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E Review Article

CME
Administration of Parenteral Prophylactic Beta-Lactam
Antibiotics in 2014: A Review
Ronald J. Gordon, MD, PhD

The role of the anesthesiologist in reducing the incidence of surgical-site infections by the
administration of prophylactic parenteral beta-lactam antibiotics is reviewed. Suggestions are
made with regard to timing, dosing, and method of administration of these drugs to potentially
reduce the risk of surgical-site infection. (Anesth Analg 2015;120:87787)

A
s of 2014, the administration of prophylactic paren- The following discussion focuses on the problem of hos-
teral antibiotics in the perioperative period is well pital-acquired infections (HAIs) after surgery. The proper
embedded into the practice of anesthesia. In popular administration of prophylactic beta-lactam antibiotics is
jargon, we own it, and are responsible for assuring peri- then reviewed. It is common knowledge among medical
operative prophylactic parenteral antibiotics are given so as providers that HAIs (or as they are more commonly known,
to optimize their effectiveness, thereby minimizing the inci- SSIs) are a major perioperative complication and add mark-
dence of surgical-site infections (SSIs). It is proper and fitting edly to the cost of health care for the American public.
that this should be so, both because of our role as periopera- A recent study indicated that the annual cost associated
tive physicians and by virtue of our central position within with HAIs in the United States is approximately 9.8 billion
the flow of the surgical patients care. Before 2006, this was dollars.4 A significant component of these HAIs and costs
not the case. Prophylactic antibiotics often were given by the occurs after surgical procedures.4 For example, a SSI in a
nursing staff, either on the hospital floor or in the preopera- routine ventral hernia repair with mesh can add more than
tive holding area. However, the aggressive and comprehen- $100,000 to the patients total cost of care.a
sive efforts of major figures in the health care establishment, SSIs are the most common reason for hospital readmis-
such as Donald Berwick through the Institute for Healthcare sion after surgery.b In elderly patients, the complication of
Improvement and the 100,000 lives campaign,1 as well as a deep incisional or organ space infection increases mor-
the Centers for Medicare and Medicaids (CMS) efforts to tality by a factor of 4 and average hospital stay by 15.7
improve medical quality via the physicians quality reporting days.5 The US Department of Health and Human Services
initiative, rapidly moved this responsibility to the anesthe- Administration on Aging website projects the number of
sia health care team. For us to be more than just technicians, elderly Americans will grow from 39.6 million in 2009 to
administering medications ordered by the surgical resident 72.1 million in 2030. Hence, the importance of this issue
or attending without having any input, we require an under- with regard to patient morbidity, mortality, and health care
standing of the pharmacokinetics and pharmacodynamics of costs will continue to increase. Historically, prevention and
prophylactic parenteral antibiotics. It is imperative that we treatment of SSIs has been within the purview of the oper-
act in a manner befitting our dual roles as the surgical team ating surgeon, but recently the complementary role of the
member responsible for providing safe and optimal operat- anesthesia provider has received attention.616 Our specialty
ing conditions, as well as being a significant contributor to has much to contribute in the battle against this major health
efforts to reduce longer-term perioperative complications.2,3 care issue. Efforts to broaden the scope of anesthesia care,
Such complications include SSIs, chronic pain, perioperative for example, with the development of the perioperative sur-
myocardial and pulmonary events, and venous thromboem- gical home17 or protocols for enhanced recovery after sur-
bolic phenomena. To effectively provide such benefits to our gery,18 increasingly focus on the role of the anesthesiologist
patients, there must also be a mutually respectful symbiotic in influencing long-term patient outcomes.3,11,16
relationship between surgeon and anesthesiologist.2 Anesthetic interventions potentially effective in decreas-
ing SSIs derive from 5 fundamental pathophysiologic
principles:
From the Department of Anesthesia, Naval Medical Center San Diego, San
Diego, California; Department of Anesthesia, the Veterans Administration 1. SSIs develop after inoculation of bacteria of sufficient
Hospital San Diego, San Diego, California; and Department of Anesthesia, dose and virulence into tissue to overcome local host
the University of California Medical Center, San Diego, San Diego, California. defenses, which in turn may be weakened by such
Accepted for publication August 13, 2014. factors as hypoxia, surgical stress, blood transfusion,
Funding: None. pain, and hyperglycemia.
The author declares no conflicts of interest.
Reprints will not be available from the author.
The views expressed in this article are those of the author and do not reflect
a
Colavita PD, Zemlyak AY, Burton PV, Dacey KT, Walters AL, Lincourt AE,
the official policy or position of the Department of the Navy, Department of Tsirline VB, Augenstein VA, Kercher KW, Heniford BT. The expansive cost of
Defense, or the US Government. wound complications following ventral hernia repair. American College of
Surgeons Clinical Congress 2013. Walter E. Washington Convention Center,
Address correspondence to Ronald J. Gordon, MD, PhD, Clinical Inves- Washington, DC, October 7, 2013. Scientific Sessions. Available at: http://
tigation Department (KCA), Naval Medical Center San Diego, 34800 Bob web2.facs.org/cc_program_planner/Detail_Session_2013.cfm?CCYEAR=20
Wilson Dr., Suite 5, San Diego, CA 92134. Address e-mail to rjgordonmd@ 13&SESSION=SP04&GROUP=SP. Accessed June 21, 2014.
gmail.com.
b
Outpatient Surgery. February 2014. Available at: http://www.outpatientsur-
Copyright 2015 International Anesthesia Research Society gery.net/surgical-facility-administration/infection-control/study-finds-ssis-
DOI: 10.1213/ANE.0000000000000468 the-best-predictor-of-surgical-readmissions--02-19-14. Accessed June 21, 2014.

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E review article

2. The primary host defense is oxidative killing by yardsticks, they represent (along with the central line place-
neutrophils. ment, PQRS Measure 76) the only publicly available means
3. Neutrophils must be delivered in sufficient number to of assessing anesthesia care.27 Current efforts by such orga-
be effective, dependent in part on local capillary blood nizations as the Anesthesia Quality Institute certainly will
flow. Hypothermia, hypovolemia, and increased sym- lead to much more comprehensive and useful assessments
pathetic tone decrease capillary blood flow whereas of anesthesia quality of care,2,27 but at present, the CMS
interventions that reduce sympathetic tone, such as measures are all that is available. To be sure we tow the
neuraxial anesthesia, increase capillary blood flow. mark regarding compliance with these measures, starting
4. The time from skin incision to a few hours after skin in 2013 CMS imposed penalties (assessed in 2015) on anes-
closure is a decisive period6,19,20 during which infec- thesia providers for noncompliance. It is disconcerting then,
tion is established. Modifications in anesthetic man- with so much riding on compliance with measure 30, that
agement to decrease SSIs are most effective when a number of editorials and studies by prominent authori-
implemented during this decisive period. ties in the field call into question the clinical benefit of its
5. To optimize effectiveness, prophylactic antibiotics enforcement. We are troubled by missives such as Surgical
must be administered at a proper time in sufficient Care Improvement: Should Performance Measures Have
dose and with sufficient frequency such that the Performance Measures,28 SCIP to the Loo,29 Reducing
maximum tissue concentration occurs at the time the Risk of Surgical Site Infections: Did We Really Think
of incision2123 and tissue concentrations exceed the SCIP was Going to Lead Us to the Promised Land?21 and
minimum inhibitory concentration (MIC) of potential Is it time to refine? An exploration and simulation of opti-
microbial pathogens for the duration of the decisive mal antibiotic timing in general surgery,30 all of which
period.24 question the clinical benefit of enforcement of performance
It follows that anesthesiologists potentially may contrib- measure 30. A major goal of the SCIP project was the reduc-
ute to a reduction in the frequency of SSIs in many ways. tion of SSIs by 25%.21 To date, despite the almost universal
Interventions suggested (but not necessarily proven) to be implementation of measure 30, very little if any reduction
beneficial include frequent handwashing,1214 maintenance has occurred.31 It is therefore a most appropriate time to
of intraoperative normothermia,6,8,15,16 neuraxial anesthe- revisit and reevaluate current literature on this topic.
sia,9 modest glucose control (maintaining blood levels The remarks that follow relate primarily to the beta-
<200 mg%),25 induced hypercarbia,6,7 increased inspired lactam class of antibiotics. This group includes the penicil-
oxygen concentrations,6,8,11 timely administration of pro- lins, cephalosporins, and carbapenems and is widely used
phylactic antibiotics,15,24 minimization of operating theater in clinical practice. The beta-lactams exhibit pharmacody-
traffic,26 avoidance of blood transfusions,8,26 and effec- namic behavior suggesting the possibility of more effective
tive postoperative pain control.6,11 Of these, perioperative utilization. In contrast to the fluoroquinolones and amino-
temperature management and timely administration of glycosides, the beta-lactams (as well as clindamycin) work
prophylactic parenteral antibiotics have become accepted primarily via a process termed time-dependent killing.32
universally and are integrated widely into clinical practice In time-dependent killing, the fraction of time the drug con-
in the United States. These latter 2 interventions also are centration exceeds MIC is the primary determinant of effec-
included in the Surgical Care Improvement Project (SCIP) tiveness.3240 The beta-lactams also demonstrate a limited
Module 1 on prevention of SSIs and in the CMS Physician postantibiotic effect (the ability to continue bacterial killing
Quality Reporting System (PQRS) measures 193 and 30: after the concentration of the drug is below MIC), whereas
PQRS Measure 193. Perioperative Temperature Manage the fluoroquinolones and aminoglycosides exhibit primar-
ment: Percentage of patients, regardless of age, undergoing ily concentration-dependent killing and a pronounced
surgical or therapeutic procedures under general or neur- postantibiotic effect.32 For these latter drugs, the maximum
axial anesthesia of 60 minutes duration or longer, except concentration achieved and the area under the concentra-
patients undergoing cardiopulmonary bypass, for whom tion-time curve are the most important variables. Drugs
either active warming was used intraoperatively for the such as vancomycin exhibit both time-dependent killing
purpose of maintaining normothermia, or at least one body and a moderate postantibiotic effect. Examples of the dif-
temperature 36C (or 96.8F) was recorded within the 30 ferent drug classes are listed in Table1. Beta-lactams such
minutes immediately before or the 15 minutes immediately as cefazolin are also highly protein bound, and only the
after anesthesia end time. free or unbound drug has antibacterial activity.42 To influ-
PQRS Measure 30. Perioperative Care: Timely Adminis ence bacterial virulence by virtue of the inhibition of bacte-
tration of Prophylactic Parenteral Antibiotics: Percentage rial cell wall synthesis (the primary mechanism of action of
of surgical patients aged 18 years and older who receive the beta-lactams), the unbound drug must first achieve an
an anesthetic when undergoing procedures with the indi- effective concentration throughout the interstitial fluid.40
cations for prophylactic parenteral antibiotics for whom In most literature on the subject, the terms tissue con-
administration of the prophylactic antibiotic ordered has centration and interstitial fluid concentration are used
been initiated within 1 hour (if fluoroquinolone or vanco- interchangeably, and that convention will be followed here.
mycin, 2 hours) before the surgical incision (or start of pro- Thus, to be effective, the unbound drug must pass though
cedure when no incision is required). the capillary membrane, diffuse throughout the interstitial
Most medical centers in the United States require anes- fluid to reach the offending pathogens, and finally bind to
thesia providers to be in compliance with these CMS mea- the penicillin-binding proteins on the bacterial wall. This
sures, and within the realm of publicly reported quality process by necessity takes time, dependent on such factors

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Table 1.Pharmacodynamics of Representative Prophylactic Antibiotics
Postantibiotic Usual dose in Half-life with normal Redosing interval
Antibiotic/class Surgical procedure and routine pathogens Mechanism of action effect adults renal function (12 half lives)
Cefazolin (first-generation Cefazolin is the most commonly prescribed of the prophylactic Time-dependent Minimal 12 g, 3 g for 1.22.2 h 3 ha
Parenteral Prophylactic Antibiotics

cephalosporin, a beta-lactam) antibiotics; it is recommended for all clean surgeries and killing patients 120 kg
many clean-contaminated surgeries: coverage includes

April 2015 Volume 120 Number 4


S epidermidis, S aureus, streptococci, and gram-negative
aerobes
Cefuroxime (second- An alternative to cefazolin with similar coverage: slightly Time-dependent Minimal 1.5 g (this dose is 12 h 3h
generation cephalosporin, a broader gram-negative coverage killing traditionally used for all
beta-lactam) adult patients)
Cefoxitin (second- generation Clean-contaminated surgeries such as colon resection: enteric Time-dependent Minimal 2g 0.71.1 hb 2h
cephalosporin, a beta-lactam) gram-negative bacilli, anaerobes esp. Bacteroides killing
Cefotetan (second-generation Clean-contaminated surgeries such as colon resection, Time-dependent Minimal 2g 2.84.6 h 6h
cephalosporin, a beta-lactam) an alternative to cefoxitin: enteric gram-negative killing
bacilli, anaerobes esp. Bacteroides. Commonly used in
gynecological surgeries.
Clindamycin (lincosamide) An alternative to cefazolin in IgE-mediated penicillin allergic Time-dependent Moderate 0.9 g 24 h 6h
patients: S. aureus, S. epidermidis, streptococci, anaerobes killing
Ampicillin-sulbactam Clean-contaminated surgeries (often head and neck): common Time-dependent No 3g 0.81.3 h 2h
(combination penicillin, beta gram positives, gram negatives, anaerobes, enterococci killing
lactamase inhibitor)
Ciprofloxacinc (fluoroquinolone) Enteric gram-negative bacilli (often used in urological Concentration- Pronounced 0.4 g 37 h 8h
procedures as a 0.5 g po dose) dependent killing
Vancomycinc,d (glycopeptide) Often used for patients who are allergic to penicillin in place of Mixed properties Moderate 0.015 g/kg 48 h Not applicable
cefazolin. Covers common gram positives, MRSA.
Metronidazole (nitroimidazole) Covers anaerobes including Clostridium difficile. Often used in Concentration- Pronounced 0.5 g 610 h Not applicable
combination with cefazolin for clean- dependent killing
contaminated surgeries, especially colon surgery
MRSA = methicillin-resistant Staphylococcus aureus.
a
The American Society of Health-System Pharmacists recommends 4 hours, but other institutions and authors suggest redosing at 3 hours.c Twice the minimum half-life of 1.2 hours would give a redosing interval of 2.4
hours. The shorter the redosing interval the greater the likelihood antibiotic concentrations will always exceed the minimum inhibitory concentration.
b
As with most beta-lactams, this is markedly dependent on creatinine clearance.41
c
Because these drugs cannot be administered by bolus infusion, secondary to undesirable side effects, administration times refer to the initiation of infusion.
d
In very prolonged cases (more than 1012 hours), either the creatinine clearance or a measured drug level could be used to determine the requirement for an additional dose of vancomycin.

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E review article

as the free drugs diffusion coefficient and the average dis- Because it is also desirous that antibiotic tissue concen-
tance from blood vessel to tissue. For the obese patient, trations be maximal at times of greatest risk, it follows that
this average distance is increased,43,44 and the antibiotic sufficient time must elapse after IV infusion for peak tissue
transport time is by necessity also increased. Finally, all and interstitial fluid concentrations to be achieved at inci-
things being equal, prophylactic antibiotic administration sion. Weber etal.50 note that for cefuroxime, drug admin-
should be timed such that maximum tissue concentrations istration less than 30 minutes before skin incision may
are achieved immediately before times of known bacterial provide insufficient time to achieve adequate tissue con-
seeding, for example, during skin incision or bowel entry centrations. Andersson etal.,23 in discussing the strategy for
in clean-contaminated cases.2123 Because it is well known antibiotic infusion, state current knowledge suggests that
that tissue concentrations of antibiotics vary significantly this is approximately 30 minutes before incision in relation
between skin, adipose tissue, muscle, and omentum sec- to the type of antibiotics with a half-life of 30 minutes. The
ondary to variations in capillary perfusion,4548 striving for authors then go on to suggest 15 to 45 minutes before inci-
a maximum average tissue concentration at incision is most sion or tourniquet application as an acceptable time span
likely to ensure adequate antibiotic coverage at all sites of for infusion. Edmiston etal.21 note that pragmatically, the
potential contamination.2123 likelihood of achieving the maximum tissue concentration
at 3045 minutes before incision is greater than if the drug is
TIMING OF INITIAL DOSE OF PROPHYLACTIC bolused 510 minutes before incision. Stefnsdttir etal.51
PARENTERAL ANTIBIOTICS also advocate administering the antibiotic 30 minutes before
As measure 30 is currently written, we are free to adminis- incision, again with a range of 15 to 45 minutes considered
ter the selected antibiotic 60 minutes before skin incision, acceptable. Indeed, the overwhelming majority of available
30 minutes before skin incision, or 30 seconds before skin studies are consistent with an optimal preincision infusion
incision. We are free to administer the drug after tourni- time window between 15 and 45 minutes. Consistent with
quet inflation in an orthopedic procedure, as long as that these empirical guidelines, the careful microdialysis studies
occurs before skin incision. Most authorities would con- of Toma etal.45 demonstrate that for cefoxitin, the peak tis-
sider administration of prophylactic parenteral antibiotics sue concentration in adipose tissue is reached at an average
30 seconds before skin incision or after tourniquet infla- time of 29 11 minutes after rapid IV infusion.
tion (often during the surgical time out) suboptimal care It would be surprising indeed if antibiotic infusion 15
because the tissue levels of the drug at the commencement to 45 minutes before incision ensured optimal tissue and
of surgery would be expected to be quite low. Deiner and serum concentrations for every beta-lactam, but because the
Silverstein16 stated it well when they noted, if prophylaxis molecular size of most of these drugs are similar, it is not an
is started as soon as 1 minute before incision, the OR team is unreasonable assumption. Clinical studies by Davies etal.52
still in compliance from a regulatory perspective. Although in which they compare cefamandole, cefuroxime, and
this practice may follow the strict definition of the criteria, it cephradine in 60 patients with hip replacement are consis-
certainly does not follow our understanding of the science tent with the premise. These authors note we feel that the
and therefore the spirit of the criteria. three agents when given at the same dose showed a similar
With these remarks as background, it is helpful to pharmacokinetic profile; the choice of antibiotic for chemo-
review in simple terms the science in question. Starting prophylaxis for total hip replacement should be influenced
with the fundamental studies of Burke,19,20 it has been dem- by the likely pathogens and the cost of the drug.52 As noted
onstrated that for antibiotics to be effective in reducing the previously, for the morbidly obese patient, the average dis-
incidence of SSIs, they must be present at sufficient levels tance from capillary to tissue is increased,43,44 suggesting
within the at-risk tissues at the time of bacterial inocula- that a longer diffusion time may be required for the antibi-
tion and throughout the surgical procedure (principle 5 otic to reach maximum tissue levels. It would seem prudent
above).24 The 2013 revised policy paper on prophylactic therefore, based on the recommendations and clinical stud-
antibiotics developed jointly by the American Society of ies noted, to further tighten our antibiotic infusion time to
Health-System Pharmacists (ASHP), the Infectious Disease 30 to 45 minutes when possible (the pragmatic suggestion
Society of America, the Surgical Infection Society, and the of Edmiston etal.)21 for the obese patient. In such a manner,
Society for Healthcare Epidemiology of America24 (which we are more likely to achieve the goal of maximum tissue
P. S. Barie49 refers to as a must read must heed for every concentrations at the initiation of surgery. Before we can
surgeon) states: make this universal recommendation, however, the ASHP
Successful prophylaxis requires the delivery of the anti- admonition that tissue concentrations should exceed MIC
microbial to the operative site before contamination occurs. for the duration of the procedure also must be considered.
Thus, the antimicrobial agent should be administered at For those antibiotics with relatively short half-lives (e.g.,
such a time to provide serum and tissue concentrations cefoxitin 0.71.1 hours) or for lengthy procedures, the tis-
exceeding the minimum inhibitory concentration (MIC) for sue concentrations may be inadequate in the latter stages of
the probable organisms associated with the procedure, at the operation (particularly for the morbidly obese patient,
the time of incision, and for the duration of the procedure. whose tissue concentrations may never achieve effective
levels).4547 Hence, administering the antibiotic closer to
c
Surgical prophylaxis antibiotic guidelines. Rochester General Health incision (for example, 010 minutes) may provide an insuf-
System. September 2012. Available at: http://nebula.wsimg.com/9678632ff
686d48917fa1a34bc83f4ef?AccessKeyId=FD7CB6ADC6CB16B0172B&dispos ficient interval to maximize tissue concentrations at inci-
ition=0&alloworigin=1. Accessed June 21, 2014. sion but may have the alternative benefit of increasing the

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Parenteral Prophylactic Antibiotics

portion of the decisive period for which the antibiotic con- incision would be expected to achieve therapeutic levels of
centration exceeds MIC. This trade-off between assuring antibiotics throughout the duration of operation. The lon-
tissue concentrations are maximum at incision and main- ger the operation, the more benefit is achieved by admin-
taining tissue concentrations above MIC for the majority of istration of prophylaxis as close as possible to the time of
the operative procedure suggests clinical studies may show incision. Steinberg etal.54 also argues against the concern
conflicting results in terms of when to administer the initial over giving antibiotics too close in time to incision. We see 2
antibiotic dose. For example, according to Dellinger53: different factors at play with respect to antibiotic timing: (1)
Some have questioned whether giving the antibiotic too high tissue levels are desired at skin incision, which is more
close to the time of incision might have less efficacy, but the likely to occur when antibiotics are given approximately
data of van Kasteren etal. and others are reassuring in this 15 to 45 minutes out; and (2) tissue levels above MIC are
regard. It is important to observe that, although there was desired for the duration of the operative procedure, which
no statistically significant difference between the results of is more likely to occur when the antibiotic is given immedi-
administration of prophylaxis during the intervals of 30 to ately before incision. These concepts are illustrated in Figs.1
60 minutes and 0 to 30 minutes before incision, the results and 2, wherein the stippled areas represent the time periods
during the 0- to 30-minute interval actually showed a lower for which tissue concentrations are below MIC.
rate of SSI, which lends no credence to the concern that In other studies, in an analysis of 3836 patients using a
administration of prophylaxis close to the time of incision single dose of cefuroxime, Weber etal.50 found that admin-
might be less effective. However, for total hip arthroplasty, istration of the antibiotic 30 to 60 minutes before incision
administration of prophylaxis during the 60 minutes before more effective than administration 0 to 30 minutes before
incision had equally good results. This may be because the incision. Here again, these data are not inconsistent with
average duration of operation was only 79 minutes, and the benefits of using the 15- to 45-minute time interval,
thus, administration of prophylaxis even 1 hour before but rather that time interval was not examined. Steinberg

Plasma Concentration

Figure 1. Schematic representation of


plasma and tissue concentration of anti-
biotic compared with time when drug is Tissue Concentration
administered approximately 30 minutes
before incision. The stippled area rep- Free Drug
resents the period during which antibi- Concentration
otic concentrations are subtherapeutic.
For concentration-dependent antibiotics MIC
such as ciprofloxacin, the peak tissue
concentration is the important variable.
Ideally, this should be achieved simulta- Time above MIC
neously with surgical incision.

Time
Injection of Surgical Closure
antibiotic Incision

Plasma Concentration

Figure 2. Schematic representation of


plasma and tissue concentration of anti- Tissue Concentration
biotic compared with time when drug is Free Drug
administered immediately before inci-
Concentration
sion. Note the time above minimum
inhibitory concentration is increased in MIC
this example. The stippled area repre-
sents the period during which antibiotic
concentrations are subtherapeutic.
Time above MIC

Time
Injection Surgical Closure
Incision

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etal.54 studied data from 4472 cardiac, hip/knee, and hys- recommends redosing at intervals of approximately 2 half
terectomy cases and found the lowest rate of infection lives.24 Hence, for cefazolin, a redosing interval of 4 hours
when antibiotics were given within 30 minutes of incision. is suggested, whereas for ampicillin-sulbactam, a redosing
An examination of their data demonstrates once again interval of 2 hours is suggested. Ho etal.60 and Goede etal.61
consistency with the 15- to 45-minute interval. In contrast, have also emphasized the importance of redosing. In Goede
in a recent analysis of 32,459 Veterans Affairs surgeries, etal.s study, the lack of redosing had the greatest noncom-
Hawn etal.55 found greater rates of SSI for procedures dur- pliance (45.1%) among the various SSI prevention measures
ing which the antibiotic was started more than 60 minutes analyzed. Those studies in which redosing was used indi-
before incision but not for antibiotics administered after cate this in turn results in a sinusoidal or sawtooth type of
incision. The authors concluded, while adherence to (mea- concentration profile, with drug levels alternatively peaking
sure 30) is not bad care, there is little evidence to suggest and decreasing.22 Many authors have suggested that a con-
it is better care. In Hawn etal.s study, there was no limi- tinuous infusion after the initial prophylactic bolus injection
tation on the length of surgery, and redosing of antibiot- so that the total amount of drug infused stays the same for
ics was not examined. Koch etal.30 examined rates of SSIs lengthy cases is much more in keeping with the pharmaco-
in 6731 patients who underwent 7095 procedures. Their kinetics and pharmacodynamics of the beta-lactams.22,3340
results were limited to procedures of less than 4 hours in For example, if cefazolin is given at an initial dose of 2 g
duration. Four hundred forty-four patients developed a in a 100-kg individual and 3 hours later is redosed with an
SSI. The authors found a continuous decrease in rates of additional 2 g, with continuous infusion the drug is imme-
SSI as the time between administration of antibiotics and diately started at a rate of 2 g over 3 hours after the initial
surgical incision was shortened, with 4 minutes before inci- bolus, so that at the end of 3 hours of surgery a total of 4 g
sion as the optimal time for infusion. They concluded that has been given. In this manner, assuming the drug reaches a
antibiotic administration should be moved closer to inci- steady-state concentration, we conform to the optimal time-
sion time, in particular within 18 minutes of incision with a dependent killing concentration profile. Although clinical
95% confidence limit.30 studies demonstrating a reduced rate of SSIs are not avail-
In another study of 28,250 cardiac surgery patients, Koch able, numerous authors have suggested such an approach
etal. found that for cefuroxime initiation of administration to be beneficial.22,3340 Available data by Adembri etal.22
of the antibiotic 15 minutes before incision resulted in the measuring tissue levels in cardiac surgery patients shows a
lowest SSI rate, whereas for vancomycin the optimal time to clearly beneficial effect on antibiotic concentrations in atrial
initiate infusion was 32 minutes before incision.56 Here yet tissue with continuous administration at the same total dose
again the data are consistent with a range of 15 to 45 min- of cefazolin. In their study, plasma concentrations of cefazo-
utes leading to the lowest rate of SSIs. It is notable that avail- lin remained above MIC for >90% of the surgical procedure
able studies demonstrate that it does not take long for many in 9 of 10 patients for continuous infusion, whereas only 3 of
antibiotics to achieve adequate tissue levels after bolus 10 patients in the bolus dosing group achieved plasma con-
IV administration (in studies by DiPiro etal.57 and Wong- centrations above MIC for >90% of the procedure at the same
Beringer etal.,58 measurable tissue levels of cefoxitin and total dose. In addition to the pharmacokinetically calculated
cefazolin and cefmetazole, respectively, were found within and expected decrease in antibiotic concentrations with time
a few moments of infusion), but it does seem to require due to physiologic clearance, some surgeries also are asso-
approximately 15 to 30 minutes for most cephalosporins to ciated with significant blood loss and fluid requirements.
reach maximum tissue levels. Even in the study by DiPiro Both factors result in additional decreases in antibiotic tis-
etal.,57 not all patients had measurable tissue levels in mus- sue concentrations, either as a result of dilution or elimina-
cle at 20 minutes. van Kasteren etal.59 noted that for total hip tion. Current recommendations in this area are limited, but
arthroplasty procedures, optimal antibiotic administration some authors recommend redosing for >1500 cm3 of esti-
times clustered around 30 minutes before incision, although mated blood loss.24 Assuming an average blood volume of
the data did not reach statistical significance. A summary of 5000 cm3, 1500 cm3 of blood loss would reduce plasma levels
some of the recent major studies on timing in the SCIP era of antibiotics (assuming euvolemia) by 30%. Because blood
primarily for the beta-lactams is listed in Table2. volume varies significantly in the adult patient population, a
better approach would be to calculate the total blood volume
REDOSING OF PROPHYLACTIC PARENTERAL using the Lemmens formula (see next section) and redose at
ANTIBIOTICS AND CONTINUOUS INFUSION a 30% estimated blood loss.
The plasma half-life of cefazolin is estimated at 1.2 to 2.2
hours.24 As the plasma concentration decreases, so ultimately WEIGHT-BASED DOSING AND OTHER ESTIMATES
does the tissue concentration. Administering cefazolin 30 OF ANTIBIOTIC REQUIREMENTS
minutes before skin incision may lead to peak tissue levels To simplify dosing schedules for commonly used beta-lac-
at incision, but rapidly decreasing plasma and tissue levels tams, often 1 g of cefazolin, cefoxitin, or cefotetan is used
thereafter. Giving cefazolin closer to the time of incision for patients 70 kg and 2 g for patients 70 kg. For cefurox-
results in lower tissue concentrations at incision but greater ime, 1.5 g often is used for all patients. In Chopra etal.s62
tissue concentrations at closure. As emphasized previously, study on obese patients, a dose of 3 g of cefazolin was rec-
because cephalosporins work via time-dependent killing, ommended for patients with a body mass index (BMI) >50.
it is the time above MIC rather that the maximum concen- It is evident, however, that the 1.5-m tall, obese individual
tration reached, which determines effectiveness. The ASHP with a BMI of 50 will have a far smaller blood volume than

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Parenteral Prophylactic Antibiotics

Table 2.Summary of Recent Timing Studies on Antibiotics


Publication Number of Timing
year Author procedures/SSIs recommendations Study design Comments
2013 Hawn etal.55 32,459/1497 Greater SSI rates for Retrospective cohort study using Did not consider redosing
administration > 60 min national Veterans Affairs or limit duration of
before but not after incision. patient-level data on orthopedic, procedures studied.
Concluded adherence to timely vascular, colorectal, and
antibiotic administration did not gynecological procedures from
improve care. 2005 to 2009
2013 Koch etal.30 7095/444 Recommend moving infusion Prospective cohort study using Excluded vancomycin
closer to incision time National Surgical Quality and procedures longer
(018 min). But data are Improvement Program data for than 4 h
also consistent with 15- to 6731 patients who underwent
45-min window for infusion of 7095 general surgery
antibiotics. procedures from 2006 to 2012
2012 Koch etal.56 28702/590 Timing recommendations varied Prospective cohort study Duration of procedures
for vancomycin and cefuroxime undergoing cardiac surgery and redosing were not
but analysis of results procedures from 1995 to 2008 considered.
suggests 1545 min optimal
infusion time for either drug.
2009 Steinberg etal.54 4472/113 30 min before incision was Prospective cohort study from Intraoperative redosing
optimal. 29 hospitals from randomly in cases >4 h
selected cardiac, hip/knee appeared to reduce
arthroplasty, and hysterectomy SSI risk, but only if
cases preoperative dose was
administered correctly.
2008 Weber etal.50 3836/180 For cefuroxime, 3059 min was Prospective observational cohort No redosing noted.
best. Did not examine 15- to study of 3836 patients
45-min time period.
2007 van Kasteren etal.59 1922/50 Total hip arthroplasty, relatively Prospective observational cohort Noted advantage of
short procedures, 30 min study of 1922 patients with hip giving antibiotic
before incision was optimal arthroplasty close to incision
although data did not reach time: measurable
statistical significance. tissue levels at
end of procedure.
Intraoperative redosing
was not administered.
SSI = surgical site infection.

the 2.0-m tall individual with a BMI of 50, and in the former BV (actual blood volume in cm 3 / kg ) =
case, the initial plasma concentration of cefazolin will con-
sequently be significantly higher. The ASHP recommends 7 0 / square root ( BMI / 22 )
a dose of 3 g of cefazolin for patients who weigh 120 kg
but does not discuss dosage modifications with increasing where BMI is the patients body mass index in kg/m.2 There
weight for many of the other beta-lactams. Once again, the fore, the required dose of cefazolin, for example, to achieve the
1.5-m tall individual with a weight of 120 kg will have a far same initial plasma level for patients >70 kg (where W is the
smaller blood volume than the 2.0-m tall individual with actual body weight in kg) is estimated as follows:
the same weight. The matter is far from settled, and the few
available studies on antibiotics and morbid obesity indicate Cefazolin dose (in gms) =
current dosing regimens to be inadequate.4446,62,63
Because serum antibiotic levels often are used as a sur- 0.135 H ( in meters ) W ( in kg )
rogate for antibiotic tissue concentrations as well as reflect-
ing to some degree the risk of toxicity, a more physiological For a morbidly obese patient with a height of 1.77 m and
approach to dosing commonly used beta-lactams would be a weight of 157 kg (BMI = 50), the required dose would be 3.0
to strive for the same initial plasma level of antibiotic. With g, identical to the recommendation of Chopra etal.62 For a
serum concentration as a guide, and with the use of a mini- morbidly obese patient with a height of 1.50 m and a weight
mum dose of 2.0 g of cefazolin, cefoxitin, or cefotetan for a of 113 kg (BMI = 50), the required dose would be reduced
70-kg patient as a floor, the calculated antibiotic dose is to 2.15 g, a result of the markedly decreased blood volume.
0.00041 g/cm3 of blood, using a blood volume of 70 cm3/kg. Selecting 3 hours as the redosing interval (approximately 1.5
Similarly, for cefuroxime, with a minimum dose of 1.5 g for half-lives) for the former patient, the initial bolus would be
a 70-kg patient as a floor,24 the calculated antibiotic dose is followed by a continuous infusion at 1.00 g/h. Maintaining
0.00031 g/cm3 of blood. this antibiotic infusion until the patients discharge from the
To estimate blood volume in the obese patient, one use- postanesthesia care unit is more likely to maintain adequate
ful tool is the Lemmens formula44: blood levels in the (obese) patient throughout the entire

April 2015 Volume 120 Number 4 www.anesthesia-analgesia.org 883


E review article

decisive period than a traditional dosing regimen.21,45,46 necessitate more aggressive antibiotic prophylaxis. Until such
Thus, as anesthesia providers, one possible and logical way time as molecules that interfere with biofilm production or
we can address the troubling issue of ineffective antibiotic facilitate penetration of the film with effective antimicrobi-
tissue levels for obese patients is by (1) calculating antibiotic als are routinely introduced into clinical practice,72 the use of
dose based on the Lemmens formula with floors for cefoxi- a beta-lactam bolus followed immediately by a continuous
tin, cefotetan, or cefazolin of 2 g and for cefuroxime of 1.5 g infusion may be justified.73 Clear recommendations in the
for a 70-kg patient and (2) for high-risk patients or patients medical literature on this subject are not available.
in whom a SSI would be catastrophic, following the initial
bolus dose by a continuous infusion. It is noteworthy that OTHER COMMON CONSIDERATIONS
the Lemmens formula gives results in approximate agree-
When to Avoid Prophylactic Antibiotics
ment with the dosing weight calculations for aminoglyco-
Many other questions and issues occur in the course of
sides, which is not surprising because the toxicity of these
selecting appropriate prophylactic antibiotic coverage,
latter drugs is also related to plasma concentration.
much of this relevant to the attending anesthesiologist. A
significant and often-controversial issue concerns the actual
USE OF A TOURNIQUET need for antibiotics. The ASHP white paper discusses a
The anesthesiologist often is charged with the task of admin- number of situations for which antibiotics are not indicated.
istering prophylactic antibiotics to patients for whom a pneu- These include clean orthopedic procedures on the extremi-
matic tourniquet is used. Use of a tourniquet creates unique ties without instrumentation, as well as clean head and neck
problems with regard to antibiotic dosing. After tourniquet procedures such as thyroidectomy or lymph node excision
inflation, the affected limb is ischemic for the duration and in low-risk patients. In addition, both the ASHP policy
oxidative neutrophil killing, the bodys primary defense paper and the Medical Letter suggest that for low risk ASA
mechanism against pathogens, stops. Hence, pathogens I or II patients undergoing elective cholecystectomy, anti-
weakened by the initial dose of antibiotics and more suscep- biotic prophylaxis is usually not indicated.74 Other surgical
tible to host defenses remain viable while bacterial seeding procedures wherein antibiotics appear to have little or no
from a variety of external sources continues during ischemia. place for low-risk patients include laparoscopic oophorec-
This bacterial load is then integrated into the clot that forms tomies, tonsillectomies, and cystoscopies. To avoid delays,
after tourniquet release, making neutrophil killing more dif- confrontations, and unpleasantries, all of these issues
ficult.64 Simultaneously, the blood infusing the affected limb should of course be discussed in a cooperative and help-
after tourniquet release has a much lower antibiotic concen- ful exchange between the surgical and anesthesia teams and
tration, affected by the duration of tourniquet use and the half general policies and guidelines put in place. In situations
life of the specific antibiotic administered.65,66 The literature in which prophylactic antibiotics may be avoided, their
on the topic is equivocal, and equal SSI rates are seen whether use should be discouraged because none of these medica-
the antibiotic is given before or after tourniquet inflation.6567 tions are without potential harm. For example, Clostridium
It has been suggested that a tourniquet release dose is appro- difficile, a rapidly growing health care problem and major
priate, as well as an initial dose at least 10 minutes but prefer- contributor to morbidity and mortality in HAIs, is strongly
ably longer before tourniquet inflation and skin incision.67,68 associated with antibiotic administration75 (as well as with
Although evidenced-based studies are lacking, this approach the use of proton pump inhibitors and increased age, both
has the weight of physiologic reasoning behind it, common increasingly common in todays surgical population), even
to many of the anesthesia techniques we use.69 On the other when antibiotic use is restricted solely to prophylactic peri-
hand, the ASHP monograph makes the point that antibiotic operative antibiotics.76
administration before tourniquet inflation seems intuitively
correct and does not discuss a tourniquet release dose.24 In
The Patient with a Penicillin Allergy
summary, it appears prudent to administer the first dose of Traditionally, patients for whom cefazolin is the recom-
antibiotic within the 15- to 45-minute time span before tour- mended antibiotic often are switched to clindamycin or
niquet inflation (being careful to satisfy the 1-hour PQRS vancomycin when they present with a history of a penicillin
requirement for antibiotic to incision time) and add an addi- allergy. However, many authorities recommend that only
tional tourniquet release dose for those procedures in which in those situations where the patients history is consistent
occurrence of a SSI would be catastrophic, such as total knee with either an IgE-mediated penicillin allergy (urticaria,
replacement. Continuous infusions of antibiotics have no angioedema, anaphylaxis, bronchospasm) or a severe non
logical place in procedures involving a tourniquet. IgE-mediated reaction (interstitial nephritis, toxic epidermal
necrolysis, hemolytic anemia, or Stevens-Johnson syn-
BIOFILMS drome) is it necessary to switch out the cefazolin.7779 Even
Many surgical procedures involve insertion of a foreign sub- in these situations, there is at least some question if cefazo-
stance into the patient (pacemakers, mesh, prostheses, etc.). lin need be avoided. Cross-sensitivity occurs when the R1
This is particularly true in the case of the extensive instru- side chains of the penicillins and cephalosporins are similar,
mentation involved in complex orthopedic procedures.70 In which perhaps surprisingly is not the case with cefazolin.
all such cases, the development of a bacterial biofilm creates a Cephalosporins with R1 side chains similar to penicillins
formidable obstacle to infection control.13,71 The development include cephalexin, cefaclor, and cefadroxil. According to
of a biofilm occurs in as little as 6 hours.71 Hence, procedures The Medical Letter, for patients with mild-to-moderate reac-
involving mesh, instrumentation, and other foreign bodies tions to penicillin G, ampicillin, or amoxicillin, the risk

884
www.anesthesia-analgesia.org anesthesia & analgesia
Parenteral Prophylactic Antibiotics

associated with use of first- or second-generation cephalo- prospective study underway in Switzerland hypothesizes
sporins with dissimilar side chains, or third- or fourth-gen- that antibiotics should be administered no earlier than 30
eration cephalosporins, appears to be very low.78 Thus, minutes before skin incision to minimize SSIs.82
reflexively dismissing cefazolin use with a vague history of The initial beat-lactam bolus dose should be followed
any penicillin allergy should be reconsidered. We can cer- by additional doses at every 1 to 2 half lives per the ASHP
tainly make our voices heard in these situations. guidelines. For situations for which a SSI would be cata-
strophic, available literature and pharmacodynamic con-
siderations suggest the initial bolus should be followed
Practical Considerations in Drug Selection
It is generally agreed that antibiotic selection should target immediately by a continuous infusion such that the same
the most likely pathogens, and that targeting all potential total dose of drug is administered as in the case of redosing.
pathogens is unnecessary and potentially harmful. The Calculation of antibiotic dosing for obese patients is con-
Medical Letters 2012 recommendations for antibiotic selec- troversial, and although the simple expedient of giving 3
tion take this approach. For many surgeries, cefazolin is the g of cefazolin for the 120-kg patient or alternatively for the
patient with a BMI of 50 is acceptable, use of the Lemmens
drug of choice.74 The ASHP white paper reflects similar sen-
formula and blood volume dosing would seem prima facie
timent but gives a wider and much more detailed selection
preferable. Estimation of blood volume and using 30%
of appropriate antibiotics, with specific recommendations
of blood volume loss as an antibiotic trigger for redosing
for a multitude of operative procedures.24 The predictable
would also seem preferable to the unqualified recommen-
culprits for different procedures vary by hospital, but it is
dation of redosing for every 1500 cm3 of blood loss in all
common consensus that skin pathogens (Staphylococcus
patients. In the case of tourniquet use, a tourniquet release
aureus, Staphylococcus epidermidis) are frequent offenders in
dose appears justified for those procedures in which a SSI
clean surgeries, whereas enteric gram-negative microbes are
would be devastating.
found in many clean contaminated surgeries. The Center
The pharmacokinetics and pharmacodynamics of anti-
for Disease Control tracks common pathogens via the
biotics should guide their administration by the anesthesia
National Healthcare Safety Network, the most widely used
provider. It is time for us to embrace our role in the overall
infection-tracking system in the United States. According
surgical experience. We can do better. E
to the National Healthcare Safety Network, the top 5 most
commonly reported pathogens are (1) Staphylococcus aureus,
DISCLOSURES
(2) coagulase-negative staphylococci, (3) Escherichia coli, (4)
Name: Ronald J. Gordon, MD, PhD.
Enterococcus faecalis, and (5) Pseudomonas aeruginosa.80
Contribution: This author wrote the manuscript.
Attestation: Ronald J. Gordon approved the final manuscript.
CONCLUSIONS This manuscript was handled by: Sorin J. Brull, MD, FCARCSI
It would certainly be unusual for an anesthesia provider (Hon).
to administer a medication in the absence of a thorough
knowledge of the pharmacology, proper dosing, and indi- ACKNOWLEDGMENTS
cations for that medication, but this is often the case with I would like to thank Dr. Charles E. Edmiston, Jr, Department of
parenteral prophylactic antibiotics. Glance and Fleisher2 Surgery, Medical College of Wisconsin, for his interest and very
note if we are unwilling to share accountability for surgi- helpful comments and suggestions.
cal outcomes, we run the risk of trivializing the specialty
of anesthesiology. SSIs are one such frequent negative out- REFERENCES
1. Berwick DM, Calkins DR, McCannon CJ, Hackbarth AD.
come, and because antibiotic administration is a corner-
The 100,000 lives campaign: setting a goal and a deadline for
stone of prevention efforts, a thorough knowledge of the improving health care quality. JAMA 2006;295:3247
fundamentals of principles supporting appropriate selec- 2. Glance LG, Fleisher LA. Anesthesiologists and the transforma-
tion and use is required. tion of the healthcare system: a call to action. Anesthesiology
If we consistently use well-understood pathophysiologi- 2014;120:2579
3. Sessler DI. Long-term consequences of anesthetic management.
cal concepts and current data with respect to the pharmaco- Anesthesiology 2009;111:14
kinetics and pharmacodynamics of prophylactic antibiotics, 4. Zimlichman E, Henderson D, Tamir O, Franz C, Song P, Yamin
it is highly likely we can reduce national rates of SSIs. We CK, Keohane C, Denham CR, Bates DW. Health care-associated
do not have the luxury of time to wait for the definitive infections: a meta-analysis of costs and financial impact on the
US health care system. JAMA Intern Med 2013;173:203946
large-scale clinical studies, so rare in modern anesthesiol- 5. Kaye KS, Anderson DJ, Sloane R, Chen LF, Choi Y, Link K,
ogy.81 Current evidence suggests that for most beta-lactams, Sexton DJ, Schmader KE. The effect of surgical site infection on
a bolus dose at 15 to 45 minutes before incision is ideal and older operative patients. J Am Geriatr Soc 2009;57:4654
provides maximum interstitial fluid concentrations at the 6. Sessler DI. Non-pharmacologic prevention of surgical wound
time of initial bacterial seeding. Because diffusion distances infection. Anesthesiol Clin 2006;24:27997
7. Aka O, Doufas AG, Morioka N, Iscoe S, Fisher J, Sessler DI.
from capillary to pathogen are greater in obese patients, Hypercapnia improves tissue oxygenation. Anesthesiology
for this patient subset initiating antibiotic infusion 30 min- 2002;97:8016
utes or longer before incision is warranted on theoretical 8. Gifford C, Christelis N, Cheng A. Preventing postoperative
grounds. Koch etal.s work is consistent with this premise, infection: the anaesthetists role. Contin Educ Anaesth Crit Care
Pain 2011;11:1516
and for cefuroxime, patients with a BMI >30 had an optimal 9. Chang CC, Lin HC, Lin HW, Lin HC. Anesthetic management
time for initiation of infusion of 39 minutes before incision and surgical site infections in total hip or knee replacement: a
versus 21 minutes for patients with a BMI < 30.56 A current population-based study. Anesthesiology 2010;113:27984

April 2015 Volume 120 Number 4 www.anesthesia-analgesia.org 885


E review article

10. Aka O, Melischek M, Scheck T, Hellwagner K, Arkili CF, Kurz 31. Stulberg JJ, Delaney CP, Neuhauser DV, Aron DC, Fu P,

A, Kapral S, Heinz T, Lackner FX, Sessler DI. Postoperative Koroukian SM. Adherence to surgical care improvement proj-
pain and subcutaneous oxygen tension. Lancet 1999;354:412 ect measures and the association with postoperative infections.
11. Kavanagh T, Buggy DJ. Can anaesthetic technique effect post- JAMA 2010;303:247985
operative outcome? Curr Opin Anaesthesiol 2012;25:18598 32. Varley AJ, Sule J, Absalom AR. Principles of antibiotic therapy.
12. Hopf HW, Rollins MD. Reducing perioperative infection is as Contin Educ Anaesth Crit Care Pain 2009;9:1848
simple as washing your hands. Anesthesiology 2009;110:95960 33. Huang H, Huang S, Zhu P, Xi X. Continuous versus inter-
13. Roy RC, Brull SJ, Eichhorn JH. Surgical site infections and
mittent infusion of cefepime in neurosurgical patients with
the anesthesia professionals microbiome: weve all been post-operative intracranial infections. Int J Antimicrob Agents
slimed! Now what are we going to do about it? Anesth Analg 2014;43:6872
2011;112:47 34. Vondracek TG. Beta-lactam antibiotics: is continuous infusion
14. Loftus RW, Muffly MK, Brown JR, Beach ML, Koff MD,
the preferred method of administration? Ann Pharmacother
Corwin HL, Surgenor SD, Kirkland KB, Yeager MP. Hand 1995;29:41524
contamination of anesthesia providers is an important risk 35. McKinnon PS, Davis SL. Pharmacokinetic and pharmacody-
factor for intraoperative bacterial transmission. Anesth Analg namics issues in the treatment of bacterial infectious diseases.
2011;112:98105 Eur J Clin Microbiol Infect Dis 2004;23:27188
15. Forbes SS, McLean RF. Review article: the anesthesiologists 36. Waltrip T, Lewis R, Young V, Farmer M, Clayton S, Myers S,
role in the prevention of surgical site infections. Can J Anaesth Gray LA Jr, Galandiuk S. A pilot study to determine the feasi-
2013;60:17683 bility of continuous cefazolin infusion. Surg Infect (Larchmt)
16. Deiner S, Silverstein JH. Long-term outcomes in elderly surgi- 2002;3:59
cal patients. Mt Sinai J Med 2012;79:95106 37. Nicolau DP, Nightingale CH, Banevicius MA, Fu Q, Quintiliani
17. Vetter TR, Goeddel LA, Boudreaux AM, Hunt TR, Jones KA, R. Serum bactericidal activity of ceftazidime: continuous
Pittet JF. The Perioperative Surgical Home: how can it make the infusion versus intermittent injections. Antimicrob Agents
case so everyone wins? BMC Anesthesiol 2013;13:6 Chemother 1996;40:614
18. Gustafsson UO, Scott MJ, Schwenk W, Demartines N, Roulin 38. MacGowan AP, Bowker KE. Continuous infusion of beta-lac-
D, Francis N, McNaught CE, MacFie J, Liberman AS, Soop tam antibiotics. Clin Pharmacokinet 1998;35:391402
M, Hill A, Kennedy RH, Lobo DN, Fearon K, Ljungqvist O. 39. Roberts JA, Lipman J, Blot S, Rello J. Better outcomes through
Guidelines for perioperative care in elective colonic surgery: continuous infusion of time-dependent antibiotics to critically
Enhanced Recovery After Surgery (ERAS) Society recommen- ill patients? Curr Opin Crit Care 2008;14:3906
dations. Clin Nutr 2012;31:783800 40. Douglas A, Udy AA, Wallis SC, Jarrett P, Stuart J, Lassig-Smith
19. Burke JF. The effective period of preventive antibiotic action M, Deans R, Roberts MS, Taraporewalla K, Jenkins J, Medley
in experimental incisions and dermal lesions. Surgery G, Lipman J, Roberts JA. Plasma and tissue pharmacokinetics
1961;50:1618 of cefazolin in patients undergoing elective and semielective
20. Burke JF. Preventing bacterial infection by coordinating anti- abdominal aortic aneurysm open repair surgery. Antimicrob
biotic and host activity: a time-dependent relationship. South Agents Chemother 2011;55:523842
Med J 1977;70:246 41. Isla A, Trocniz IF, de Tejada IL, Vzquez S, Canut A, Lpez
21. Edmiston CE, Spencer M, Lewis BD, Brown KR, Rossi PJ, JM, Solins M, Rodrguez GA. Population pharmacokinetics
Henen CR, Smith HW, Seabrook GR. Reducing the risk of of prophylactic cefoxitin in patients undergoing colorectal sur-
surgical site infections: did we really think SCIP was going gery. Eur J Clin Pharmacol 2012;68:73545
to lead us to the promised land? Surg Infect (Larchmt) 42. Singhvi SM, Heald AF, Schreiber EC. Pharmacokinetics of

2011;12:16977 cephalosporin antibiotics: protein-binding considerations.
22. Adembri C, Ristori R, Chelazzi C, Arrigucci S, Cassetta MI, De Chemotherapy 1978;24:12133
Gaudio AR, Novelli A. Cefazolin bolus and continuous admin- 43. Fujii T, Tsutsumi S, Matsumoto A, Fukasawa T, Tabe Y, Yajima
istration for elective cardiac surgery: improved pharmacoki- R, Asao T, Kuwano H. Thickness of subcutaneous fat as a
netic and pharmacodynamic parameters. J Thorac Cardiovasc strong risk factor for wound infections in elective colorectal
Surg 2010;140:4715 surgery: impact of prediction using preoperative CT. Dig Surg
23. Andersson AE, Bergh I, Karlsson J, Eriksson BI, Nilsson K. The 2010;27:3315
application of evidence-based measures to reduce surgical site 44. Lemmens HJ, Bernstein DP, Brodsky JB. Estimating blood

infections during orthopedic surgeryreport of a single-center volume in obese and morbidly obese patients. Obes Surg
experience in Sweden. Patient Saf Surg 2012;6:11 2006;16:7736
24. Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaeter PG, 45. Toma O, Suntrup P, Stefanescu A, London A, Mutch M,

Bolon MK, Fish DN, Napolitano LM, Sawyer RG, Slain D, Kharasch E. Pharmacokinetics and tissue penetration of cefox-
Steinberg JP, Weinstein RA; American Society of Health-System itin in obesity: implications for risk of surgical site infection.
Pharmacists (ASHP); Infectious Diseases Society of America Anesth Analg 2011;113:7307
(IDSA); Surgical Infection Society (SIS); Society for Healthcare 46. Edmiston CE, Krepel C, Kelly H, Larson J, Andris D, Hennen
Epidemiology of America (SHEA). Clinical practice guidelines C, Nakeeb A, Wallace JR. Perioperative antibiotic prophylaxis
for antimicrobial prophylaxis in surgery. Surg Infect (Larchmt) in the gastric bypass patient: do we achieve therapeutic levels?
2013;14:73156 Surgery 2004;136:73847
25. Kao LS, Meeks D, Moyer DA, Lally KP. Peri-operative glycae- 47. Pevzner L, Swank M, Krepel C, Wing DA, Chan K, Edmiston
mic control regimens for preventing surgical site infections in CE Jr. Effects of maternal obesity on tissue concentrations
adults. Cochrane Database Syst Rev 2009;3:CD006806 of prophylactic cefazolin during cesarean delivery. Obstet
26. Bryan CS, Yarbrough WM. Preventing deep wound infection Gynecol 2011;117:87782
after coronary artery bypass grafting: a review. Tex Heart Inst J 48. Stitely M, Sweet M, Slain D, Alons L, Holls W, Hochberg C,
2013;40:12539 Briggs F. Plasma and tissue cefazolin concentrations in obese
27. Glance LG, Neuman M, Martinez EA, Pauker KY, Dutton RP. patients undergoing cesarean delivery and receiving dif-
Performance measurement at a tipping point. Anesth Analg fering pre-operative doses of drug. Surg Infect (Larchmt)
2011;112:95866 2013;14:4559
28. Hawn MT. Surgical care improvement: should performance 49. Barie PS. Guidelines for antimicrobial prophylaxis in surgery: a
measures have performance measures. JAMA 2010;303:25278 must-read, must-heed for every surgeon. Surg Infect (Larchmt)
29. Barie PS. SCIP to the loo? Surg Infect (Larchmt) 2011;12:1612 2013;14:57
30. Koch CG, Li L, Hixson E, Tang A, Gordon S, Longworth D, 50. Weber WP, Marti WR, Zwahlen M, Misteli H, Rosenthal R,
Phillips S, Blackstone E, Henderson JM. Is it time to refine? An Reck S, Fueglistaler P, Bolli M, Trampuz A, Oertli D, Widmer
exploration and simulation of optimal timing in general sur- AF. The timing of surgical antimicrobial prophylaxis. Ann Surg
gery. J Am Coll Surg 2013;217:62835 2008;247:91826

886
www.anesthesia-analgesia.org anesthesia & analgesia
Parenteral Prophylactic Antibiotics

51. Stefnsdttir A, Robertsson O, W-Dahl A, Kiernan S, Gustafson 66. Akinyoola AL, Adegbehingbe OO, Odunsi A. Timing of anti-
P, Lidgren L. Inadequate timing of prophylactic antibiotics in biotic prophylaxis in tourniquet surgery. J Foot Ankle Surg
orthopedic surgery. We can do better. Acta Orthop 2009;80:6338 2011;50:3746
52. Davies AJ, Lockley RM, Jones A, el-Safty M, Clothier JC.
67. Bannister GC, Auchincloss JM, Johnson DP, Newman JH. The
Comparative pharmacokinetics of cefamandole, cefuroxime timing of tourniquet application in relation to prophylactic
and cephradine during total hip replacement. J Antimicrob antibiotic administration. J Bone Joint Surg Br 1988;70:3224
Chemother 1986;17:63740 68. Bicanic G, Crnogaca K, Barbaric K, Delimar D. Cefazolin should
53. Dellinger EP. Prophylactic antibiotics: administration and tim- be administered maximum 30 min before incision in total
ing before operation are more important than administration knee arthroplasty when tourniquet is used. Med Hypotheses
after operation. Clin Infect Dis 2007;44:92830 2014;82:7668
54. Steinberg JP, Braun BI, Hellinger WC, Kusek L, Bozikis MR, 69. Horlocker TT, Brown DR. Evidence-based medicine: haute

Bush AJ, Dellinger EP, Burke JP, Simmons B, Kritchevsky SB; couture or the emperors new clothes? Anesth Analg
Trial to Reduce Antimicrobial Prophylaxis Errors (TRAPE) 2005;100:180710
Study Group. Timing of antimicrobial prophylaxis and the 70. Kasliwal MK, Tan LA, Traynelis VC. Infection with spinal

risk of surgical site infections: results from the Trial to Reduce instrumentation: review of pathogenesis, diagnosis, preven-
Antimicrobial Prophylaxis Errors. Ann Surg 2009;250:106 tion, and management. Surg Neurol Int 2013;4:S392403
55. Hawn MT, Richman JS, Vick CC, Deierhoi RJ, Graham LA, 71. Stewart PS. Theoretical aspects of antibiotic diffusion into micro-
Henderson WG, Itani KM. Timing of surgical antibiotic pro- bial biofilms. Antimicrob Agents Chemother 1996;40:251722
phylaxis and the risk of surgical site infection. JAMA Surg 72. Roman CL, Toscano M, Roman D, Drago L. Antibiofilm

2013;148:64957 agents and implant-related infections in orthopaedics: where
56. Koch CG, Nowicki ER, Rajeswaran J, Gordon SM, Sabik JF are we? J Chemother 2013;25:6780
3rd, Blackstone EH. When the timing is right: antibiotic timing 73. Hiby N, Bjarnsholt T, Givskov M, Molin S, Ciofu O. Antibiotic
and infection after cardiac surgery. J Thorac Cardiovasc Surg resistance of bacterial biofilms. Int J Antimicrob Agents
2012;144:931937.e4 2010;35:32232
57. DiPiro JT, Vallner JJ, Bowden TA Jr, Clark BA, Sisley JF.
74. Antimicrobial prophylaxis for surgery. Treat Guidel Med Lett
Intraoperative serum and tissue activity of cefazolin and cefoxi- 2012;10:738
tin. Arch Surg 1985;120:82932 75. Silva JM. Recent changes in Clostridium difficile infection.

58. Wong-Beringer A, Corelli RL, Schrock TR, Guglielmo BJ.
Einstein (Sao Paulo) 2012;10:1059
Influence of timing of antibiotic administration on tissue con- 76. Carignan A, Allard C, Ppin J, Cossette B, Nault V, Valiquette
centrations during surgery. Am J Surg 1995;169:37981 L. Risk of Clostridium difficile infection after perioperative
59. van Kasteren ME, Mannin J, Ott A, Kullberg BJ, de Boer AS, antibacterial prophylaxis before and during an outbreak
Gyssens IC. Antibiotic prophylaxis and the risk of surgical site of infection due to a hypervirulent strain. Clin Infect Dis
infections following total hip arthroplasty: timely administra- 2008;46:183843
tion is the most important factor. Clin Infect Dis 2007;44:9217 77. Campagna JD, Bond MC, Schabelman E, Hayes BD. The use
60. Ho VP, Barie PS, Stein SL, Trencheva K, Milsom JW, Lee SW, of cephalosporins in penicillin-allergic patients: a literature
Sonoda T. Antibiotic regimen and the timing of prophylaxis are review. J Emerg Med 2012;42:61220
important for reducing surgical site infection after elective abdom- 78. Cephalosporins for patients with penicillin allergy. Med Lett
inal colorectal surgery. Surg Infect (Larchmt) 2011;12:25560 Drugs Ther 2012;54:101
61. Goede WJ, Lovely JK, Thompson RL, Cima RR. Assessment of 79. Haslam S, Yen D, Dvirnik N, Engen D. Cefazolin use in patients
prophylactic antibiotic use in patients with surgical site infec- who report a non-IgE mediated penicillin allergy: a retrospec-
tions. Hosp Pharm 2013;48:5607 tive look at adverse reactions in arthroplasty. Iowa Orthop J
62. Chopra T, Zhao JJ, Alangaden G, Wood MH, Kaye KS.
2012;32:1003
Preventing surgical site infections after bariatric surgery: value 80. Sievert DM, Ricks P, Edwards JR, Schneider A, Patel J, Srinivasan
of perioperative antibiotic regimens. Expert Rev Pharmacoecon A, Kallen A, Limbago B, Fridkin S. Antimicrobial-resistant
Outcomes Res 2010;10:31728 pathogens associated with healthcare-associated infections:
63. Barbour A, Schmidt S, Rout WR, Ben-David K. Soft tissue pen- summary of data reported to the National Healthcare Safety
etration of cefuroxime by clinical microdialysis in morbidly Network at the Centers for Disease Control and Prevention,
obese patients undergoing abdominal surgery. Int J Antimicrob 20092010. Infect Control Hosp Epidemiol 2013;34:114
Agents 2009;34:2315 81. Devereaux PJ, Chan MT, Eisenach J, Schricker T, Sessler DI.
64. Soriano A, Bori G, Garca-Ramiro S, Martinez-Pastor JC, Miana The need for large clinical studies in perioperative medicine.
T, Codina C, Macul F, Basora M, Martnez JA, Riba J, Suso Anesthesiology 2012;116:116975
S, Mensa J. Timing of antibiotic prophylaxis for primary total 82. Mujagic E, Zwimpfer T, Marti WR, Zwahlen M, Hoffmann H,
knee arthroplasty performed during ischemia. Clin Infect Dis Kindler C, Fux C, Misteli H, Iselin L, Lugli AK, Nebiker CA,
2008;46:100914 von Holzen U, Vinzens F, von Strauss M, Reck S, Kraljevi M,
65. Richardson JB, Roberts A, Robertson JF, John PJ, Sweeney G. Widmer AF, Oertli D, Rosenthal R, Weber WP. Evaluating the
Timing of antibiotic administration in knee replacement under optimal timing of surgical antimicrobial prophylaxis: study
tourniquet. J Bone Joint Surg Br 1993;75:325 protocol for a randomized controlled trial. Trials 2014;15:188

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