Infectious Diseases II

cephalosporin allergy had a higher odds of developing an SSI than those without a

reported allergy.

penicillin. The 2022 drug allergy practice parameter update states that in patients with a

history of anaphylaxis to penicillin, a structurally dissimilar R1 side chain cephalosporin

(e.g., cefazolin) can be administered routinely without prior testing (J Allergy Clin

Immunol. 2022;150(6):1333-1393).

iv.

Adjust dose of antibiotics for obesity – See Table 2 for suggested dosing.

Patients with known nasal carriage of S. aureus should receive intranasal applications

of mupirocin 2% ointment twice daily for up to 5 days before surgery with or without a

combination of chlorhexidine gluconate body wash.

vi.

Alcohol-based antiseptic solutions with chlorhexidine gluconate for surgical site skin preparation

should be used in patients undergoing surgical procedures.

vii.

Preoperative bowel preparation

surgery was recommended by the ACS/SIS and WHO guidelines.

with mechanical bowel preparation was associated with reduced SSI rates compared with

mechanical bowel preparation alone. Oral antibiotic prophylaxis was associated with

significant decreases in rates of anastomotic leak and 30-day mortality without increasing

rates of Clostridioides difficile infections.

preparation is recommended by the 2019 American Society of Colon and Rectal Surgeons

Clinical Practice Guidelines.

Re-dose antibiotics, if necessary – See Table 2 for dosing schedule during surgery.

ii.

In general, antibiotics with short half-lives should be re-dosed at a frequency of 2 times the

half-life of the agent. Antibiotics should also be re-dosed if there is significant intraoperative

blood loss.

iii.

Goal of re-dosing is to maintain bactericidal concentrations throughout the operation. It may

be prudent to consider re-dosing prophylaxis intraoperatively if large amounts of fluids and/or

transfusions are being administered.

iv.

Maintain normothermia. Two small randomized controlled trials showed that maintaining

normothermia reduced the risk of SSIs. The mechanism for this protective effect is currently

unknown; however, a hypothesis is that this effect may result from impaired neutrophil

function or subcutaneous vasoconstriction and subsequent tissue hypoxia with hypothermia.

Postoperative

Discontinue prophylactic antibiotics within 24 hours after non-cardiac surgery and within

48 hours after cardiac surgery. Drains are not a sufficient reason to continue prophylactic

antibiotics.

ii.

Early recovery after surgery (ERAS) protocols: Aim to reduce the stress of surgery on patients

by maintaining near normal physiology in the preoperative, intraoperative, and postoperative

phases of care.

recommendations, such as parenteral antibiotic prophylaxis and strict glycemic control,

as well as interventions with newer evidence, such as oral antibiotic prophylaxis with

mechanical bowel preparation, goal directed fluid therapy, and early enteral feeding.

abdominal/pelvic surgery showed a significant reduction in postoperative SSI for patients

enrolled in ERAS pathways compared with conventional perioperative pathways.

Diagnosis, management, and treatment of SSIs: See Infectious Diseases I chapter.