ID: antimicrobial ppx for surgical procedure

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twinklemuse
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ID: antimicrobial ppx for surgical procedure
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2011-03-09 16:29:00
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ID antimicrobial ppx surgical procedure
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ID: antimicrobial ppx for surgical procedure
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  1. infective endocarditis has mostly what kind of bugs?
    • G positive (staph, strep, enterococcus)
    • sticky bugs that sit on heart valves
    • rarely GN unless immunocompromised
  2. ppx is not really helpful for IE. when do you ppx?
    • high risk:
    • prosthetic cardiac valve or prosthetic material used for cardiac valve repair
    • previous IE
    • congenital heart disease
    • cardiac transplant pts who develop cardiac valvulopathy
  3. ppx?
    dental procedures that involve manipulation of gingival tissue
    yes
  4. ppx?
    dental procedures that involve manipulation of periapical region of teeth
    yes
  5. ppx?
    dental procedures that involve perforation of oral mucosa
    yes
  6. ppx?
    routine anesthetic injections through noninfected tissue
    nope
  7. ppx?
    dental radiograph
    nope
  8. ppx?
    placement of removable prosthodontic or orthodontic appliances
    nope
  9. ppx?
    adjustment of orthodontic appliances
    nope
  10. ppx?
    shedding of deciduous teeth
    nope
  11. ppx?
    placement of orthodontic brackets
    nope
  12. ppx?
    bleeding from trauma to the lips or oral mucosa
    nope
  13. for dental, ___ spectrum abx is used, single dose 30-60min before procedure.
    narrow
  14. if pt can take PO, what abx used for dental procedure?
    amoxicillin 2g adult
  15. if pt cannot take PO for dental procedure, what abx used?
    • ampicillin 2g iv/im
    • or
    • cefazolin or ceftriaxone 1g iv/im
  16. if pt is allergic to pcn or ampicillin but still can take PO, what to give for dental procedure abx?
    • cephalexin 2g
    • clindamycin 600mg
    • or azithromycin or clarithromycin 500mg
  17. if pt is allergic to pcn or amp and cannot take PO, what to give for dental procedure ppx?
    • cefazolin or ceftriaxone 1g im/iv
    • or clindamycin 600mg im/iv
  18. ppx for respiratory T&A (tonsillectomy and adenoidectomy)?
    • yes
    • high risk
  19. ppx for respiratory incision or biopsy of respiratory mucosa?
    • yes
    • high risk
  20. ppx for respiratory drainage of an abscess or empyema?
    • yes
    • high risk
  21. ppx for respiratory bronchoscopy?
    not required unless procedures involves incision of the resp tract mucosa
  22. ppx for GI/GU?
    • not recommended
    • mostly GN bugs
  23. ppx for esophagogastroduodenoscopy or colonoscopy?
    • nope
    • GI/GU usually not recomm
  24. ppx for transrectal GI/GU procedure?
    • yes
    • the only time when abx needed for GI/GU procedure
  25. ppx for urethral procedure?
    • not normally b/c urine is sterile and we don't treat colonization
    • but if colonization in urine for prostate biopsy, then consider cipro for abx
  26. which abx cover for enterococci?
    • ampicillin
    • amox
    • vanco
  27. abx if infected skin or musculoskeletal and pt on long term abx therapy?
    • keep on abx
    • (high risk)
    • slide 9
  28. ppx if established infxn of GI/GU?
    yes
  29. ppx for elective cystoscopy or urinary tract manipulation with infection or colonization?
    yes
  30. ppx for heart valves or prosthetic intravascular or intracardiac materials?
    yes
  31. ppx for stents or CABG?
    nope not necessary
  32. most common complications of surgery?
    • surgical site infection (SSI) - very high
    • sepsis
    • CV
    • respiratory
    • thromboembolic (esp b/c pt are bedridden; need DVT ppx)
  33. risk factors of surgical site infection?
    • extremes of age (too young, too old)
    • undernutrition
    • obesity (gastrobypass is a high risk for obese pt)
    • diabetes
    • hypoxemia
    • remote infxn
    • corticosteroid tx (concern in COPD)
    • recent operation
    • chronic inflamm
    • prior site irradiation
  34. for surgical ppx optimal agent is narrow spectrum abx. so what abx should you avoid?
    • carbapenem
    • cipro
    • these are broad spectrum
  35. guideline for appropriate abx ppx for surgery?
    • low tox and safe
    • not routinely used for tx of serious infxn
    • abx that includes causative agent
    • adequate conc in relevant tissue
    • admin for short period
    • timely admin to ensure abx in surgical site during incision
  36. primarily closed

    A) clean
    B) contaminated
    C) dirty
    D) clean-contaminated
    A) clean
    (this multiple choice question has been scrambled)
  37. elective procedure involving no acute inflammation

    A) clean
    B) clean-contaminated
    C) contaminated
    D) dirty
    A) clean
    (this multiple choice question has been scrambled)
  38. no break in technique

    A) dirty
    B) contaminated
    C) clean
    D) clean-contaminated
    C) clean
    (this multiple choice question has been scrambled)
  39. no transection of GI, oropharyngeal, GU, bilirary, or tracheobroncial tract

    A) clean
    B) clean-contaminated
    C) contaminated
    D) dirty
    A) clean
    (this multiple choice question has been scrambled)
  40. biopsy of breast

    A) contaminated
    B) clean
    C) clean-contaminated
    D) dirty
    B) clean
    (this multiple choice question has been scrambled)
  41. procedures involving transection of GI, oropharyngeal, GU, biliary, trancheobronchial tracts with minimal spillage

    A) clean-contaminated
    B) dirty
    C) clean
    D) contaminated
    A) clean contaminated
    (this multiple choice question has been scrambled)
  42. minor breaks in technique

    A) contaminated
    B) clean
    C) clean-contaminated
    D) dirty
    C) clean contaminated
    (this multiple choice question has been scrambled)
  43. clean procedures performed emergently

    A) dirty
    B) contaminated
    C) clean
    D) clean-contaminated
    D) clean contaminated
    (this multiple choice question has been scrambled)
  44. clean procedures with major breaks in technique

    A) clean-contaminated
    B) clean
    C) dirty
    D) contaminated
    A) clean-contaminated
    (this multiple choice question has been scrambled)
  45. reoperation of clean surgery within 7 days

    a) clean
    b) clean-contaminated
    c) contaminated
    d) dirty
    clean contaminated
  46. procedures following blunt trauma

    A) dirty
    B) clean-contaminated
    C) clean
    D) contaminated
    B) clean contaminated
    (this multiple choice question has been scrambled)
  47. clean contaminated procedures during which acute, non-prulent inflamm is encountered

    A) clean-contaminated
    B) clean
    C) contaminated
    D) dirty
    C) contaminated
    (this multiple choice question has been scrambled)
  48. procedures performed within 4 hr of penetrating trauma or involving a chronic open wound

    A) clean
    B) contaminated
    C) clean-contaminated
    D) dirty
    B) contaminated
    (this multiple choice question has been scrambled)
  49. clean contaminated procedures during which major spillage or technique break occurs

    A) dirty
    B) contaminated
    C) clean
    D) clean-contaminated
    B) contaminated
    (this multiple choice question has been scrambled)
  50. procedures performed when there is obvious pre-existing infection (abscess, pus, necrotic tissue present)

    A) dirty
    B) clean-contaminated
    C) contaminated
    D) clean
    A) dirty
    (this multiple choice question has been scrambled)
  51. pre-operative performation of GI, oropharyngeal, biliary or tracheobronchial tracts

    A) dirty
    B) clean-contaminated
    C) contaminated
    D) clean
    A) dirty
    (this multiple choice question has been scrambled)
  52. penetrating trauma greater than 4 hrs old

    A) contaminated
    B) dirty
    C) clean
    D) clean-contaminated
    B) dirty
    (this multiple choice question has been scrambled)
  53. which two do not receive ppx abx but TREATMENT for preseumed infxn?

    a) clean
    b) clean-contaminated
    c) contaminated
    d) dirty
    • c) contaminated
    • d) dirty
  54. diabetes with cellulitis who needs debridement

    A) clean-contaminated
    B) dirty
    C) clean
    D) contaminated
    D) contaminated
    (this multiple choice question has been scrambled)
  55. ppx?
    clean contaminated
    yes
  56. ppx?
    any procedure in which post-operative infxn, however unlikely, may have severe consequences
    yes
  57. ppx?
    breat procedures and hernia procedures
    yes but questionable
  58. ppx?
    cardiothoracic
    • yes
    • high risk
  59. ppx?
    GI, head/neck, neurosurgical, OBGYN, orthopedic, urologic, vascular, implantation of prosthetic material
    yes (slide 22)
  60. SCIP says, parenteral abx ppx should be started within ___h before incision. if vanco or FQ, start within __h.
    • 1 h
    • 2 h
  61. SIP says, ppx abx should be d/c'd within ___h after surgery end time.
    24h
  62. if procedure is >4h or major blood loss occurs, abx should be re-dosed q _____.
    1-2 half lives.
  63. what happens if unnecessary abx?
    c.dif
  64. infection rates are lower if duration of ppx is longer. T or F?
    • F!!
    • infxn rates are the same regardless of duration of ppx (slide 27)
  65. prolonged ppx decreses the flora and lower infection rate. T or F
    • F!
    • prolonged ppx only changes the flora and does NOT lower infectino rate.
  66. according to SCIP, how do you prevent infxn for cardiac surgery pt specifically?
    • blood glucose control
    • (slide 31)
  67. according to SCIP, how d you prevent infxn for colorectal surgery specifically?
    normothermia
  68. according to SCIP, should you remove hair to prevent infxn?
    • nope
    • proper hair removal with clipper or no removal at all
  69. 4 things to prevent during/after surgery according to SCIP?
    • prevent infection
    • prevent VTE
    • prevent cardiac event
    • prevenet respiratory complication
  70. SCIP: to prevent VTE during surgery, appropriate VTE ppx should be administered within ___h before or after surgery.
    24h
  71. SCIP: how do you prevent cardiac events?
    if pt receiving b-block before arrival, give peri-operative b-blockers
  72. SCIP: how to prevent repiratory complication?
    • if mechanical vent
    • 1) elevate head 30o
    • 2) stress ulcer dz ppx
    • 3) standard weaning protocol
  73. 3 organisms in abdominal or vaginal hysterectomy?
    • enteric GN bacilli
    • Gp B strep (could cause endocarditis)
    • enterococci
  74. what is preferred and alt ppx abx for abdominal or vaginal hysterectomy?
    • preferred: cefotetan (cephamycin)
    • cefazolin, cefoxitin, cefuroxime
    • (Unasyn can be used but reserved for TX b/c only one that can cover enterococci)
  75. what is ppx abx for abdominal or vaginal hysterectomy, if b-lactam allergy?
    • clinda + gent/cipro/aztreonam (GN cover)
    • metro + gent/cipro
    • clinda mono
    • tinidazole 2g single PO 4-12h before surgery
    • levo 750mg
  76. reason for ppx in cesarean section?
    after cord clamping, to reduce exposure to infant
  77. what is ppx abx for cesarean section?
    cefazolin 1-2g
  78. what is ppx abx for cesarean section, if pcn allergy?
    clinda + gent/cipro/levo/aztreonam
  79. new recommendation suggests abx within __ h prior to cesarean section.
    1 h
  80. for abortion surgery, what is ppx abx for 1st trimester?
    • pen G 2mu IV
    • or doxycycline 300mg po
  81. for abortion surgery, what is ppx abx for 2nd trimester?
    cefazolin 1-2g IV
  82. 2 prevalent organisms for hip or knee arthroplasty?
    • staph aureus
    • staph epi
  83. hip or knee arthroplasty

    a) clean
    b) clean-contaminated
    c) contaminated
    d) dirty
    • a) clean
    • (slide 38)
  84. if a tourniquet is used in the procedure, do you need abx for hip or knee arthroplasty? how long?
    • yes
    • entire dose of abx must be infused before the inflation
    • may continue for 24h
  85. what ppx for hip or knee arthroplasty?
    cefazolin or cefuroxime
  86. what ppx for hip or knee arthroplasty if b-lactam allergy?
    • vanco
    • or clinda
  87. what ppx for hip or knee arthroplasty if high risk for MRSA?
    vanco
  88. what ppx to use for open reduction of closed fracture with interal fixation?
    • ceftriaxone 2g IV (broad coverage)
    • this is clean-contaminated
  89. ppx?
    cardiac surgery putting electrophysiologic device
    yes
  90. ppx?
    ventricular assist device
    • yes
    • cardiac surgery
    • (slide 41)
  91. ppx?
    ventriculoatrial shunts
    • yes
    • cardiac surgery
    • (slide 41)
  92. ppx?
    arterial patches
    • yes
    • cardiac surgery (slide 41)
  93. ppx?
    permanent pacemakers
    • yes
    • cardiac surgery (slide 41)
  94. 2 organisms involved during cardiothoracic and vascular surgery?
    • staph aureus
    • staph epi
  95. ppx for cardiothoracic and vascular surgery can continue for ___ h.
    72 h (3 days)
  96. do you need to continue abx ppx for cardiothoracic and vascular surgery until chest or mediastinal drainage tubes are removed?
    • nope
    • (slide 42)
  97. abx for cardiothoracic and vascular surgery can prevent what 2 things?
    • mediastinitis
    • sternal wound infxn
    • (slide 42)
  98. open reduction of closed fraction with internal fixation

    a) clean
    b) clean-contaminated
    c) contaminated
    d) dirty
    • clean contaminated
    • (orthopedic)
    • slide 40
  99. what ppx for cardiothoracic and vascular surgery?
    • cefazolin
    • cefuroxime
  100. what ppx for cardiothoracic and vascular surgery if b-lactam allergy?
    vanco or clinda
  101. what ppx for cardiothoracic and vascular surgery, if high risk MRSA?
    vanco
  102. decolonization is not for everyone. but for SA colonized CT surgery pt, what can you consider?
    • preoperative admin of intranasal mupirocin
    • (controversial)
    • (slide 44)
  103. arterial surgery involving prosthesis, abdominal aorta, and legs requiring groin incision are all vascular surgery. what orgs are involved here?
    • S aur
    • S epi
    • enteric GN bacilli

    (slide 45)
  104. lower extremity amputation for ischemia is a vascular surgery. what orgs are involved here?
    • S. aur
    • S. epi
    • enteric GN bacilli
    • clostridia
  105. what ppx for vascular surgery?
    • cefazolin or vanco
    • or cefuroxime
  106. what ppx for vascular surgery if pcn allergy?
    • vanco
    • +/- gent or clinda
  107. 2 examples of thoracic (non-cardiac) surgery?
    • pulmonary resection
    • closed tube throcostomy
    • (slide 47)
  108. prevalent bugs in thoracic, non cardiac, surgery?
    • s aur
    • s epi
    • streptococci
    • enteric GN bacilli
  109. what ppx for thoracic, non cardiac, surgery?
    • cefazolin
    • cefuroxime
    • vanco
  110. head and neck surgery is usually clean. if prosthesis is added, what abx?
    cefazolin
  111. if head/neck surgery is clean/contaminated, what are the prevalent bugs?
    • anaerobes
    • enteric GN bacilli
    • S. aureus
  112. if head/neck surgery is clean/contaminated, what abx? how long do you continue the abx?
    • cefazolin
    • clinda + gent
    • cefazolin + metro
    • continue for 24h
  113. neuro surgery has what bugs?
    • s. aur
    • s. epi
  114. what abx for craniotomy?
    • cefazolin
    • vanco
    • nafcillin
  115. what abx ppx for spinal surgery? (cross sinuses or naso/oropharynx)
    clinda
  116. what abx ppx for CSF shunt?
    • cefazolin
    • vanco
    • nafcillin
  117. what bugs in ophthalmic surgery?
    • s. epi
    • s. aur
    • streptococcus
    • enteric GN bacilli
    • pseudo
  118. what abx ppx for ophthalmic surgery?
    • FQ drops - multiple over 2-24h
    • neomycin-gramicidin-polymixin B drops
    • AG drops
    • cefazolin 100mg sugconjunct.
  119. when can esophageal surgery can get infected?
    when obstruction
  120. risk factors for gastroduodenal surgery getting infected?
    • obstruction
    • hemorrhage
    • gastric ulcer or malignancy
    • H2 blocker/ PPI (inc pH so bacteria grow better)
    • morbid obesity
  121. risk factors for biliary tract surgery getting infected? what abx?
    • >70yo
    • diabetes
    • obesity
    • acute cholecystitis
    • non-functioning gallbladder
    • obstructive jaundice or common duct stones
    • endoscopic retrograte cholangiopancreatography (ERCP)
    • CEFAZOLIN!
  122. do you need abx ppx if elective laparoscopic cholecystectomy for biliary tract surgery?
    no if low risk (slide 53)
  123. when do you need abx ppx for esopageal, gastroduodenal surgery? what abx?
    • morbid obesity
    • esophageal obstruction
    • dec gastric acidity (H2, PPI)
    • gastrointestinal motility
    • CEFAZOLIN!
  124. bilirary tract surgery has which bugs?
    • enteric GN bacilli
    • enterococci
    • clostridia
  125. appendectomy (non-perforated) has which bugs?
    • enteric GN bacilli
    • anaerobes
    • enterococci
  126. which abx ppx for appendectomy (non-perforated)?
    • cefoxitin, cefotetan (for anaerobes)
    • cefazolin + metro
    • amp/sulbact
  127. how long do you treat if perforation or complicated acute appendicitis from appendectomy?
    5-7 days
  128. what to do before colorectal surgery?
    • remove feces with golytely
    • po abx ppx 19, 18, and 9 h before surgery
    • or iv abx ppx
  129. what po abx ppx for colorectal surgery?
    • neomycin +erythromycin base
    • metronidazole (+ neomycin)
    • 19, 18 and 9 h before surgery
  130. what iv abx ppx for colorectal surgery?
    • clinda + gent/cipro/aztreonam
    • metro + gent/cipro
  131. how long should the tx be if perforation happens during colorectal surgery?
    5-7 days of tx
  132. bugs in genitourinary surgery?
    • enteric GN bacilli
    • enterococci
  133. when to give genitourinary abx ppx?
    • high risk:
    • urine cx (+) or unavail
    • pre-operative catheter
    • transrectal prostatic biopsy
    • transurethral prostatectomy
    • placement of prosthetic material
  134. what abx ppx to give for genitourinary surgery?
    • cipro 500mg po
    • bactrim DS po 2 h before surgery
  135. ppx?
    cardiac catheterization
    nope
  136. ppx?
    varicose vein
    nope
  137. ppx?
    dermatologic and plastic sx
    • nope
    • unless >3h of surgery: give cefazolin
  138. ppx?
    arterial puncture, paracentesis, thoracetesis
    nope
  139. ppx?
    simple laceration
    nope
  140. ppx?
    outpatient treatment of burns
    nope
  141. ppx?
    dental extraction or root canal therapy
    nope
  142. do you use 3rd and 4th generation cephalo for abx ppx surgery?
    • nope
    • (more expensive, less active than cefazolin)

    • cefotaxime (Claforan)
    • Ceftriaxone (Rocephin)
    • cefoperazone (Cefobid)
    • Ceftazidime (Fortaz)
    • Cefepime (Maxipime)
  143. can you use cefazolin if pcn allergy? what else can you use?
    • yes
    • alt: vanco, clinda
  144. what kind of bacteria do vanco, clinda, cefazolin cover?
    gram positive only!
  145. what abx can you use for GN cover?
    • cipro, levl
    • gent
    • aztreonam
  146. if pt is obese, what dose of cefazolin should you give?
    • 2g instead of 1g
    • slide 64
  147. is vanco better than cefazolin for resistant org?
    • nope
    • (slide 65)
  148. what carbapenem is FDA approved for elective colorectal procedure ppx? compare with cefotetan
    • ertapenem
    • erta is more effective than cefotetan for preventing SSI
    • but may have inc C.diff
    • not routinely recomm b/c broad spectrum

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