Antibiotics are commonly used in infected and critically colonized wounds to eradicate the infection and allow the wound to follow the normal physiological healing pathway. However, although prophylactic antibiotics are not recommended due to the risk of building host resistance, antibiotics also have an important role in preventing infection in the specific case of surgical wounds.
Surgical site infections are a leading cause of nosocomial infections after surgery, accounting for approximately 500,000 infections every year in the US and costing more than $1.6 billion annually.(1) It has been shown that patients who develop surgical site infections are five times more likely to be readmitted to hospital and twice as likely to die compared with surgical patients without the infections.(1)
The Surgical Care Improvement Project (SCIP), implemented in 2003, aims to reduce post-operative site infections by recommending a number of measures, including the following:(2)
- Prophylactic antibiotics should be initiated within one hour before surgical incision, or within two hours if the patient is receiving vancomycin or fluoroquinolones.
- Patients should receive prophylactic antibiotics appropriate for their specific procedure.
- Prophylactic antibiotics should be discontinued within 24 hours of surgery completion (within 48 hours for cardiothoracic surgery).
Despite demonstrated reductions in surgical site infections following implementation of these measures, the use of prophylactic antibiotics in surgery is still not universal.(1) As an incentive to reduce rates of surgical site infections, the Centers for Medicare and Medicaid Services have begun reducing reimbursement for hospitals with high rates of surgical site infection.(1)
For most patients undergoing clean-contaminated surgeries (e.g., cardiothoracic, gastrointestinal, orthopedic, vascular, gynecologic), a cephalosporin is the recommended prophylactic antibiotic.(1,3,4) Other, generalized recommendations for prophylaxis based on type of surgery are given in the Table below.(1)
Prevention of wound infection is an essential skill in wound management, and an important part of the wound care certification program.
Table. Antibiotic prophylaxis to prevent surgical site infections1
| Surgery | Common pathogens | Recommended antimicrobials |
| Cardiothoracic | Staphylococcus aureus, coagulase-negative staphylococci | Cefazolin, cefuroxime sodium (Zinacef), or vancomycin |
| Gastrointestinal | Enteric gram-negative bacteria, anaerobes, enterococci | Cefoxitin (Mefoxin), cefotetan (Cefotan), ampicillin/sulbactam (Unasyn), or cefazolin plus metronidazole |
| Gynecologic | Enteric gram-negative bacteria, group B streptococci, enterococci, anaerobes | Cefoxitin, cefotetan, cefazolin, or ampicillin/sulbactam |
| Orthopedic | S. aureus, coagulase-negative staphylococci | Cefazolin, cefuroxime sodium, or vancomycin |
| Vascular | S. aureus, coagulase-negative staphylococci, enteric gram-negative bacilli | Cefazolin or vancomyc |
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References
- Salkin AR and Rao KC. Antibiotic prophylaxis to prevent surgical site infections. Am Fam Physician. March, 2011; 83(5): 585-90.
- Bratzler DW and Hunt DR. The surgical infection prevention and surgical care improvement projects: national initiatives to improve outcomes for patients having surgery. Clin Infect Dis. 2006;43(3):322–330.
- Landis SJ. Chronic Wound Infection and Antimicrobial Use. Adv Skin & Wound Care 2008; 21: 531–540.
- Bates-Jensen BM, Ovington LG. Management of exudate and infection. In: Sussman C and Bates-Jensen B. Wound Care: A Collaborative Practice Manual for Health Professionals. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007.
I have to say I have come across this situation so many times…..a venous stasis ulcer that doesn’t heal so we maybe need to look at the medications and check that the patient is on a proper diuretic dosage and if that fails maybe the primary MD needs to refer for a vascular surgeon consult. Or a thin frail person that may not be getting enough protein or adequate nutrition. Co-factors in wounds cannot be overlooked and poor healing can come from alot of sources elsewhere. Diabetics and blood sugar, smokers and PAD, etc. Sometimes wound healing can come from just good patient teaching about controlling the underlying disease process! I like this blog!!!!