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Serious Medicine. Extraordinary Care.

Surgical Prophylaxis Protocol

Purpose

The antimicrobial surgical prophylaxis protocol establishes evidence-based standards for surgical prophylaxis at The Nebraska Medical Center. The antimicrobial surgical prophylaxis protocol will be implemented through the use of a standard antimicrobial surgical prophylaxis order form (download available at the bottom of this page). The protocol includes dosing guidelines specified on the order form. To see details of the order entry process, click here.

Procedure

  1. The order forms will be included in the pre-operative packet and placed in all relevant places, including clinics, to ensure accessibility. The surgical prophylaxis or transplant surgical prophylaxis forams are to be used for all adult surgical procedures performed at The Nebraska Medical Center. For purposes of surgical prophylaxis, these forms replace any currently existing standard order sets that include antibiotics.
  2. The physician or physician's agent will complete the order form, including patient allergies. The form will then be given to the pharmacist, who will enter the orders into CareCast, making automatic weight adjustments as specified on the form and automatic adjustments for renal function as specified below. Clarification orders regarding renal dosage adjustments will be recorded in the patient's medical record by the pharmacist. If the patient is allergic to the antibiotic that is ordered, the pharmacist will automatically order the option listed on the form for use in the case of allergy.
  3. If the physician does not use the order form (i.e., writes surgical antimicrobial prophylaxis orders on a different form), the pharmacist will inform the physician that an antibiotic will not be dispensed until the form is completed.
  4. The Intraoperative Antimicrobial Readministration Guidelines will be posted in the operating rooms, and the specific readministration time for a particular case, based on when the pre-operative dose is given, should be written on the wipe boards in the operating rooms by the pharmacy technician.

Tables

Antimicrobial Dosage Adjustments With Renal Insufficiency (CrCl less than 50 ml/min)
Antimicrobial Dosing Regimen with Normal Renal Function Dosing Regimen with CrCl less than 50 ml/min Dosing Regimen with CrCl less than 10 ml/min
Ampicillin/Sulbactam 3 g IV q6h 3 g IV q12h 3 g IV q24h
Cefazolin 1 g IV q8h 1 g IV q12h 1 g IV q24h
Gentamicin 80 mg IV q8h 60 mg IV q12h 40 mg IV q24h
Metronidazole 500 mg IV q8h 500 mg IV q8h 500 mg IV q12h
Vancomycin 1 g IV q12h 1 g IV q24h N/A (greater than 48h)
Intraoperative Antimicrobial Readministration Guidelines
Antimicrobial Half-life with Normal Renal Function (h) Half-life with End-stage Renal Disease Recommended Re-dosing Interval in Individuals with NORMAL Renal Function*
Ampicillin/Sulbactam 1 - 2 unavailable 4 hours
Cefazolin 1.2 - 2.5 40 - 70 4 hours
Cefoxitin 0.5 - 1.1 6.5 - 23 3 hours
Ciprofloxacin 3.5 - 5 5 - 9 8 hours
Doxycycline 15 - 24 18 - 25; no change unnecessary
Gentamicin 2 - 3 50 - 70 6 hours
Metronidazole 6 - 14 7 - 21; no change 8 hours
Trimethoprim / Sulfamethoxazole 8 - 12 20 - 30 unnecessary
Vancomycin 4 - 6 44.1 - 406.4 12 hours
* In general, antimicrobials should be readministered at intervals of 1-2 times the half-life of the drug.

Adapted from Bratzler et al. Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project. CID. 2004;38:1706-15.

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