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Chapter 110: Antimicrobial Prophylaxis for Surgery

Jun Makino; John M. Oropello

INTRODUCTION

A surgical site infection (SSI) is an infection related to an operative procedure that occurs at or near the surgical incision within 30 days of the procedure, or within 90 days if prosthetic material is implanted at surgery.1 SSIs are classified into incisional (superficial/deep) or organ/space infections (Table 110–1A).1 According to the Centers for Disease Control and Prevention (CDC), prevalence survey in 183 acute care hospitals in the United States, SSIs and pneumonia were the most common health-care-associated infections.2 Also the National Healthcare Safety Network (NHSN) data for 2006 to 2008 reported the overall SSI rate was 1.9% (16,147 SSIs following 849,659 operative procedures).3 The aim of antimicrobial prophylaxis is to prevent SSI by reducing the burden of microorganisms at the surgical site during the operative procedure,4 and ultimately to prevent related morbidity and mortality. Indications for antimicrobial prophylaxis, antibiotic selection, timing, and dosing are reviewed.

Table 110–1AClassification of surgical site infection (SSI).1
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Table 110–1A Classification of surgical site infection (SSI).1
Type Description
Incisional SSI Superficial Skin and subcutaneous tissue of the incision
Deep Deep tissue of the incision (eg, fascial and muscle layers)
Organ/space SSI Infection involving any part of the body excluding incisional SSIs

Data from Centers for Disease Control. Surgical Site Infection (SSI) Event.

Surgical wound infections are historically classified into 4 groups based on the degree of expected microbial contamination during surgery (Table 110–1B).5 Antimicrobial treatment (vs prophylaxis) is required for dirty procedures or established infections. Antimicrobial prophylaxis is justified for contaminated or most clean-contaminated procedures and in certain clean procedures (eg, prosthetic implants).6 Also, antimicrobial prophylaxis may be justified for any procedure if the patient has an underlying medical condition associated with a high risk of SSI (Table 110–2).6

Table 110–1BWound classification.5
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Table 110–1B Wound classification.5
Class Definition SSI Rate (%) Microbiology
Clean An uninfected operative wound in which no inflammation is encountered and the wound is primarily closed. 1.3-2.9 Skin flora; gram-positive cocci
Clean-contaminated Operative wounds in which a viscusa is entered under controlled conditions and without unusual contamination. 2.4-7.7 Gram-negative rods; enterococci
Contaminated Operative wounds in which the respiratory, alimentary, genital (including reproductive organs), or urinary tracts are entered under controlled conditions and without unusual contamination. Specifically, operations involving the biliary tract, appendix, vagina, and oropharynx are included in this category, provided no evidence of infection or major break in technique is encountered. 6.4-15.2 polymicrobial
Dirty Old traumatic wounds with retained devitalized tissue and those that involve existing clinical infection or perforated viscera 7.1-40 polymicrobial

aRespiratory, alimentary, genital (including reproductive organs), or urinary tracts.

Data from Culver DH, Horan TC, Gaynes RP, et al: Surgical wound infection rates by wound class, operative procedure, and patient ...

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