeat antimicrobial dosing following wound closure is not
necessary and may increase antimicrobial resistance
 In a systematic review of randomized trials, there was no difference in the rate
of SSI with single dose compared with multiple dose regimens given for less
than or more than 24 hours (combined odds ratio 1.04, 95% CI 0.86-1.25)
Antibiotic selection

Guidelines established by the Medical Letter and the Surgical Care Improvement Project :

Cefazolin (1 to 2 g IV) is a first generation cephalosporin active against streptococci and methicillin
susceptible staphylococci; it is generally appropriate for clean procedures

Cefuroxime (1.5 g IV) is a second generation cephalosporin with broader coverage against gram-negative
organisms; it may be administered in place of cefazolin for thoracic (cardiac and noncardiac) and
orthopedic procedures

For procedures that may involve exposure to bowel anaerobes (including Bacteroides
fragilis), cefoxitin (1 to 2 g IV) or cefotetan (second generation cephalosporins) have broader coverage
including anaerobic activity than the above agents

However, some gram-negative bacilli such as E. coli have become resistant to cefoxitin; in such
circumstances reasonable alternatives include cefazolin plus metronidazole (500 mg IV) or monotherapy
with ampicillin-sulbactam (3 g IV)

Patients with history of allergy to penicillin manifesting as an uncomplicated or minor skin rash may be
treated with cephalosporins; allergic cross-reactions to cephalosporins are infrequent except in patients
with severe IgE-mediated reactions to penicillin

If an IgE-mediated reaction against penicillin has occurred in the past, cephalosporins should be avoided

Alternatives to cephalosporins include intravenous vancomycin (15 to 20 mg/kg) or clindamycin (600 to
900 mg) PLUS an agent with activity against gram-negative bacteria such
as gentamicin, ciprofloxacin, levofloxacin, or aztreonam

This is particularly important in patients undergoing colorectal or vascular surgery involving a groin
incision

Local resistance patterns should be considered
Role of vancomycin

Vancomycin is preferable to cephalosporins in locations where:
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Methicillin-resistant Staphylococcus aureus or methicillin-resistant coagulase-negative
staphylococci are a frequent cause of surgical site infections
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In patients who are known to be colonized with methicillin-resistant S. aureus
preoperatively
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in patients undergoing cardiac, vascular, and orthopedic procedures and/or implantation
of prosthetic material who also have risk factors for postoperative MRSA infection (such as
recent hospitalization, renal disease, or diabetes)
A beta-lactam antibiotic (cefazolin or cefuroxime) should be added for activity against
gram-negative organisms
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Alternatives for patients allergic to cephalosporins
include: gentamicin, ciprofloxacin, levofloxacin, or aztreonam

Thus far the literature does not support benefit of vancomycin over cefazolin, cefuroxime,
or ceftizoxime for prevention of SSI

even though guidelines issued by the Surgical Care Improvement Project state that
vancomycin is an acceptable antibiotic for the circumstances outlined above

In fact, a study of preoperative testing for nasal colonization with methicillin-resistant or
methicillin-susceptible S. aureus (MRSA) concluded that preoperative prophylaxis with
vancomycin was associated with an increased risk (RR 4.34 95% CI 2.19-8.57) of
postoperative SSI in patients who had negative nasal testing for MRSA but not in those
who had positive nasal tests for MRSA
Cardiac surgery

Cardiac surgery (eg, coronary artery bypass, heart valve replacement) is primarily a clean surgery with the majority
of patients having a low preoperative risk of infection

Despite their infrequency, deep organ/space SSIs (eg, mediastinitis and prosthetic valve endocarditis) are
catastrophic complications associated with substantial morbidity and mortality

S. aureus and coagulase-negative staphylococci are the predominant pathogens responsible for SSIs in cardiac
surgery
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When gram-negative bacilli (eg, Escherichia coli, Klebsiella spp, Enterobacter spp, Proteus spp, and Pseudomonas
spp) are responsible for SSIs, contamination of the chest usually occurs during the saphenous vein harvesting

A meta-analysis of 28 studies concluded that antimicrobial prophylaxis is beneficial in cardiothoracic surgery
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Several early studies describing failures of first generation cephalosporins in preventing SSIs due to methicillinsensitive S. aureus led to the adoption of second generation cephalosporins (such as cefuroxime) as the preferred
antimicrobial prophylaxis in many centers
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However, subsequent clinical trials showed equivalent or even lower rates of S. aureus
SSIs with cefazolin compared with cefuroxime
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Cefazolin is our prophylactic agent of choice as it is in the Medical Letter and Surgical Care Improvement Project
Because of :
its greater intrinsic activity against staphylococci
narrower side effect profile
antimicrobial spectrum
much lower cost
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The drugs are given intravenously within 60 minutes before the first incision

Vancomycin and clindamycin are alternatives if allergy limits the use of a cephalosporin

The use of gentamicin-collagen sponges does not appear to reduce the 90-day sternal wound infection rate among
patients with diabetes and/or high body mass index
Intravascular device placement
 Although not well studied, antimicrobial prophylaxis is generally used
before placement of permanent pacemakers, electrophysiologic
devices, ventricular assist devices, ventriculoatrial shunts, and arterial
patches
 The dosing regimens are similar to those used for cardiac surgery
 Antimicrobial prophylaxis for placement of a new pacemaker or
replacement of a pulse generator :
 At the time of device implantation or generator exchange, we
recommend prophylaxis with antistaphylococcal antimicrobial
drugs (Grade 1A).
 With regard to routine endocarditis prophylaxis (eg, for dental work),
patients with a cardiac pacemaker or an ICD are considered to be at
low risk for endocarditis
 For these patients, we suggest that routine antibiotic prophylaxis for
endocarditis not be given (Grade 2C).
Vascular surgery
 Preoperative antimicrobial prophylaxis reduces the
incidence of postoperative SSI in patients
undergoing reconstructive surgery on the abdominal
aorta, arterial surgery on the leg involving a groin
incision, and amputation of the lower extremity due
to critical limb ischemia
 Many also recommend prophylaxis for arterial
surgery involving implantation of prosthetic material,
such as grafts for vascular access for hemodialysis
 The recommended drugs in patients undergoing
vascular (arterial) surgery are cefazolin or
cefuroxime and, for patients with beta-lactam
allergy, vancomycin
Noncardiac thoracic surgery
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Antimicrobial prophylaxis is given routinely in thoracic surgery

Cefazolin therapy was associated with a significant reduction in wound infection (1.5 versus 14
percent) but not in empyema or pneumonia

The recommended antibiotics are cefazolin (1 to 2 g IV), cefuroxime (1.5 g IV), or, in selected
patients, vancomycin (1 g [10 to 15 mg/kg] IV) (table 4)
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As mentioned above, the indications for vancomycin are:
previous colonization with MRSA
hospitals in which MRSA and/or coagulase-negative staphylococci are a common cause of
postoperative infection
allergy to penicillins or cephalosporins

Clindamycin is an alternative to vancomycin in patients with beta-lactam allergy

We recommend administering prophylactic antibiotics prior to chest tube placement in
patients with penetrating thoracic injury over no prophylaxis (Grade 1B)

Patients with penetrating trauma have significantly decreased rates of empyema and pneumonia
when given antibiotics prior to chest tube placement, as compared with placebo

No consistent reduction in infectious complications has been found in patients with blunt
thoracic injury or nontraumatic indications for tube thoracostomy; thus, prophylactic antibiotic
treatment in these populations is not necessary

The optimal duration of antibiotic therapy is uncertain; a single dose may be administered, or in
cases of penetrating injury, antibiotic therapy may be continued for up to 24 hours
Gastrointestinal surgery , Gastrointestinal procedures
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Gastrointestinal procedures are among the highest risk procedures for SSI due to the
presence of intraluminal bacteria
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Antimicrobial prophylaxis is warranted for patients undergoing gastrointestinal surgery
involving the colon or rectum
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The regimen should include activity against enteric gram-negative bacilli, anaerobes, and
enterococci; there are several appropriate regimens (table 1).
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Carbapenems should not be used for surgical prophylaxis
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Widespread use of carbapenems may result in increased rates of resistance

This is especially important because carbapenems are the best available drugs for the
treatment of serious infections caused by aerobic gram-negative organisms that are
resistant to other widely-used antimicrobial drugs

In some circumstances antimicrobial prophylaxis is warranted for patients undergoing
gastrointestinal surgery at sites other than the colon or rectum, including esophageal or
duodenal surgery, biliary tract surgery, pancreatic surgery, appendectomy, and mesh
inguinal hernioplasty

Bowel preparation consists of two components: mechanical bowel preparation and
administration of antibiotics (ciprofloxacin plus metronidazole)

We suggest administration of both oral and intravenous antibiotics to decrease the risk of
SSI following colorectal surgical procedures (Grade 2B).
1)Morbid obesity,esophageal obstruction,decreased gastric acidity or gastrointestinal motility
2)Age>70,acute cholecystitis,nonfunctioning gall bladder,obstructive jaundice,or common duct stones
For ruptured viscus therapy is often continued for about five days
Orthopedic surgery
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Prophylaxis is warranted for:
total hip or knee replacement
other orthopedic procedures, such as surgical repair of hip and other closed fractures and internal fixation by
nails, plates, screws, or wires
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No benefit from antibiotics for whom undergoing diagnostic and operative arthroscopic surgery
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Prevention of prosthetic joint infection is important due to the difficulty in treating prosthetic joint infections

Preoperative antimicrobial prophylaxis is standard for all patients undergoing joint replacement
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The recommended regimen is cefazolin (1 g if less than 80 kg and 2 g if more than 80 kg) or cefuroxime (1.5 g)
given intravenously at the induction of anesthesia and repeated for two doses postoperatively at two to
five and three to four hour intervals, respectively

Patients with type I allergy to beta-lactams should receive vancomycin (1 g [10 to 15 mg/kg] IV and repeated
once postoperatively at twelve hours

Vancomycin is also commonly used in patients at high risk for MRSA or in institutions in which there is a
"high rate of MRSA infection" even though current guidelines do not define minimum criteria for "high rates

We suggest NOT administering antibiotic prophylaxis prior to dental procedures for immunocompetent
patients with history of prosthetic joint implantation more than two years previously (Grade 2C).

Antibiotic prophylaxis prior to dental procedures with increased risk for bacteremia may be appropriate for
patients with:
history of prosthetic joints implantation who are immunocompromised
or underwent joint replacement within the last two years
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There is no evidence to suggest that patients with prosthetic joints undergoing procedures (eg, dental,
urologic) should receive antibiotic prophylaxis to prevent a subsequent infection of the prosthesis
Gynecologic or obstetric surgery
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The goal of antimicrobial prophylaxis is to eradicate or retard the growth of endogenous
microorganisms that may cause surgical site infection
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Antibiotics should be used when there is an elevated probability of microbial contamination during
gynecologic surgery (eg, surgical transection of the vagina) and the incidence of postoperative
infection is high

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The antibiotic chosen for prophylaxis should be
effective against bacteria found in most gynecological infections, but not an agent used routinely for
treatment of serious infectious complications
of low toxicity and able to achieve appropriate tissue levels in the surgical field

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Prophylaxis is warranted for hysterectomy, surgical abortion, cesarean delivery, and certain other
procedures
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The 2009 American College of Obstetricians and Gynecologists (ACOG) recommends antibiotic
prophylaxis prior to the following gynecologic operations or procedures :
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Hysterectomy
Randomized trials have demonstrated the efficacy of antibiotic prophylaxis for vaginal hysterectomy
There is a smaller, but significant, reduction in infectious complications for abdominal hysterectomy
The use of antibiotics before laparoscopically assisted hysterectomy seems appropriate since the
vagina is entered, but this has not been evaluated in randomized trials
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Urogynecology procedures, including those involving mesh
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Hysterosalpingogram or chromopertubation (only if the patient has a history of pelvic inflammatory
disease or the procedure demonstrates dilated fallopian tubes)

Surgical abortion
Antibiotic prophylaxis in gynaecologic procedures

All women undergoing an abdominal or vaginal hysterectomy should receive antibiotic
prophylaxis. (I-A)

All women undergoing laparoscopic hysterectomy or laparoscopically assisted vaginal
hysterectomy should receive prophylactic antibiotics. (III-B)

The choice of antibiotic for hysterectomy should be a single dose of a first-generation
cephalosporin

If patients are allergic to cephalosporin, then clindamycin, erythromycin, or metronidazole
should be used. (I-A)
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Prophylactic antibiotics should be administered 15 to 60 minutes prior to skin incision

No additional doses are recommended. (I-A)

If an open abdominal procedure is lengthy (e.g., > 3 hours), or if the estimated blood loss is >
1500 mL, an additional dose of the prophylactic antibiotic may be given 3 to 4 hours after the
initial dose. (III-C)

Antibiotic prophylaxis is not recommended for laparoscopic procedures that involve no direct
access from the abdominal cavity to the uterine cavity or vagina. (l-E)

All women undergoing surgery for pelvic organ prolapse and/or stress urinary incontinence
should receive a single dose of first-generation cephalosporin. (III-B)
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Antibiotic prophylaxis in gynaecologic procedures
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Antibiotic prophylaxis is not recommended for hysteroscopic surgery. (II-2D)
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All women undergoing an induced (therapeutic) surgical abortion should receive
prophylactic antibiotics to reduce the risk of post-abortal infection. (I-A)
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Prophylactic antibiotics are not suggested to reduce infectious morbidity following surgery
for a missed or incomplete abortion. (I-E)
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Antibiotic prophylaxis is not recommended for insertion of an intrauterine device. (I-E)
However, health care professionals could consider screening for sexually transmitted
infections in high-risk populations. (III-C)
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There is insufficient evidence to support the use of antibiotic prophylaxis for an
endometrial biopsy. (III-L)
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The best method to prevent infection after hysterosalpingography is unknown
Women with dilated tubes found at the time of hysterosalpingography are at highest risk,
and prophylactic antibiotics (e.g., doxycycline) should be given. (II-3B)

Antibiotic prophylaxis is not recommended for urodynamic studies in women at low risk,
unless the incidence of urinary tract infection post-urodynamics is > 10%. (1-E)
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In patients with morbid obesity (BMI > 35 kg/m²), doubling the antibiotic dose may be
considered. (III-B)
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Administration of antibiotics solely to prevent endocarditis is not recommended for
patients who undergo a genitourinary procedure. (III-E).
Gynecologic or obstetric surgery

Patients who receive prophylactic antibiotics within a two hour "window" period before the
initial incision have lower rates of surgical site infection than patients who receive them either
too early or postoperatively (table 7)
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Cephalosporins (eg, cefazolin 1 or 2 g, cefoxitin 1 to 2 g, cefotetan 1 to 2 g) are the drugs of
choice for prophylaxis in hysterectomy or urogynecologic procedures because of their low
incidence of allergy and side effects, broad antibacterial spectrum, long half-life, and low cost

They are usually given as a single intravenous dose 30 minutes prior to the incision and should
be repeated to maintain tissue levels if the procedure extends beyond four hours or if blood
loss is greater than 1500 mL.

Regimens that continue prophylaxis postoperatively do not confer any additional benefit and
are not recommended

Ampicillin-sulbactam is an option in women who also require endocarditis prophylaxis (table 8)

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In patients with a well-documented beta-lactam allergy, options include :
Clindamycin (600 to 900 mg) plus gentamicin (1.5 mg/kg)
Clindamycin (600 to 900 mg) plus a fluoroquinolone (eg, ciprofloxacin 400 mg
or levofloxacin 750 mg or moxifloxacin 400 mg)
Clindamycin (600 to 900 mg) plus aztreonam (1 to 2 g)
Metronidazole (0.5 to 1 g) plus gentamicin or a fluoroquinolone
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Clindamycin or metronidazole monotherapy are no longer recommended for perioperative
antibiotic prophylaxis by the Centers for Medicare & Medicaid Services in collaboration with the
CDC or by ACOG
Genitourinary surgery
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Antimicrobial prophylaxis is warranted before urologic procedures when:
the urine culture is positive
or not obtained
or a urinary catheter is in place
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Such patients should be treated to sterilize the urine before surgery or should receive a single preoperative dose of
a drug active against the most likely pathogen
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Antimicrobial prophylaxis also decreases the incidence of postoperative bacteriuria and sepsis in patients with
sterile urine undergoing:
transurethral prostatectomy
before transrectal prostatic biopsy
implantation of a prosthesis, such as penile implant or artificial sphincter
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Prophylaxis significantly reduced the rates of both postoperative bacteriuria (9 versus 26 percent) and clinical
septicemia (0.7 versus 4.4 percent)
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Effective antibiotics included quinolones, cephalosporins, trimethoprim-sulfamethoxazole, and aminoglycosides

The Medical Letter recommends ciprofloxacin (500 mg PO or 400 mg IV) or trimethoprim-sulfamethoxazole (1 DS
tablet orally) in these settings (table 3)
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No specific recommendations are given for prophylaxis prior to implantation of a penile prosthesis

One randomized controlled trial demonstrated that outcomes and antibiotic tissue concentrations in the corpora
cavernosa were similar among patients receiving either ofloxacin or cefazolin/gentamicin prior to penile prosthesis
implantation
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In the absence of an indwelling catheter, antimicrobial therapy can be discontinued promptly following the
procedure
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When an indwelling catheter must remain in place following prostatic resection, some advocate continuing
antimicrobial therapy until the catheter is removed
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Finally, cefazolin (1 to 2 g IV) should be given prior to open or laparoscopic genitourinary procedures (including
percutaneous renal surgery or procedures with entry into the urinary tract)
Neurosurgery
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Antimicrobial prophylaxis can reduce the incidence of infection, mostly due to Staphylococcus
aureus or S. epidermidis, after craniotomy and spinal surgery, including low-risk procedures

Efficacy in clean neurosurgical operations was illustrated in a trial in which 846 patients were
randomly assigned to cefazolin and gentamicin or no therapy
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The treated group had a significantly lower rate of wound infection (1.0 versus 3.6 percent).

All infections that occurred involved gram-positive organisms

Although no individual trial demonstrated a statistically significant benefit from prophylaxis in
patients undergoing spinal surgery, a significant reduction in infection rate was noted in the
pooled analysis (2.2 versus 5.9 percent, pooled odds ratio 0.37, 95% CI 0.17-0.78).

The recommended antibiotics are cefazolin (1 to 2 g IV) or, in selected patients, vancomycin (1
g IV) (table 4) .

The indications for vancomycin are previous colonization with MRSA, hospitals in which
MRSA and/or coagulase-negative staphylococci are a common cause of postoperative
infection, and allergy to penicillins or cephalosporins.

Clindamycin is an alternative to vancomycin in patients with beta-lactam allergy
Head and neck surgery

The 2009 Medical Letter guidelines recommended antimicrobial prophylaxis for head and neck
surgery involving an incision through the oral or pharyngeal mucosa
Areas of controversy
 The efficacy of antimicrobial prophylaxis is
controversial in breast surgery and other "clean"
procedures
 The 2009 Medical Letter guideline consultants do not
recommend prophylaxis for such procedures due to:
 the low rate of infection
 low morbidity if infection does occur
 the potential adverse effect of antimicrobial therapy
 However, some experts recommend prophylaxis for
breast or reconstructive procedures that involve
placement of prosthetic material such as synthetic
mesh or saline implants
antimicrobial prophylaxis for the prevention of infective endocarditis

Despite the devastating consequences of bacterial endocarditis, evidence to support antimicrobial
prophylaxis as an effective preventative measure is weak and inconclusive

The 2007 AHA guideline for the prevention of infective endocarditis has narrowed the indications for
bacterial endocarditis prophylaxis, compared with prior versions, in recognition of the absence of strong
supportive evidence
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Similar indications by the Working Party of the British Society for Antimicrobial Chemotherapy

Despite a lack of evidence supporting the necessity of antimicrobial prophylaxis for IE, it is reasonable to
prescribe antimicrobial prophylaxis for patients with:
the highest risk medical conditions
which undergoing procedures likely to result in bacteremia with a microorganism that has the potential
ability to cause bacterial endocarditis (Grade 2C).
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Which patients — The following are the highest risk conditions:
Prosthetic heart valves, including bioprosthetic and homograft valves
A prior history of IE
Unrepaired cyanotic congenital heart disease, including palliative shunts and conduits
Completely repaired congenital heart defects with prosthetic material or device, whether placed by
surgery or by catheter intervention, during the first six months after the procedure
Repaired congenital heart disease with residual defects at the site or adjacent to the site of the prosthetic
device
Cardiac valvulopathy in a transplanted heart
The following are the highest risk procedures:
All dental procedures that involve manipulation of either gingival tissue or the periapical region of teeth
or perforation of the oral mucosa
Procedures of the respiratory tract that involve incision or biopsy of the respiratory mucosa
Procedures in patients with ongoing GI or GU tract infection
Procedures on infected skin, skin structure, or musculoskeletal tissue
Surgery to place prosthetic heart valves or prosthetic intravascular or intracardiac materials
antimicrobial prophylaxis for the prevention of
infective endocarditis
Which antibiotic
 The choice of antibiotic is patient and procedure specific

For patients undergoing a dental procedure, who will be the majority of individuals for
whom prophylaxis is appropriate, the preferred regimen is oral amoxicillin two grams given
30 to 60 minutes before the procedure
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Alternative regimens for patients with penicillin allergy or who are unable to take oral
medication are shown above
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Regimens for non-dental procedures are described in detail above
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Patients with skin or musculoskeletal infections undergoing procedures should receive
agents active against staphylococci and beta-hemolytic streptococci
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In patients with GI or GU tract infection, antibiotic therapy to prevent associated wound
infection or sepsis should include an agent active against enterococci
American Heart Association guideline

The 2009 European Society of Cardiology (ESC) guidelines are largely in agreement with the
American guidelines(2007-2008)

The recommendation for antimicrobial prophylaxis for dental and other procedures (and others) is
now limited to those patients with cardiac conditions with the highest risk of adverse outcome from
IE
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The following points were made by the AHA in support of their recommendation for the important
change
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IE is much more likely to result from frequent exposure to random bacteremias associated with
daily activities (eg, tooth brushing) than from bacteremia caused by a dental, gastrointestinal, or
genitourinary procedure
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Prophylaxis may prevent an exceedingly small number of cases of IE, if any, in individuals who
undergo these procedures
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The risk of antibiotic-associated adverse events exceeds the benefit, if any, from prophylactic
antibiotic therapy
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Maintenance of optimal oral health and hygiene may reduce the incidence of bacteremia from daily
activities and is therefore more important than prophylactic antibiotics for a dental procedure to
reduce the risk of IE
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The guidelines are not intended to be the standard of care in all instances in which prophylactic
antibiotic therapy might be considered

Clinicians can exercise their own judgment in selecting the dose and duration of antibiotic therapy
in individual cases or in special circumstances

Among the selected patients for whom antimicrobial prophylaxis is suggested, the antimicrobial
regimen recommended by the AHA guidelines varies with the procedure being performed (table 1)
CHOICE OF ANTIMICROBIAL AGENT
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Dental, oral, or upper respiratory tract procedures — The primary antibiotic regimen for most patients, including
those with prosthetic valves, is amoxicillin, 2 g orally 30 to 60 minutes before the procedure; a second dose is not
necessary

A different regimen is warranted in the following circumstances; all drugs are given 30 to 60 minutes before the
procedure:

Patients who are allergic to penicillins or ampicillin can be treated with cephalexin (2 g)
or azithromycin or clarithromycin (500 mg) or clindamycin (600 mg)

Patients who are unable to take oral medications can be treated with 2 g of intravenous or intramuscular ampicillin

Patients allergic to penicillin can be given cefazolin or ceftriaxone (1 g intravenously) OR 600 mg of intravenous or
intramuscular clindamycin

Genitourinary or gastrointestinal procedures — For those high risk patients who undergo gastrointestinal or
genitourinary procedures at a time of ongoing gastrointestinal or genitourinary infection, antibiotic coverage for
enterococcal bacteremia should be provided with amoxicillin orampicillin or, in the patient unable to tolerate these
drugs, vancomycin
 Skin and musculoskeletal tissue — Although infection of the skin or musculoskeletal tissue is often
polymicrobial, only staphylococcal or beta-hemolytic streptococcal bacteremia is likely to cause endocarditis in such
circumstances

Thus, an antistaphylococcal penicillin or a cephalosporin is appropriate (table 1).

In patients undergoing procedures involving infected skin and musculoskeletal tissue (eg, incision and drainage of skin
abscess), the treatment regimen should include drugs active against these organisms

Clindamycin or vancomycin may be used when the patient is unable to take a beta-lactam or is known or suspected to
have an infection caused by a methicillin-resistant staphylococcus

Pregnancy — Uncomplicated vaginal or cesarean delivery is not a routine indication for antibiotic prophylaxis although
prophylaxis may be considered in certain circumstances

If antibiotic prophylaxis is given to prevent enterococcal endocarditis, amoxicillin, ampicillin, and vancomycin are
appropriate agents and they should be administered at the time of delivery
Children prophylaxis
 Children given endocarditis prophylaxis should receive the
same antibiotic regimens and dosing intervals as noted above
 Equivalent pediatric doses for oral therapy are as follows:
 Amoxicillin — 50 mg/kg to a maximum dose of 2 g
 Azithromycin or clarithromycin — 15 mg/kg to a maximum dose
of 500 mg
 Clindamycin —20 mg/kg to a maximum dose of 600 mg
 Cephalexin — 50 mg/kg to a maximum dose of 2 g
 Equivalent pediatric doses for intramuscular or intravenous
therapy are as follows:
 Ampicillin — 50 mg/kg to a maximum dose of 2 g
 Cefazolin or ceftriaxone — 50 mg/kg to a maximum dose of 1 g
 Clindamycin — 20 mg/kg to a maximum dose of 600 mg
 Vancomycin — 15 mg/kg to a maximum dose of 1 g
SPECIAL CIRCUMSTANCES

The following four situations require special attention:
 Patients on antibiotics
If patients are receiving antibiotics for other indications at the time that dental or invasive
procedures are undertaken, an alternate antibiotic of a different class is often chosen
As an example, if a patient receiving penicillin for rheumatic fever prophylaxis undergoes
an invasive dental procedure and requires IE prophylaxis, clindamycin, cephalexin,
or azithromycin is often chosen.
 Patients receiving anticoagulants
Intramuscular injections of antibiotics should be avoided in patients receiving
anticoagulation therapy
Oral antibiotic regimens are preferred, and intravenous therapy should be used when oral
treatment is not possible
 Surgery for placement of prosthetic valves or intracardiac/ intravascular
materials
Patients undergoing surgery for placement of prosthetic valves or intracardiac or
intravascular materials are at risk for the development of bacterial endocarditis
In this setting the morbidity and mortality of infection is high and antimicrobial prophylaxis
directed against staphylococci is advisable
First generation cephalosporins are often used, but local hospital susceptibility patterns
need to be taken into account, and if methicillin-resistant staphylococci are common or
prevalent local pathogens, vancomycin should be substituted for cephalosporins
Recommendations for the prevention of
perinatal group B streptococcal (GBS) disease

Since The CDC revised guidelines that recommended universal antenatal GBS screening
the incidence of early-onset GBS disease in neonates has decreased by an estimated 80%

However, in 2010, GBS disease remained the leading cause of early-onset neonatal sepsis

The CDC issued revised guidelines in 2010 based on evaluation of data generated after
2002

These revised and comprehensive guidelines, which have been endorsed by the AAP,
reaffirm the major prevention strategy

universal antenatal GBS screening and intrapartum antibiotic prophylaxis for culture
positive and high-risk women

and include new recommendations for laboratory methods for identification of GBS
colonization during pregnancy

algorithms for screening and intrapartum prophylaxis for women with preterm labor and
premature rupture of membranes,

updated prophylaxis recommendations for women with a penicillin allergy, and a revised
algorithm for the care of newborn infants

The purpose of this policy statement is to review and discuss the differences between the
2002 and 2010 CDC guidelines that are most relevant for the practice of pediatrics
Algorithm for the prevention of early-onset GBS infection in the newborn
Committee on Infectious Diseases and Committee on
Fetus and Newborn Pediatrics 2011;128:611-616
©2011 by American Academy of Pediatrics
Algorithm for the prevention of early-onset GBS
infection in the newborn

Full diagnostic evaluation includes; a blood culture; CBC count, including white blood cell differential and platelet
counts; chest radiograph (if respiratory abnormalities are present); and lumbar puncture (if the patient is stable
enough to tolerate procedure and sepsis is suspected).

Antibiotic therapy should be directed toward the most common causes of neonatal sepsis, including intravenous
ampicillin for GBS and coverage for other organisms (including Escherichia coli and other Gram-negative
pathogens) and should take into account local antibiotic-resistance patterns.

Consultation with obstetric providers is important in determining the level of clinical suspicion for chorioamnionitis.
Chorioamnionitis is diagnosed clinically, and some of the signs are nonspecific.

Limited evaluation includes blood culture (at birth) and CBC count with differential and platelets (at birth and/or at
6–12 hours of life).



GBS prophylaxis is indicated if 1 or more of the following is true:
(1) mother is GBS-positive within the preceding 5 weeks
(2) GBS status is unknown and there are 1 or more intrapartum risk factors, including <37 weeks' gestation, rupture
of membranes for ≥18 hours, or temperature of ≥100.4°F (38.0°C);
(3) GBS bacteriuria during current pregnancy; or
(4) history of a previous infant with GBS disease



If signs of sepsis develop, a full diagnostic evaluation should be performed, and antibiotic therapy should be
initiated.

If at ≥37 weeks' gestation, observation may occur at home after 24 hours if other discharge criteria have been met,
there is ready access to medical care, and a person who is able to comply fully with instructions for home
observation will be present

If any of these conditions is not met, the infant should be observed in the hospital for at least 48 hours and until
discharge criteria have been achieved.

Some experts recommend a CBC count with differential and platelets at 6 to 12 hours of age.

CDC, 2010. MMWR Recomm Rep. 2010;59[RR-10]:1–32.)
INTRAPARTUM ANTIBIOTIC PROPHYLAXIS
 Penicillin remains the agent of choice for IAP, and ampicillin is
an acceptable alternative (AI)
 Penicillin-allergic women who do not have a history of
anaphylaxis, angioedema, respiratory distress, or urticaria after
administration of penicillin or a cephalosporin should receive
cefazolin (BII)
 Penicillin-allergic women at high risk of anaphylaxis should
receive clindamycin if their GBS isolate is susceptible or
vancomycin if their GBS isolate is intrinsically resistant to
clindamycin (CIII)
 The definition of adequate IAP has been clarified to be at least 4
hours of penicillin, ampicillin, or cefazolin.(before delivery)
 The initial intravenous dose of penicillin is 5 million units; for
ampicillin and cefazolin, the initial dose is 2 g (AIII)
 All other antibiotics, doses, or durations are considered
inadequate for the purposes of neonatal management (AIII).
LABORATORY DIAGNOSIS OF GBS COLONIZATION
 Recommendations
 Options for GBS identification from culture of
maternal vaginal/rectal swabs have been expanded
to include a positive identification from chromogenic
agar media.
 Identification of GBS directly by nucleic acid
amplification tests (NAATs), such as commercially
available polymerase chain reaction assays, can
also be used after broth enrichment if laboratories
have validated their NAAT performance and
instituted appropriate quality controls (CII).
Novel Methods of Antibiotic Prophylaxis

Newer methods for delivery of antimicrobial prophylaxis have expanded the available armamentarium for the prevention
of SSls.

First introduced in 1939,132 antibiotic-impregnated cement placed directly into the operative wound (as a local
antimicrobial brachytherapy) is increasingly being used as a method of antibiotic prophylaxis and treatment, particularly
in procedures involving the replacement of infected prosthetic joints

Brachytherapy uses powdered antibiotic mixed with a cement polymer (such as polymerized polymethylmethacrylate) to
form a compound that may be directly applied onto prosthetic material or manufactured into beads (usually 3 to 10 mm in
diameter) that are placed into the wound.

Candidate antibiotics for use as brachytherapy must be available as a pharmaceutical-grade powder, must be heat stable
(because of the exothermic reaction induced with polymerization), and must have an appropriate microbiologic spectrum
of activity for the predominant pathogens at the operative site

The aminoglycosides and vancomycin are the compounds most commonly used for brachytherapy; oxacillinand
cefazolin have comparable elution characteristics but are less frequently used because of concerns regarding ~-lactam
allergy.

The majority of antibiotic elution occurs in the first days after implantation, but elution from impregnated cement has
been detected years following surgery

The use of antibiotic-impregnated cement (in conjunction with systemic prophylaxis) was significantly associated with a
reduction in SSls in studies from several large clinical registries in Europe

Concerns remain, however, regarding routine use of this mode of prophylaxis because of possible adverse effects,such
as allergicreactions.

Systemic absorption of antibiotic brachytherapy is also a concern because potentially high boluses of antibiotic may lead
to toxicity.

In one series of 14 subjects, I patient developed permanent and 2 others temporary high-frequency hearing loss
following implantation of gentamicin-impregnated beads

Renal failure attributed to impregnated cement, while rare, has also been reported.137 Further studies into the systemic
absorption, efficacy,and adverse effects of these brachytherapeutic compounds appear warranted.
Use of antibacterial prophylaxis for patients with neutropenia. Australian
Consensus Guidelines 2011 Steering Committee

The use of oral prophylactic antibiotics in patients with neutropenia is controversial and not
recommended by this group because of a lack of evidence showing a reduction in mortality and concerns
that such practice promotes antimicrobial resistance.

Recent evidence has demonstrated non-significant but consistent, improvement in all-cause mortality
when fluoroquinolones (FQs) are used as primary prophylaxis

However, the consensus was that this evidence was not strong enough to recommend prophylaxis

The evidence base for FQ prophylaxis is presented alongside current consensus opinion to guide the
appropriate and judicious use of these agents

Due consideration is given to patient risk, as it pertains to specific patient populations, as well as the net
effect on selective pressure from antibiotics if FQ prophylaxis is routinely used in a target population.

The potential costs and consequences of emerging FQ resistance, particularly among Escherichia coli,
Clostridium difficile and Gram-positive organisms, are considered.

As FQ prophylaxis has been advocated in some chemotherapy protocols, specific regard is given to
whether FQ prophylaxis should be used to support these regimens.

The group also provides recommendations for monitoring and surveillance of emerging resistance in
those centres that have adopted FQ prophylaxis.

.

Intern Med J. 2011 Jan;41(1b):102-9. doi: 10.1111/j.1445-5994.2010.02341.x.
Slavin MA, Lingaratnam S, Mileshkin L, Booth DL, Cain MJ, Ritchie DS, Wei A, Thursky KA; Australian
Consensus Guidelines 2011 Steering Committee.
 Table 1. Key practice points – prophylaxis
 SCT, stem cell transplant; FQ, fluoroquinolone.
 • There is currently insufficient evidence to recommend routine
use of FQ prophylaxis in patients at low risk of developing
neutropenic fever (grade C)• FQ prophylaxis should also not be
routinely used in high-risk haematology patients (grade C)• FQ
prophylaxis could be considered in outpatient SCT and
palliative patients with bone marrow failure (grade C)•
Appropriate surveillance (detailed within text) should be
undertaken by centres using FQ prophylaxis (grade C)• When
the prevalence of FQ resistance in E. coli in internal medicine
patients at an institution approaches 20%, FQ prophylaxis is
unlikely to be effective (grade C)
Mandel surgical site
 Journal of Infection and Chemotherapy
 April 2008, Volume 14, Issue 2, pp 172-177
 Guidelines for implementation of clinical studies on
surgical antimicrobial prophylaxis (2007)
 Yoshio Takesue,
 Hiroshige Mikamo,
 Soichi Arakawa,
 Kenji Suzuki,
 Haruo Sakamoto,
 Takashi Okubo,
 Junzo Shimizu,
 Takashi Yokoyama
Antibiotic prophylaxis in gynaecologic
procedures

J Obstet Gynaecol Can. 2012 Apr;34(4):382-91.

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
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Van Eyk N, van Schalkwyk J; Infectious Diseases Committee.
COLLABORATORS (12)
Yudin MH, Allen VM, Bouchard C, Boucher M, Caddy S, Castillo E, Money DM, Murphy KE, Ogilvie G, Paquet C, van Schalkwyk J, Senikas V.
Abstract
OBJECTIVE:
To review the evidence and provide recommendations on antibiotic prophylaxis for gynaecologic procedures.
OUTCOMES:
Outcomes evaluated include need and effectiveness of antibiotics to prevent infections in gynaecologic procedures.
EVIDENCE:
Medline and The Cochrane Library were searched for articles published between January 1978 and January 2011 on the topic of antibiotic
prophylaxis in gynaecologic procedures. Results were restricted to systematic reviews, randomized control trials/controlled clinical trials,
and observational studies. Searches were updated on a regular basis and incorporated in the guideline to June 2011. Grey (unpublished)
literature was identified through searching the websites of health technology assessment and health technology assessment-related
agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.
VALUES:
The quality of evidence obtained was rated using the criteria described in the Report of the Canadian Task Force on Preventative Health Care
(Table 1).
BENEFITS, HARMS, AND COSTS:
Guideline implementation should result in a reduction of cost and related harm of administering antibiotics when not required and a
reduction of infection and related morbidities when antibiotics have demonstrated a proven benefit.
RECOMMENDATIONS:
(1) All women undergoing an abdominal or vaginal hysterectomy should receive antibiotic prophylaxis. (I-A) (2) All women undergoing
laparoscopic hysterectomy or laparoscopically assisted vaginal hysterectomy should receive prophylactic antibiotics. (III-B) (3) The choice of
antibiotic for hysterectomy should be a single dose of a first-generation cephalosporin. If patients are allergic to cephalosporin, then
clindamycin, erythromycin, or metronidazole should be used. (I-A) (4) Prophylactic antibiotics should be administered 15 to 60 minutes prior
to skin incision. No additional doses are recommended. (I-A) (5) If an open abdominal procedure is lengthy (e.g., > 3 hours), or if the
estimated blood loss is > 1500 mL, an additional dose of the prophylactic antibiotic may be given 3 to 4 hours after the initial dose. (III-C) (6)
Antibiotic prophylaxis is not recommended for laparoscopic procedures that involve no direct access from the abdominal cavity to the
uterine cavity or vagina. (l-E) (7) All women undergoing surgery for pelvic organ prolapse and/or stress urinary incontinence should receive a
single dose of first-generation cephalosporin. (III-B) (8) Antibiotic prophylaxis is not recommended for hysteroscopic surgery. (II-2D) (9) All
women undergoing an induced (therapeutic) surgical abortion should receive prophylactic antibiotics to reduce the risk of post-abortal
infection. (I-A) (10) Prophylactic antibiotics are not suggested to reduce infectious morbidity following surgery for a missed or incomplete
abortion. (I-E) (11) Antibiotic prophylaxis is not recommended for insertion of an intrauterine device. (I-E) However, health care professionals
could consider screening for sexually transmitted infections in high-risk populations. (III-C) (12) There is insufficient evidence to support the
use of antibiotic prophylaxis for an endometrial biopsy. (III-L) (13) The best method to prevent infection after hysterosalpingography is
unknown. Women with dilated tubes found at the time of hysterosalpingography are at highest risk, and prophylactic antibiotics (e.g.,
doxycycline) should be given. (II-3B) (14) Antibiotic prophylaxis is not recommended for urodynamic studies in women at low risk, unless the
incidence of urinary tract infection post-urodynamics is > 10%. (1-E) (15) In patients with morbid obesity (BMI > 35 kg/m²), doubling the
antibiotic dose may be considered. (III-B) (16) Administration of antibiotics solely to prevent endocarditis is not recommended for patients
who undergo a genitourinary procedure. (III-E).













Pediatrics. 2011 Sep;128(3):611-6. Epub 2011 Aug 1.
Policy statement—Recommendations for the prevention of perinatal group B streptococcal (GBS) disease.
Committee on Infectious Diseases; Committee on Fetus and Newborn, Baker CJ, Byington CL, Polin RA.
COLLABORATORS (45)
Brady MT, Bernstein HH, Byington CL, Edwards KM, Fisher MC, Glode MP, Jackson MA, Keyserling HL,
Kimberlin DW, Maldonado YA, Orenstein WA, Schutze GE, Willoughby RE, Bell B, Bortolussi R, Fischer
MA, Gellin B, Gorman RL, Lee L, Pratt R, Read JS, Starke JR, Swanson J, Tan TQ, Baker CJ, Long SS,
Meissner H, Pickering LK, Rubin LG, Frantz J, Cummings J, Baley JE, Bhutani VK, Carlo WA, Kumar P,
Polin RA, Tan RC, Wang KS, Watterberg KL, Barfield WD, Barth WH Jr, Jefferies AL, Mainous RO, Raju TN,
Couto J.
Abstract
The Centers for Disease Control and Prevention (CDC) guidelines for the prevention of perinatal group B
streptococcal (GBS) disease were initially published in 1996. The American Academy of Pediatrics (AAP)
also published a policy statement on this topic in 1997. In 2002, the CDC published revised guidelines that
recommended universal antenatal GBS screening; the AAP endorsed these guidelines and published
recommendations based on them in the 2003 Red Book. Since then, the incidence of early-onset GBS
disease in neonates has decreased by an estimated 80%. However, in 2010, GBS disease remained the
leading cause of early-onset neonatal sepsis. The CDC issued revised guidelines in 2010 based on
evaluation of data generated after 2002. These revised and comprehensive guidelines, which have been
endorsed by the AAP, reaffirm the major prevention strategy--universal antenatal GBS screening and
intrapartum antibiotic prophylaxis for culture-positive and high-risk women--and include new
recommendations for laboratory methods for identification of GBS colonization during pregnancy,
algorithms for screening and intrapartum prophylaxis for women with preterm labor and premature
rupture of membranes, updated prophylaxis recommendations for women with a penicillin allergy, and a
revised algorithm for the care of newborn infants. The purpose of this policy statement is to review and
discuss the differences between the 2002 and 2010 CDC guidelines that are most relevant for the practice
of pediatrics














Circulation. 2007 Oct 9;116(15):1736-54. Epub 2007 Apr 19.
Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association
Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on
Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research
Interdisciplinary Working Group.
Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M, Bolger A, Cabell CH, Takahashi M, Baltimore RS,
Newburger JW, Strom BL, Tani LY, Gerber M, Bonow RO, Pallasch T, Shulman ST, Rowley AH, Burns JC, Ferrieri P, Gardner T,
Goff D, Durack DT; American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee; American
Heart Association Council on Cardiovascular Disease in the Young; American Heart Association Council on Clinical
Cardiology; American Heart Association Council on Cardiovascular Surgery and Anesthesia; Quality of Care and Outcomes
Research Interdisciplinary Working Group.
Source
Mayo Clinic, USA.
Erratum in
Circulation. 2007 Oct 9;116(15):e376-7.
Abstract
BACKGROUND:
The purpose of this statement is to update the recommendations by the American Heart Association (AHA) for the prevention of
infective endocarditis that were last published in 1997.
METHODS AND RESULTS:
A writing group was appointed by the AHA for their expertise in prevention and treatment of infective endocarditis, with liaison
members representing the American Dental Association, the Infectious Diseases Society of America, and the American
Academy of Pediatrics. The writing group reviewed input from national and international experts on infective endocarditis. The
recommendations in this document reflect analyses of relevant literature regarding procedure-related bacteremia and infective
endocarditis, in vitro susceptibility data of the most common microorganisms that cause infective endocarditis, results of
prophylactic studies in animal models of experimental endocarditis, and retrospective and prospective studies of prevention of
infective endocarditis. MEDLINE database searches from 1950 to 2006 were done for English-language papers using the
following search terms: endocarditis, infective endocarditis, prophylaxis, prevention, antibiotic, antimicrobial, pathogens,
organisms, dental, gastrointestinal, genitourinary, streptococcus, enterococcus, staphylococcus, respiratory, dental surgery,
pathogenesis, vaccine, immunization, and bacteremia. The reference lists of the identified papers were also searched. We also
searched the AHA online library. The American College of Cardiology/AHA classification of recommendations and levels of
evidence for practice guidelines were used. The paper was subsequently reviewed by outside experts not affiliated with the
writing group and by the AHA Science Advisory and Coordinating Committee.
CONCLUSIONS:
The major changes in the updated recommendations include the following: (1) The Committee concluded that only an extremely
small number of cases of infective endocarditis might be prevented by antibiotic prophylaxis for dental procedures even if such
prophylactic therapy were 100% effective. (2) Infective endocarditis prophylaxis for dental procedures is reasonable only for
patients with underlying cardiac conditions associated with the highest risk of adverse outcome from infective endocarditis. (3)
For patients with these underlying cardiac conditions, prophylaxis is reasonable for all dental procedures that involve
manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa. (4) Prophylaxis is not
recommended based solely on an increased lifetime risk of acquisition of infective endocarditis. (5) Administration of
antibiotics solely to prevent endocarditis is not recommended for patients who undergo a genitourinary or gastrointestinal tract
procedure. These changes are intended to define more clearly when infective endocarditis prophylaxis is or is not
recommended and to provide more uniform and consistent global recommendations.
American Heart Association guideline

The 2007 AHA guideline for the prevention of infective endocarditis (IE) made major revisions to the 1997 AHA guideline, the
2005 update of those guidelines published by the Medical Letter, and the 2006 ACC/AHA guideline on the management of
valvular heart disease

Since the publication of the 2007 AHA guideline, the ACC/AHA guideline was updated in 2008 .

The 2009 European Society of Cardiology (ESC) guidelines are largely in agreement with the American guidelines(2007-2008)

The recommendation for antimicrobial prophylaxis for dental and other procedures (and others) is now limited to those patients
with cardiac conditions with the highest risk of adverse outcome from IE

In contrast, the prior guidelines recommended prophylaxis for patients at moderate to high risk of IE, a much larger population

The rationale for this change was to make guidelines more evidence-based since, there is no convincing evidence that
antimicrobial prophylaxis provides significant benefit in most patients in terms of prevention of IE.

This change has the added advantage of simplifying care for practitioners and patients

The following points were made by the AHA in support of their recommendation for the important change :

IE is much more likely to result from frequent exposure to random bacteremias associated with daily activities (eg, tooth
brushing) than from bacteremia caused by a dental, gastrointestinal, or genitourinary procedure

Prophylaxis may prevent an exceedingly small number of cases of IE, if any, in individuals who undergo these procedures

The risk of antibiotic-associated adverse events exceeds the benefit, if any, from prophylactic antibiotic therapy

Maintenance of optimal oral health and hygiene may reduce the incidence of bacteremia from daily activities and is therefore
more important than prophylactic antibiotics for a dental procedure to reduce the risk of IE.

The guideline recommendations were based upon results of in vitro studies, clinical experience, data from experimental animal
models, and assessment of both the bacteria most likely to produce bacteremia from a given site and those most likely to result
in endocarditis

The guidelines are not intended to be the standard of care in all instances in which prophylactic antibiotic therapy might be
considered

Clinicians can exercise their own judgment in selecting the dose and duration of antibiotic therapy in individual cases or in
special circumstances
Recommendations for the prevention of
perinatal group B streptococcal (GBS) disease

The Centers for Disease Control and Prevention (CDC) guidelines for the prevention of perinatal group B streptococcal (GBS)
disease were initially published in 1996

The American Academy of Pediatrics (AAP) also published a policy statement on this topic in 1997

In 2002, the CDC published revised guidelines that recommended universal antenatal GBS screening; the AAP endorsed these
guidelines and published recommendations based on them in the 2003 Red Book

Since The CDC revised guidelines that recommended universal antenatal GBS screening the incidence of early-onset GBS
disease in neonates has decreased by an estimated 80%

However, in 2010, GBS disease remained the leading cause of early-onset neonatal sepsis

The CDC issued revised guidelines in 2010 based on evaluation of data generated after 2002

These revised and comprehensive guidelines, which have been endorsed by the AAP, reaffirm the major prevention strategy

universal antenatal GBS screening and intrapartum antibiotic prophylaxis for culture positive and high-risk women

and include new recommendations for laboratory methods for identification of GBS colonization during pregnancy, algorithms
for screening and intrapartum prophylaxis for women with preterm labor and premature rupture of membranes,

updated prophylaxis recommendations for women with a penicillin allergy, and a revised algorithm for the care of newborn
infants

The purpose of this policy statement is to review and discuss the differences between the 2002 and 2010 CDC guidelines that
are most relevant for the practice of pediatrics
Recommendations for Management of Newborn Infants

All newborn infants with signs of sepsis should undergo a full diagnostic evaluation
(including a lumbar puncture) and receive empirical antimicrobial therapy (AII).

All well-appearing newborn infants born to women given a diagnosis of chorioamnionitis
by their obstetrical provider should undergo a limited diagnostic evaluation (no lumbar
puncture) and receive empirical antimicrobial therapy (AII).

For all women who received adequate IAP defined as penicillin (preferred), ampicillin, or
cefazolin (penicillin-allergic women at low risk of anaphylaxis) for 4 or more hours before
delivery, their newborn infants require only routine care and observation in the hospital for
48 hours (BIII).

If these infants meet other discharge criteria, including term birth and ready access to
medical care, discharge can occur as early as 24 hours after birth with follow-up care by a
care provider within 48 to 72 hours (CII).

Well-appearing term newborn infants whose mothers received no or inadequate IAP
(including clindamycin or vancomycin) and had rupture of membranes for less than 18
hours require only observation for 48 hours (BIII).

Well-appearing term infants born to women with no or inadequate IAP and rupture of
membranes for 18 or more hours before delivery should undergo a “limited evaluation” (ie,
blood culture and CBC count with differential and platelets at birth) and observation for at
least 48 hours (BIII).

All preterm infants born to women with no or inadequate IAP should undergo a “limited
evaluation” (ie, blood culture and CBC count with differential and platelets at birth) and
observation for at least 48 hours (BIII).