Department of Anesthesiology, Washington University School of Medicine, Saint Louis, Missouri, US
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Hannah R. Maybrier
Department of Anesthesiology, Washington University School of Medicine, Saint Louis, Missouri, US
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Arbi Ben Abdallah
Department of Anesthesiology, Washington University School of Medicine, Saint Louis, Missouri, US
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Eric Jacobsohn
Department of Anesthesiology, Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, CA
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Phillip E. Vlisides
Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan, US
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Kane O. Pryor
Department of Anesthesiology, Weill Cornell Medicine, New York City, New York, US
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Robert A. Veselis
Department of Neuroanesthesiology, Memorial Sloan Kettering Cancer Center, New York City, New York, US
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Hillary P. Grocott
Department of Anesthesia & Perioperative Medicine, University of Manitoba, Winnipeg, Manitoba, CA
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Daniel A. Emmert
Department of Anesthesiology, Washington University School of Medicine, Saint Louis, Missouri, US
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Emma M. Rogers
Department of Anesthesiology, Weill Cornell Medicine, New York City, New York, US
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Robert J. Downey
Department of Surgery, Memorial Sloan Kettering Cancer Center, New York City, New York, US
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Heidi Yulico
Department of Anesthesiology, Memorial Sloan Kettering Cancer Center, New York City, New York, US
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Gyu-Jeong Noh
Department of Anesthesiology, Asan Medical Center, Seoul, South Korea
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Yonghun Lee
Department of Anesthesiology, Asan Medical Center, Seoul, South Korea
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Christine M. Waszynski
Department of Medicine, Hartford Hospital, Hartford, Connecticut, US
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Virendra K. Arya
Department of Anaesthesiology and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Paul S. Pagel
Department of Anesthesiology, Medical College of Wisconsin, Madison, Wisconsin, US
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Judith A. Hudetz
Department of Anesthesiology, Medical College of Wisconsin, Madison, Wisconsin, US
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Maxwell R. Muench
Department of Anesthesiology, Washington University School of Medicine, Saint Louis, Missouri, US
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Bradley A. Fritz
Department of Anesthesiology, Washington University School of Medicine, Saint Louis, Missouri, US
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Witold Waberski
Department of Anesthesiology, Hartford Hospital, Hartford, Connecticut, US
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Sharon K. Inouye
Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School; and Institute for Aging Research, Hebrew SeniorLife, Boston, Massachussetts, US.
The choice of the antibiotic for prophylaxis is based on several factors. Always ask the patient about a prior history of antibiotic allergy, as beta-lactams are the commonest type of antibiotics used in prophylaxis. A history of severe penicillin allergy [anaphylaxis, angioedema] means that cephalosporins are also contraindicated, as there is a small but significant risk of cross-reaction.
Most importantly, the antibiotic should be active against the bacteria most likely to cause an infection . Most postoperative infections are due to the patient's own bacterial flora. Prophylaxis does not need to cover all bacterial species found in the patient's flora, as some species are either not particularly pathogenic or are low in numbers or both.
It is important to select an antibiotic with the narrowest antibacterial spectrum required, to reduce the emergence of multi-resistant pathogens and also because broad spectrum antibiotics may be required later if the patient develops serious sepsis. The use of 'third generation' cephalosporins such as ceftriaxone and cefotaxime should therefore be avoided in surgical prophylaxis. Often several antibiotics are equal in terms of antibacterial spectrum, efficacy, toxicity, and ease of administration. If so, the least expensive drug should be chosen, as antibiotics for surgical prophylaxis comprise a large portion of hospital pharmacy budgets.
Commonly used surgical prophylactic antibiotics include:
- intravenous 'first generation' cephalosporins - cephazolin or cephalothin
- intravenous gentamicin
- intravenous or rectal metronidazole [if anaerobic infection is likely]
- oral tinidazole [if anaerobic infection is likely]
- intravenous flucloxacillin [if methicillin-susceptible staphylococcal infection is likely]
- intravenous vancomycin [if methicillin-resistant staphylococcal infection is likely].
Parenteral 'second generation' cephalosporins such as cefotetan have improved anaerobic and aerobic Gram-negative cover compared to first generation cephalosporins. They are sometimes used as a more convenient, but more expensive, alternative to the combination of metronidazole plus either first generation cephalosporin or gentamicin for abdominal surgical prophylaxis.
The bacterial flora in some hospitalised patients may include multi-resistant bacteria such as methicillin-resistant staphylococci. An assessment then needs to be made for each surgical procedure about whether or not prophylaxis with parenteral vancomycin is indicated. Unnecessary use of vancomycin selects for vancomycin-resistant enterococci [VRE], vancomycin-intermediate Staphylococcus aureus [VISA], and vancomycin-resistant Staphylococcus aureus [VRSA], the first two of which already occur in Australian hospitals.