Surgical Prophylaxis - Help

Overview

The Surgical Prophylaxis module provides real-time monitoring and validation of surgical antibiotic prophylaxis following ASHP/IDSA/SHEA/SIS clinical practice guidelines. The module validates agent selection, timing, duration, and dosing for perioperative antibiotics.

Screening Workflow

The Surgical Prophylaxis module performs retrospective monitoring of surgical cases to evaluate compliance with antibiotic prophylaxis guidelines. It queries the FHIR server for completed surgical procedures, evaluates each case against 7 bundle elements, and generates alerts for non-compliant cases.

Timing Guidelines

Antibiotic Class	Recommended Timing	Notes
Standard antibiotics (cefazolin, ampicillin-sulbactam)	Within 60 minutes of incision	Optimal: 30-60 minutes before
Vancomycin	Within 120 minutes of incision	Requires slow infusion (1-2 hours)
Fluoroquinolones	Within 120 minutes of incision	Longer infusion time required

Duration Guidelines

Procedure Type	Maximum Duration	Notes
Most procedures	≤24 hours post-op	Single dose often sufficient for clean procedures
Cardiac surgery	≤48 hours post-op	Extended duration acceptable
Clean procedures	Single dose	No post-op doses needed

Key Principle: Prophylaxis should be discontinued within 24 hours for most procedures. Extended duration does not reduce SSI risk and increases resistance.

Re-dosing During Surgery

For prolonged procedures, re-dosing is recommended based on antibiotic half-life (intervals for normal GFR >60):

Antibiotic	Re-dose Interval	From First Dose
Cefazolin	Every 3 hours	Re-dose if surgery >3 hours
Cefoxitin	Every 3 hours	Re-dose if surgery >3 hours
Ceftriaxone	Every 12 hours	Re-dose if surgery >12 hours
Ampicillin-sulbactam	Every 2 hours	Re-dose if surgery >2 hours
Clindamycin	Every 6 hours	Re-dose if surgery >6 hours
Vancomycin	Every 8 hours	Re-dose if surgery >8 hours
Metronidazole	Every 12 hours	Re-dose if surgery >12 hours

Also re-dose if significant blood loss (>1500 mL) occurs during surgery. Extend intervals for renal impairment.

Weight-Based Dosing

Antibiotic	Pediatric Dose	Max Dose	High-Weight Adjustment
Cefazolin	40 mg/kg IV	2g	≥100 kg: 3g IV
Cefoxitin	40 mg/kg IV	2g	-
Ceftriaxone	50 mg/kg IV	2g	-
Metronidazole	15 mg/kg IV (30 mg/kg for appendectomy)	1g (1.5g for appendectomy)	-
Vancomycin	15 mg/kg IV	2g per dose	Consult pharmacy
Clindamycin	10 mg/kg IV	900 mg	-
Gentamicin	4.5 mg/kg IV	160 mg (<40 kg) / 360 mg (≥40 kg)	Use adjusted body weight if obese

Procedure-Specific Recommendations

Cardiac Surgery

• Primary: Cefazolin 40 mg/kg (max 2g; 3g if ≥100 kg)
• MRSA risk/colonized: Add vancomycin 15 mg/kg
• Beta-lactam allergy: Clindamycin or Vancomycin
• Duration: ≤48 hours (post-op continuation optional)

Appendectomy

• Primary: Ceftriaxone 50 mg/kg (max 2g) + Metronidazole 30 mg/kg (max 1.5g)
• Beta-lactam allergy: Clindamycin + Gentamicin
• Perforated appendectomy: Continue prophylaxis for 24 hours post-op
• Duration: ≤24 hours

Colorectal Surgery

• Primary: Cefoxitin 40 mg/kg (max 2g)
• Beta-lactam allergy: Clindamycin + Gentamicin
• Note: No post-op continuation - stop after surgery
• Duration: ≤24 hours

Orthopedic Surgery (with implant)

• Primary: Cefazolin 40 mg/kg (max 2g; 3g if ≥100 kg)
• MRSA colonized: Add vancomycin
• Beta-lactam allergy: Vancomycin or clindamycin
• Duration: ≤24 hours

Neurosurgery

• Craniotomy: Cefazolin 40 mg/kg (max 2g)
• CSF shunt: Cefazolin 40 mg/kg (some add vancomycin)
• Spinal with hardware: Cefazolin 40 mg/kg
• Duration: ≤24 hours

ENT Surgery

• Primary: Ampicillin-sulbactam 75 mg/kg (max 3g)
• Clean procedures (cochlear implant): Cefazolin 40 mg/kg
• Beta-lactam allergy: Clindamycin
• Duration: ≤24 hours

MRSA Considerations

Add vancomycin to standard prophylaxis when:

• Known MRSA colonization (positive nasal screen)
• Recent MRSA infection
• High institutional MRSA rates
• Cardiac surgery with sternotomy
• Orthopedic surgery with implant (per institutional protocol)

Note: Vancomycin should be added to (not replace) cefazolin for gram-negative coverage.

Allergy Alternatives

Allergy Type	Can Use	Avoid
Penicillin (any severity)	Cefazolin (safe per current cross-reactivity evidence)	Ampicillin, piperacillin, ampicillin-sulbactam
Cephalosporin allergy	Clindamycin (preferred), Vancomycin	All cephalosporins
All beta-lactam allergy	Clindamycin ± Gentamicin (for gram-negative coverage)	All beta-lactams

Note: Per current evidence, cefazolin cross-reactivity with penicillin is <1%. Cefazolin is safe to give to patients with ANY severity of penicillin allergy.

Compliance Bundle Elements

The module evaluates 7 key bundle elements for each surgical case:

#	Element	Description
1	Indication Appropriate	Prophylaxis given (or withheld) appropriately for the procedure
2	Agent Selection	Correct antibiotic(s) for the procedure type and patient allergies
3	Pre-op Timing	Administered within 60 min of incision (120 min for vancomycin)
4	Weight-Based Dosing	Appropriate dose for patient weight (mg/kg with max caps)
5	Intraoperative Redosing	Redose given for prolonged surgery (e.g., Q3H for cefazolin)
6	Post-op Continuation	Appropriate post-operative prophylaxis when required (e.g., perforated appendectomy: 24h)
7	Timely Discontinuation	Stopped within 24h (48h for cardiac)

Bundle Compliance: A case is considered fully compliant when ALL applicable elements are met.

References

• CCHMC Surgical Prophylaxis Guidelines v2024.2 (September 2024) - Local institutional guidelines
• Bratzler DW, Dellinger EP, Olsen KM, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70(3):195-283.
• ASHP/IDSA/SHEA/SIS. Clinical Practice Guidelines for Antimicrobial Prophylaxis in Surgery. 2013.
• Ban KA, et al. American College of Surgeons and Surgical Infection Society: Surgical Site Infection Guidelines, 2016 Update. J Am Coll Surg. 2017.