Infectious Disease
Updates to pre/post-operative antibiotic guidelines and associated order sets
Dear Colleagues, The Antimicrobial Stewardship Subgroup, the Infectious Diseases CDT, and the Perioperative CPG have updated surgical antimicrobial prophylaxis guidelines for Providence St. Joseph Health. These guidelines were developed by merging existing guidelines across our system and are consistent with published national guidelines. The full guidelines are visible within the surgery navigator of Epic. Because of variations in resistance patterns across our system, some surgeries have more than one acceptable regimen listed. In these cases, providers should consult with their local antimicrobial stewardship team and decide on the appropriate regimen. Order sets have been updated to reflect these updated guidelines, and clinical decision support tools have been added. Please see the attached list of the affected order sets. A few order sets were not updated due to a lack of updated system guidelines for those procedure types. These order sets will be updated at a later time. While this general workflow is unchanged for Providence providers, this is a change for Swedish providers. Swedish providers will be expected to use the correct order set and enter antibiotic choices based on the embedded clinical decision support tools. If there are questions, comments, or concerns, please contact Dr. Diaz at [email protected]. Sincerely,
Philip Robinson, M.D., FIDSA
Providence St. Joseph Health Infectious
Disease Clinical Decision Team Co-Chair
Hoag Medical Director of Infection
Prevention and Hospital Epidemiology
Hoag Memorial Hospital Presbyterian
John Pauk, M.D., MPH Medical Director, Infection Prevention,
Antimicrobial Stewardship, and Infectious
Disease
Swedish Medical Center
George Diaz, M.D. Infectious Diseases Hospitalist Medical Director Antimicrobial Stewardship Providence Regional Medical Center Everett System Provider Informaticist Providence St. Joseph Health
Ellen Derrick, M.D., MPH, FACS, FSVS
Providence St. Joseph Health Perioperative Clinical Decision Team Co-
Chair
Lead Surgical Provider Informaticist, Providence St. Joseph Health
Vascular Surgery, BoxBar Vascular
Providence St. Joseph Health Recommendations for Surgical Antimicrobial Prophylaxis in Adults
Joint Project of ID CDT and AMS Action Community
February 2019
Medication Weight Range (kg) Dosage Re-dosing
interval Guidelines
(hrs)
Maximum dose/day Maximum Re-dosing per case (for BPA purposes) Rule of thumb. Not to exceed 75% of the Max dose in 24hours within a
12hour dosing interval from 1st dose
Cefazolin <120 2 gm 4 12g 2 (6g in 8 hours)
≥120 3 gm 4 12g 2 (9g in 8hours)
Clindamycin All 600 mg 8 1
Metronidazole All 500 mg N.A N.A N.A
Vancomycin
<80 1 gm N.A N.A N.A
80-120 1.5 gm N.A N.A N.A
≥120 2 gm N.A N.A N.A
Levofloxacin All 500 mg N.A N.A N.A
Gentamicin 5 mg/kg C-section – 1.5 mg/kg
N.A N.A N.A
Aztreonam All 2 g 4 8g 1
Ampicillin-sulbactam All 3 g 2 12g 2 (9g in 4hours)
Piperacillin-tazobactam All 3.375 g 2 18g 3 (13.5g in 6 hours)
Cefuroxime All 1.5 g 4 9g 3 (6g in 12hours)
Ceftriaxone All 2 g N.A N.A N.A
Fluconazole All 200mg-400mg N.A. 400mg N.A
NOTE: Regimens may specify options as “or” (e.g. Metronidazole + Select one: Levofloxacin Or Vancomycin and Gentamicin). Consultation with
Antimicrobial Stewardship Pharmacist or an ID Provider is strongly encouraged if clinical uncertainty exists.
Procedure Recommended agents (No anaphylaxis
MRSA NEGative)
Severe allergy to β-lactam (anaphylaxis,
angioedema, Stevens-Johnson syndrome)
No Anaphylaxis MRSA POSitive
HxMRSA
Severe allergy to β-lactam (anaphylaxis, angioedema,
Stevens-Johnson syndrome) and MRSA POSitive
HxMRSA
Cardiac Coronary artery bypass
Valve replacement
Cefazolin Vancomycin (unchecked)
Vancomycin + Select one: Gentamicin or Levofloxacin
Cefazolin + Vancomycin Vancomycin+ Select one: Gentamicin or Levofloxacin
Cardiac device insertion procedure (e.g., pacemaker implantation)
TAVR
Cefazolin Vancomycin Vancomycin Vancomycin
Procedure Recommended agents (No anaphylaxis
MRSA NEGative)
Severe allergy to β-lactam (anaphylaxis,
angioedema, Stevens-Johnson syndrome)
No Anaphylaxis MRSA POSitive
HxMRSA
Severe allergy to β-lactam (anaphylaxis, angioedema,
Stevens-Johnson syndrome) and MRSA POSitive
HxMRSA
Ventricular assist devices Cefazolin or cefepime Add fluconazole for concern of post-operative fungal infection Vancomycin (unchecked)
Vancomycin + Levofloxacin Add fluconazole for concern of post-operative fungal infection
Vancomycin + Cefazolin or cefepime Add fluconazole for concern of post-operative fungal infection
Vancomycin + Levofloxacin Add fluconazole for concern of post-operative fungal infection
Thoracic Non-cardiac procedures, including thoracotomy and Video-assisted thoracoscopic surgery (VATS)
Cefazolin Vancomycin
Vancomycin Cefazolin unchecked
Vancomycin
Lobectomy/pneumonectomy/ lung resection, lung biopsies
Cefazolin Vancomycin+ Levofloxacin
Vancomycin+ Cefazolin
Vancomycin+ Levofloxacin
Gastroduodenal (consolidate procedures)
Procedures involving entry into lumen of gastrointestinal tract (ex: bariatric)
Cefazolin
Vancomycin + Select one: Gentamicin or Levofloxacin
Cefazolin + Vancomycin Vancomycin + Select one: Gentamicin or Levofloxacin
Procedures without entry into gastrointestinal tract (antireflux, highly selective vagotomy) for high-risk patients
Cefazolin Vancomycin + Select one: Gentamicin or Levofloxacin
Cefazolin + Vancomycin Vancomycin + Select one: Gentamicin or Levofloxacin
Biliary tract Open procedures Metronidazole + Select one: Cefazolin or Ceftriaxone
Metronidazole + Select one: Levofloxacin Or Vancomycin and Gentamicin
Metronidazole + Vancomycin + Select one: Cefazolin or Ceftriaxone
Vancomycin +Metronidazole+ Select one: Gentamicin or Levofloxacin
Laparoscopic procedures (elective, low-risk)
None None None None
Laparoscopic procedures (elective, high risk), including IR gastrointestinal procedures.
Metronidazole + Select one: Cefazolin or Ceftriaxone
Metronidazole + Select one: Levofloxacin Or Vancomycin and Gentamicin
Metronidazole + Vancomycin + Select one: Cefazolin or Ceftriaxone
Vancomycin +Metronidazole+ Select one: Gentamicin or Levofloxacin
Appendectomy For uncomplicated appendicitis Metronidazole + Select one: Cefazolin or Ceftriaxone
Metronidazole + Select one: Levofloxacin
Metronidazole + Vancomycin + Select one:
Vancomycin +Metronidazole+ Select one: Gentamicin or Levofloxacin
Procedure Recommended agents (No anaphylaxis
MRSA NEGative)
Severe allergy to β-lactam (anaphylaxis,
angioedema, Stevens-Johnson syndrome)
No Anaphylaxis MRSA POSitive
HxMRSA
Severe allergy to β-lactam (anaphylaxis, angioedema,
Stevens-Johnson syndrome) and MRSA POSitive
HxMRSA
Or Vancomycin and Gentamicin
Cefazolin or Ceftriaxone
Small intestine Nonobstructed and obstructed Includes pancreaticoduodenectomy
Metronidazole + Select one: Cefazolin or Ceftriaxone
Metronidazole + Select one: Levofloxacin Or Vancomycin and Gentamicin
Metronidazole + Vancomycin + Select one: Cefazolin or Ceftriaxone
Vancomycin +Metronidazole+ Select one: Gentamicin or Levofloxacin
Hernia repair Hernioplasty and herniorrhaphy Cefazolin Vancomycin Vancomycin Vancomycin
Colorectal-Anorectal
Metronidazole + Select one: Cefazolin or Ceftriaxone
Metronidazole + Select one: Levofloxacin Or Vancomycin and Gentamicin
Metronidazole + Vancomycin + Select one: Cefazolin or Ceftriaxone
Vancomycin +Metronidazole+ Select one: Gentamicin or Levofloxacin
Head and neck Clean None None None None
Clean with placement of prosthesis (excludes tympanostomy tubes)
Cefazolin Clindamycin Vancomycin Vancomycin
Clean-contaminated cancer surgery Select one: 1. Cefazolin +
metronidazole or 2. Amp/sulbactam
Precheck option #1
Clindamycin Vancomycin + Select one:
1. metronidazole 2. Amp/sulbactam
(pre-check metronidazole)
Vancomycin + metronidazole
Other clean-contaminated procedures with the exception of tonsillectomy and functional endoscopic sinus procedures
Select one: 1. Cefazolin +
metronidazole or 2. Amp/sulbactam
Precheck option #1
Clindamycin Vancomycin + Select one:
1. Metronidazole 2. Amp/sulbactam
(pre-check metronidazole)
Vancomycin + metronidazole
Neurosurgery Elective craniotomy and cerebrospinal fluid-shunting procedures
Cefazolin Vancomycin Cefazolin + vancomycin Vancomycin
Implantation of intrathecal pumps Cefazolin Vancomycin Cefazolin + vancomycin Vancomycin
Procedure Recommended agents (No anaphylaxis
MRSA NEGative)
Severe allergy to β-lactam (anaphylaxis,
angioedema, Stevens-Johnson syndrome)
No Anaphylaxis MRSA POSitive
HxMRSA
Severe allergy to β-lactam (anaphylaxis, angioedema,
Stevens-Johnson syndrome) and MRSA POSitive
HxMRSA
Cesarean delivery
Cefazolin Clindamycin + gentamicin
Cefazolin + vancomycin Gentamicin + clindamycin + vancomycin
Hysterectomy Vaginal or abdominal Cefazolin+
Gentamicin and clindamycin
Cefazolin + vancomycin Gentamicin + clindamycin + vancomycin
Orthopedic Clean operations involving hand, knee, or foot and not involving implantation of foreign materials
None None None None
Spinal procedures with and without instrumentation
Cefazolin Vancomycin Vancomycin + Cefazolin Vancomycin
Hip fracture repair Cefazolin Vancomycin Vancomycin + Cefazolin Vancomycin
Implantation of internal fixation devices (e.g., nails, screws, plates, wires)
Cefazolin Vancomycin Vancomycin + Cefazolin Vancomycin
Total joint replacement Cefazolin Vancomycin Vancomycin + Cefazolin Vancomycin
Urologic Lower tract instrumentation with risk factors for infection (includes transrectal prostate biopsy)
Ceftriaxone Select one: Levofloxacin or gentamicin
Ceftriaxone + Vancomycin Vancomycin+ Select one: Levofloxacin or gentamicin
Involving implanted prosthesis Cefazolin + gentamicin Vancomycin + Select one: gentamicin or levofloxacin
Cefazolin + Vancomycin+ Select one: gentamicin or levofloxacin
Vancomycin + Select one: gentamicin or levofloxacin
Clean with or without entry into urinary tract, including IR procedures involving the urinary track (percutaneous nephrostomy tubes)
Cefazolin Vancomycin + Select one: gentamicin or levofloxacin
Cefazolin + Vancomycin+ Select one: gentamicin or levofloxacin
Vancomycin + Select one: gentamicin or levofloxacin
Clean-contaminated Metronidazole+ Select one: Cefazolin or Ceftriaxone
Metronidazole + Select one: 1. Levofloxacin Or 2. Vancomycin+
Gentamicin
Metronidazole+ Vancomycin+ Select one: Cefazolin or Ceftriaxone
Vancomycin + Metronidazole+ Select one: Levofloxacin Or Gentamicin
Vascular
Vascular Implants, including IR procedures requiring skin prophylaxis.
Cefazolin Vancomycin Vancomycin Vancomycin
Open vascular, groin procedures Cefazolin Vancomycin + Levofloxacin Vancomycin + Cefazolin Vancomycin + Levofloxacin
Transplant Heart transplantation Vancomycin + Cefazolin or cefepime
Vancomycin + Levofloxacin Vancomycin + Cefazolin or cefepime
Vancomycin + Levofloxacin
Procedure Recommended agents (No anaphylaxis
MRSA NEGative)
Severe allergy to β-lactam (anaphylaxis,
angioedema, Stevens-Johnson syndrome)
No Anaphylaxis MRSA POSitive
HxMRSA
Severe allergy to β-lactam (anaphylaxis, angioedema,
Stevens-Johnson syndrome) and MRSA POSitive
HxMRSA
Add fluconazole for concern of post-operative fungal infection
Add fluconazole for concern of post-operative fungal infection
Add fluconazole for concern of post-operative fungal infection
Add fluconazole for concern of post-operative fungal infection
Liver transplant Piperacillin-tazobactam Vancomycin + aztreonam Piperacillin-tazobactam + Vancomycin
Aztreonam + Vancomycin
Kidney, pancreas or kidney-pancreas transplant
Cefazolin Add fluconazole for patients with pancreas or kidney-pancreas procedures at high risk for fungal infection (eg. Those with enteric drainage of the pancreas)
Levofloxacin Add fluconazole for patients with pancreas or kidney-pancreas procedures at high risk for fungal infection (eg. Those with enteric drainage of the pancreas)
Cefazolin + Vancomycin Add fluconazole for patients with pancreas or kidney-pancreas procedures at high risk for fungal infection (eg. Those with enteric drainage of the pancreas)
Levofloxacin + Vancomycin Add fluconazole for patients with pancreas or kidney-pancreas procedures at high risk for fungal infection (eg. Those with enteric drainage of the pancreas)
Kidney donor Cefazolin Vancomycin Vancomycin Vancomycin
Plastic surgery Clean with risk factors or clean-contaminated
Cefazolin Vancomycin Vancomycin Vancomycin
Reference:
Bratzler, et al. (2013). ASHP report: Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health-Syst Pharm 70, 195-283.
ID# ORDERSET NAME
GENERAL SURGERY
2874 GENERAL SURGERY POSTOP
3041100001 SUR OUTPATIENT POST OP
1676 SURGERY PREOP
1679 LAPAROSCOPIC APPENDECTOMY POSTOP
1731 LIVER RESECTION POSTOP
1734 PANCREATIC RESECTION POSTOP
1723 HERNIA POSTOP
1677 LAPAROSCOPY POSTOP
1722 GALLBLADDER POSTOP
1681 LAPAROTOMY POSTOP
1704 ANTI REFLUX POSTOP
1750 BARIATRIC POSTOP
2483 BARIATRIC PREOP
1729 PARAESOPHAGEAL POSTOP
RAD IR
3040127301 RAD IR BILIARY CATHETER 1 PREPROCEDURE
30401269 RAD IR HEPATIC CHEMOEMBO 1 PREPROCEDURE
30401272 RAD IR HEPATIC Y-90 1 POSTPROCEDURE
30401271 RAD IR HEPATIC Y-90 1 PREPROCEDURE
30401267 RAD IR PERCUTANEOUS ABLATION 1 PREPROCEDURE
30401219 RAD IR PERIPHERAL THROMBOLYSIS TPA POSTPROCEDURE
3040126801 RAD IR VERTEBROPLASTY/KYPHOPLASTY 1 PREPROCEDURE
3040126601 RAD IR NEPHROSTOMY 1 PREPROCEDURE
3040126501 RAD IR TIPS 1 PREPROCEDURE
UROLOGY
2065 UROLOGY FEMALE POSTOP
2064 UROLOGY MALE POSTOP
2063 RADICAL PROSTATECTOMY POSTOP
2062 TURP-TURBT POSTOP
2067 UROLOGY PREOP
CARDIOLOGY
2760 CARDIAC DEVICE INSERTION PROCEDURE
1793 CARDIAC DEVICE PROCEDURE - POST
1812 CARDIAC DEVICE PROCEDURE - PRE
2855 HEART SURGERY POSTOP - ENTIRE POSTOP PERIOD
2854 HEART SURGERY PREOP
2851 MECHANICAL HEART IMPLANT POSTOP - ENTIRE POSTOP PERIOD
2850 MECHANICAL HEART IMPLANT PREOP
2761 TF TAVR/TMVR POSTOP
OB/GYN
4561 OB CESAREAN - PREOP SCHEDULED
1786 GYN PREOP
4569 OB CESAREAN - PREOP UNSCHEDULED
COLORECTAL
1710 ANORECTAL POSTOP
91 COLORECTAL SURGERY POSTOP (ERP)
288 COLORECTAL SURGERY PREOP (ERAS)
HEAD AND NECK
1778 EAR POSTOP
224 ENDOSCOPIC TRANSSPHENOIDAL/SKULL BASE POSTOP
1765 ENT PREOP
1768 MAJOR HEAD & NECK SURGERY POSTOP
1784 NASAL / SINUS / RHINOPLASTY POSTOP
1706 NECK POSTOP
1769 TONSIL / ADENOID / UPPP POSTOP
NEUROSURGERY
227 CRANIAL POSTOP
1864 LUMBAR DRAIN POSTOP - NEUROSURGERY
1850 NEUROSURGERY PREOP
ORTHOPEDIC
1860 CERVICAL SPINE POSTOP - NEUROSURGERY
1899 CERVICAL SPINE POSTOP - ORTHO
1880 GERIATRIC FRACTURE POSTOP
89 GERIATRIC FRACTURE PREOP
1878 HIP, FEMUR, PELVIS POSTOP
1882 Knee and leg postop
1876 ORTHO PREOP
1852 SPINE POSTOP - NEUROSURGERY
1862 THORACIC LUMBAR SPINE POSTOP - NEUROSURGERY
1901 THORACIC LUMBAR SPINE POSTOP - ORTHO
1892 TOTAL HIP ARTHROPLASTY POSTOP
1895 TOTAL KNEE ARTHROPLASTY POSTOP
1890 TOTAL SHOULDER ARTHROPLASTY POSTOP
1872 WRIST, HAND, ELBOW POSTOP
PLASTIC SURGERY
1737 BREAST CONSERVATION POSTOP
1875 LOWER EXTREMITY TRAUMA POSTOP
1738 MASTECTOMY POSTOP
1741 MASTECTOMY W/ RECONSTRUCTION POSTOP
THORACIC
539 CTS IP THORACIC PREOP
3048000261 CTS IP THORACOTOMY POST OP
3048000251 CTS IP VATS POST OP
TRANSPLANT
2732 HEART TRANSPLANT POSTOP - ENTIRE POSTOP PERIOD
2783 HEART TRANSPLANT PREOP
2743 KIDNEY TRANSPLANT POSTOP - RECIPIENT
2741 KIDNEY TRANSPLANT PREOP - DONOR
2748 KIDNEY TRANSPLANT PREOP - RECIPIENT
199 PANCREAS KIDNEY TRANSLANT POSTOP
197 PANCREAS KIDNEY TRANSPLANT PREOP
VASCULAR
1797 CAROTID ENDARTERECTOMY POSTOP
1804 ENDOVASCULAR ABDOMINAL AORTIC ANEURYSM POSTOP
1805 INFRAINGUINAL BYPASS POSTOP
304110006 VAS IP VASCULAR ABDOMINAL ADMISSION
1824 VASCULAR ABDOMINAL PREOP
1827 VASCULAR CAROTID ENDARTERECTOMY PREOP
1829 VASCULAR DIALYSIS ACCESS PREOP
1834 VASCULAR EVAR PREOP
1831 VASCULAR PERIPHERAL VASCULAR PREOP
Pre-Op Prophylaxis
Coming April 7, 2019
Pre-Op Order Sets Revised with Guides for Surgery CategoriesThe updated order sets will be divided into sections with appropriate
medications for those surgeries.
Clearer path to right med