Dr. R. Sherkat

Isfahan University of Medical Sciences

Perioperative Antimicrobial Prophylaxis

Surgical wound infections Surgical wound infections are the second most common healthcare-associated

infection

Although usually localized to the incision site, surgical wound infections can also extend into adjacent deeper structures; thus, the term surgical wound infection has now been replaced with the more suitable name, surgical site infection (SSI)

CDC has developed criteria for defining SSIs, which have become the national standard and are widely used by surveillance and surgical personnel

These criteria define SSIs as: Infections related to the operative procedure that occur at or near the surgical

incision (incisional or organ/space) within 30 days of an operative procedure or within one year if an implant is left in place

Among surgical patients, SSIs are the most common nosocomial infection, accounting for 38 percent of nosocomial infections

It is estimated that SSIs develop in 2 to 5 percent of the more than 30 million patients undergoing surgical procedures each year (ie, one out of every 24 patients who have inpatient surgery in the United States has a postoperative SSI)

The cost of SSIs is substantial

DETERMINANTS AND PATHOPHYSIOLOGY

Whether a wound infection occurs after surgery depends on a complex interaction between the following:

(I) Patient-related factors (e.g., host immunity, nutritional status, the presence or absence of diabetes)

(2) Procedure-related factors (e.g., implantation of foreign bodies, degree of trauma to the host tissues)

(3) Microbial factors (tissue adherence and invasion) (4) Perioperative antimicrobial prophylaxis

Sources of Wound Bacteria

Although numerous sources of bacterial contamination of surgical wounds have been described, it is virtually impossible to identify with

certainty the source(s) and route(s) of contamination

The direct inoculation of a patient's endogenous flora at the time of surgery is believed to be the most common mechanism; however, others undoubtedly occur

Transmission from contaminated surgical instruments or surgical material

Hematogenous seeding from preexisting infection of a nonwound site

Contamination from either the skin, mucous membranes, or clothing of operating room staff

A combination of them, have all been implicated as potential sources of microbial contamination

GENERAL PRINCIPLES in the prevention of SSIs

The most important factors are meticulous operative techniques and timely administration of effective preoperative antibiotics

A number of interventions have been used over the years to reduce the risk of SSIs, including :

Preoperative showering with antimicrobial soaps

Preoperative application of antiseptics to the skin of the patient

Washing and gloving of the surgeon's hands

Use of sterile drapes

Use of gowns and masks by operating room personnel

Most of these interventions were developed to reduce contact with flora from the hands, hair, scalp, nares, and oropharynx of hospital personnel, which were believed to be potential sources of microorganisms causing SSIs

ANTIMICROBIAL PROPHYLAXIS The goal of antimicrobial prophylaxis is to prevent SSI by reducing the burden

of microorganisms at the surgical site during the operative procedure

The efficacy of antibiotic prophylaxis for reducing surgical SSI has been clearly established

Preoperative antibiotics are warranted: if there is a high risk of infection or if there is high risk of deleterious outcomes should infection develop at the

surgical site (such in the setting of immune compromise, cardiac surgery, and/or

implantation of a foreign device)

Patients who receive prophylactic antibiotics within one to two hours before the initial incision have lower rates of SSI than patients who receive antibiotics sooner or later than this window

Antimicrobial therapy administered in the setting of contaminated wounds is not considered prophylactic; in such cases a therapeutic course of antimicrobial therapy is warranted

Errors in selection or dose of prophylactic antimicrobials are common

Timing of prophylaxis 

Antimicrobial therapy should be administered within 60 minutes prior to the surgery to ensure adequate drug tissue levels at the time of initial incision (or within 120 minutes if vancomycin or a fluoroquinolone is used)

This practice also reduces the likelihood of antibiotic-associated reactions at the time of induction of anesthesia

If the 60 minute window for prophylaxis has past, administration of antimicrobial therapy 30 to 60 minutes prior to surgery appears to be more effective than administration immediately before surgery

Repeat dosing For procedures lasting less than four hours, a single repeat dose of

intravenous antimicrobials is appropriate

Repeat dosing is indicated every one to two half-lives of the drug in patients with normal renal function

for procedures lasting more than four hours or in the setting of major blood loss

Cefazolin every two to five hours, cefoxitin every two to three hours, cefuroxime every three to four hours,ampicillin/sulbactam every two to four hours, vancomycin every 6 to 12 hours, clindamycin every three to six hours, and metronidazole every six to eight hours

Antibiotic concentration >MIC pathogen at the time of incision and throughout the procedure

In general, repeat antimicrobial dosing following wound closure is not necessary and may increase antimicrobial resistance

In a systematic review of randomized trials, there was no difference in the rate of SSI with single dose compared with multiple dose regimens given for less than or more than 24 hours (combined odds ratio 1.04, 95% CI 0.86-1.25)

Antibiotic selection Guidelines established by the Medical Letter and the Surgical Care Improvement Project :

Cefazolin (1 to 2 g IV) is a first generation cephalosporin active against streptococci and methicillin susceptible staphylococci; it is generally appropriate for clean procedures

Cefuroxime (1.5 g IV) is a second generation cephalosporin with broader coverage against gram-negative organisms; it may be administered in place of cefazolin for thoracic (cardiac and noncardiac) and orthopedic procedures

For procedures that may involve exposure to bowel anaerobes (including Bacteroides fragilis), cefoxitin (1 to 2 g IV) or cefotetan (second generation cephalosporins) have broader coverage including anaerobic activity than the above agents

However, some gram-negative bacilli such as E. coli have become resistant to cefoxitin; in such circumstances reasonable alternatives include cefazolin plus metronidazole (500 mg IV) or monotherapy with ampicillin-sulbactam (3 g IV)

Patients with history of allergy to penicillin manifesting as an uncomplicated or minor skin rash may be treated with cephalosporins; allergic cross-reactions to cephalosporins are infrequent except in patients with severe IgE-mediated reactions to penicillin

If an IgE-mediated reaction against penicillin has occurred in the past, cephalosporins should be avoided

Alternatives to cephalosporins include intravenous vancomycin (15 to 20 mg/kg) or clindamycin (600 to 900 mg) PLUS an agent with activity against gram-negative bacteria such as gentamicin, ciprofloxacin, levofloxacin, or aztreonam 

This is particularly important in patients undergoing colorectal or vascular surgery involving a groin incision

Local resistance patterns should be considered

Role of vancomycin Vancomycin is preferable to cephalosporins in locations where:

Methicillin-resistant Staphylococcus aureus or methicillin-resistant coagulase-negative staphylococci are a frequent cause of surgical site infections

In patients who are known to be colonized with methicillin-resistant S. aureus preoperatively

in patients undergoing cardiac, vascular, and orthopedic procedures and/or implantation of prosthetic material who also have risk factors for postoperative MRSA infection (such as recent hospitalization, renal disease, or diabetes)

A beta-lactam antibiotic (cefazolin or cefuroxime) should be added for activity against gram-negative organisms

Alternatives for patients allergic to cephalosporins include:  gentamicin, ciprofloxacin, levofloxacin, or aztreonam 

Thus far the literature does not support benefit of vancomycin over cefazolin, cefuroxime, or ceftizoxime for prevention of SSI

even though guidelines issued by the Surgical Care Improvement Project state that vancomycin is an acceptable antibiotic for the circumstances outlined above

In fact, a study of preoperative testing for nasal colonization with methicillin-resistant or methicillin-susceptible S. aureus (MRSA) concluded that preoperative prophylaxis with vancomycin was associated with an increased risk (RR 4.34 95% CI 2.19-8.57) of postoperative SSI in patients who had negative nasal testing for MRSA but not in those who had positive nasal tests for MRSA

Cardiac surgery Cardiac surgery (eg, coronary artery bypass, heart valve replacement) is primarily a clean surgery with the majority of

patients having a low preoperative risk of infection

Despite their infrequency, deep organ/space SSIs (eg, mediastinitis and prosthetic valve endocarditis) are catastrophic complications associated with substantial morbidity and mortality

S. aureus and coagulase-negative staphylococci are the predominant pathogens responsible for SSIs in cardiac surgery

When gram-negative bacilli (eg, Escherichia coli, Klebsiella spp, Enterobacter spp, Proteus spp, and Pseudomonas spp) are responsible for SSIs, contamination of the chest usually occurs during the saphenous vein harvesting

A meta-analysis of 28 studies concluded that antimicrobial prophylaxis is beneficial in cardiothoracic surgery

Several early studies describing failures of first generation cephalosporins in preventing SSIs due to methicillin-sensitive S. aureus  led to the adoption of second generation cephalosporins (such as cefuroxime) as the preferred antimicrobial prophylaxis in many centers

However, subsequent clinical trials showed equivalent  or even lower rates of S. aureus SSIs  with cefazolin compared with cefuroxime

Cefazolin is our prophylactic agent of choice as it is in the Medical Letter and Surgical Care Improvement Project Because of :

its greater intrinsic activity against staphylococci narrower side effect profile antimicrobial spectrum much lower cost

The drugs are given intravenously within 60 minutes before the first incision

 Vancomycin and clindamycin are alternatives if allergy limits the use of a cephalosporin

The use of gentamicin-collagen sponges does not appear to reduce the 90-day sternal wound infection rate among patients with diabetes and/or high body mass index

Intravascular device placement

Although not well studied, antimicrobial prophylaxis is generally used before placement of permanent pacemakers, electrophysiologic devices, ventricular assist devices, ventriculoatrial shunts, and arterial patches

The dosing regimens are similar to those used for cardiac surgery 

Antimicrobial prophylaxis for placement of a new pacemaker or replacement of a pulse generator :

At the time of device implantation or generator exchange, we recommend prophylaxis with antistaphylococcal antimicrobial drugs  (Grade 1A).

With regard to routine endocarditis prophylaxis (eg, for dental work), patients with a cardiac pacemaker or an ICD are considered to be at low risk for endocarditis

For these patients, we suggest that routine antibiotic prophylaxis for endocarditis not be given (Grade 2C).

Vascular surgery  Preoperative antimicrobial prophylaxis reduces the

incidence of postoperative SSI in patients undergoing reconstructive surgery on the abdominal aorta, arterial surgery on the leg involving a groin incision, and amputation of the lower extremity due to critical limb ischemia

Many also recommend prophylaxis for arterial surgery involving implantation of prosthetic material, such as grafts for vascular access for hemodialysis

The recommended drugs in patients undergoing vascular (arterial) surgery are cefazolin or cefuroxime and, for patients with beta-lactam allergy, vancomycin

Noncardiac thoracic surgery Antimicrobial prophylaxis is given routinely in thoracic surgery

Cefazolin therapy was associated with a significant reduction in wound infection (1.5 versus 14 percent) but not in empyema or pneumonia

The recommended antibiotics are cefazolin (1 to 2 g IV), cefuroxime (1.5 g IV), or, in selected patients, vancomycin (1 g [10 to 15 mg/kg] IV) (table 4)

As mentioned above, the indications for vancomycin are: previous colonization with MRSA hospitals in which MRSA and/or coagulase-negative staphylococci are a common cause of postoperative infection allergy to penicillins or cephalosporins

Clindamycin is an alternative to vancomycin in patients with beta-lactam allergy

We recommend administering prophylactic antibiotics prior to chest tube placement in patients with penetrating thoracic injury over no prophylaxis (Grade 1B)

Patients with penetrating trauma have significantly decreased rates of empyema and pneumonia when given antibiotics prior to chest tube placement, as compared with placebo

No consistent reduction in infectious complications has been found in patients with blunt thoracic injury or nontraumatic indications for tube thoracostomy; thus, prophylactic antibiotic treatment in these populations is not necessary

The optimal duration of antibiotic therapy is uncertain; a single dose may be administered, or in

cases of penetrating injury, antibiotic therapy may be continued for up to 24 hours

Gastrointestinal surgery , Gastrointestinal procedures

Gastrointestinal procedures are among the highest risk procedures for SSI due to the presence of intraluminal bacteria

Antimicrobial prophylaxis is warranted for patients undergoing gastrointestinal surgery involving the colon or rectum

The regimen should include activity against enteric gram-negative bacilli, anaerobes, and enterococci; there are several appropriate regimens (table 1).

Carbapenems should not be used for surgical prophylaxis

Widespread use of carbapenems may result in increased rates of resistance

This is especially important because carbapenems are the best available drugs for the treatment of serious infections caused by aerobic gram-negative organisms that are resistant to other widely-used antimicrobial drugs

In some circumstances antimicrobial prophylaxis is warranted for patients undergoing gastrointestinal surgery at sites other than the colon or rectum, including esophageal or duodenal surgery, biliary tract surgery, pancreatic surgery, appendectomy, and mesh inguinal hernioplasty

Bowel preparation consists of two components: mechanical bowel preparation and administration of antibiotics (ciprofloxacin plus metronidazole)

We suggest administration of both oral and intravenous antibiotics to decrease the risk of SSI following colorectal surgical procedures (Grade 2B).

1)Morbid obesity,esophageal obstruction,decreased gastric acidity or gastrointestinal motility2)Age>70,acute cholecystitis,nonfunctioning gall bladder,obstructive jaundice,or common duct stones

For ruptured viscus therapy is often continued for about five days

Orthopedic surgery Prophylaxis is warranted for: total hip or knee replacement other orthopedic procedures, such as surgical repair of hip and other closed fractures and internal fixation by nails,

plates, screws, or wires

No benefit from antibiotics for whom undergoing diagnostic and operative arthroscopic surgery

Prevention of prosthetic joint infection is important due to the difficulty in treating prosthetic joint infections

Preoperative antimicrobial prophylaxis is standard for all patients undergoing joint replacement

The recommended regimen is cefazolin (1 g if less than 80 kg and 2 g if more than 80 kg) or cefuroxime (1.5 g) given intravenously at the induction of anesthesia and repeated for two doses postoperatively at two to five and three to four hour intervals, respectively

Patients with type I allergy to beta-lactams should receive vancomycin (1 g [10 to 15 mg/kg] IV and repeated once postoperatively at twelve hours

Vancomycin is also commonly used in patients at high risk for MRSA or in institutions in which there is a "high rate of MRSA infection" even though current guidelines do not define minimum criteria for "high rates

We suggest NOT administering antibiotic prophylaxis prior to dental procedures for immunocompetent patients with history of prosthetic joint implantation more than two years previously (Grade 2C).

Antibiotic prophylaxis prior to dental procedures with increased risk for bacteremia may be appropriate for patients with:

history of prosthetic joints implantation who are immunocompromised or underwent joint replacement within the last two years

There is no evidence to suggest that patients with prosthetic joints undergoing procedures (eg, dental, urologic) should receive antibiotic prophylaxis to prevent a subsequent infection of the prosthesis

Gynecologic or obstetric surgery The goal of antimicrobial prophylaxis is to eradicate or retard the growth of endogenous microorganisms

that may cause surgical site infection

Antibiotics should be used when there is an elevated probability of microbial contamination during gynecologic surgery (eg, surgical transection of the vagina) and the incidence of postoperative infection is high

The antibiotic chosen for prophylaxis should be effective against bacteria found in most gynecological infections, but not an agent used routinely for

treatment of serious infectious complications of low toxicity and able to achieve appropriate tissue levels in the surgical field

Prophylaxis is warranted for hysterectomy, surgical abortion, cesarean delivery, and certain other procedures

The 2009 American College of Obstetricians and Gynecologists (ACOG) recommends antibiotic prophylaxis prior to the following gynecologic operations or procedures :

Hysterectomy Randomized trials have demonstrated the efficacy of antibiotic prophylaxis for vaginal hysterectomy There is a smaller, but significant, reduction in infectious complications for abdominal hysterectomy The use of antibiotics before laparoscopically assisted hysterectomy seems appropriate since the vagina is

entered, but this has not been evaluated in randomized trials

Urogynecology procedures, including those involving mesh

Hysterosalpingogram or chromopertubation (only if the patient has a history of pelvic inflammatory disease or the procedure demonstrates dilated fallopian tubes)

Surgical abortion

Antibiotic prophylaxis in gynaecologic procedures

All women undergoing an abdominal or vaginal hysterectomy should receive antibiotic prophylaxis. (I-A)

All women undergoing laparoscopic hysterectomy or laparoscopically assisted vaginal hysterectomy should receive prophylactic antibiotics. (III-B)

The choice of antibiotic for hysterectomy should be a single dose of a first-generation cephalosporin

If patients are allergic to cephalosporin, then clindamycin, erythromycin, or metronidazole should be used. (I-A)

Prophylactic antibiotics should be administered 15 to 60 minutes prior to skin incision

No additional doses are recommended. (I-A)

If an open abdominal procedure is lengthy (e.g., > 3 hours), or if the estimated blood loss is > 1500 mL, an additional dose of the prophylactic antibiotic may be given 3 to 4 hours after the initial dose. (III-C)

Antibiotic prophylaxis is not recommended for laparoscopic procedures that involve no direct access from the abdominal cavity to the uterine cavity or vagina. (l-E)

All women undergoing surgery for pelvic organ prolapse and/or stress urinary incontinence should receive a single dose of first-generation cephalosporin. (III-B)

Antibiotic prophylaxis in gynaecologic procedures

Antibiotic prophylaxis is not recommended for hysteroscopic surgery. (II-2D)

All women undergoing an induced (therapeutic) surgical abortion should receive prophylactic antibiotics to reduce the risk of post-abortal infection. (I-A)

Prophylactic antibiotics are not suggested to reduce infectious morbidity following surgery for a missed or incomplete abortion. (I-E)

Antibiotic prophylaxis is not recommended for insertion of an intrauterine device. (I-E) However, health care professionals could consider screening for sexually transmitted infections in high-risk populations. (III-C)

There is insufficient evidence to support the use of antibiotic prophylaxis for an endometrial biopsy. (III-L)

The best method to prevent infection after hysterosalpingography is unknown Women with dilated tubes found at the time of hysterosalpingography are at highest risk, and

prophylactic antibiotics (e.g., doxycycline) should be given. (II-3B)

Antibiotic prophylaxis is not recommended for urodynamic studies in women at low risk, unless the incidence of urinary tract infection post-urodynamics is > 10%. (1-E)

In patients with morbid obesity (BMI > 35 kg/m²), doubling the antibiotic dose may be considered.

(III-B)

Administration of antibiotics solely to prevent endocarditis is not recommended for patients who undergo a genitourinary procedure. (III-E).

Gynecologic or obstetric surgery

Patients who receive prophylactic antibiotics within a two hour "window" period before the initial incision have lower rates of surgical site infection than patients who receive them either too early or postoperatively (table 7)

Cephalosporins (eg, cefazolin 1 or 2 g, cefoxitin 1 to 2 g, cefotetan 1 to 2 g) are the drugs of choice for prophylaxis in hysterectomy or urogynecologic procedures because of their low incidence of allergy and side effects, broad antibacterial spectrum, long half-life, and low cost

They are usually given as a single intravenous dose 30 minutes prior to the incision and should be repeated to maintain tissue levels if the procedure extends beyond four hours or if blood loss is greater than 1500 mL.

Regimens that continue prophylaxis postoperatively do not confer any additional benefit and are not recommended

Ampicillin-sulbactam is an option in women who also require endocarditis prophylaxis  (table 8)

In patients with a well-documented beta-lactam allergy, options include : Clindamycin (600 to 900 mg) plus gentamicin (1.5 mg/kg) Clindamycin (600 to 900 mg) plus a fluoroquinolone (eg, ciprofloxacin 400 mg or levofloxacin 750

mg or moxifloxacin 400 mg) Clindamycin (600 to 900 mg) plus aztreonam (1 to 2 g) Metronidazole (0.5 to 1 g) plus gentamicin or a fluoroquinolone

Clindamycin or metronidazole monotherapy are no longer recommended for perioperative antibiotic prophylaxis by the Centers for Medicare & Medicaid Services in collaboration with the CDC or by ACOG 

Genitourinary surgery Antimicrobial prophylaxis is warranted before urologic procedures when: the urine culture is positive or not obtained or a urinary catheter is in place

Such patients should be treated to sterilize the urine before surgery or should receive a single preoperative dose of a drug active against the most likely pathogen

Antimicrobial prophylaxis also decreases the incidence of postoperative bacteriuria and sepsis in patients with sterile urine undergoing:

transurethral prostatectomy before transrectal prostatic biopsy implantation of a prosthesis, such as penile implant or artificial sphincter

Prophylaxis significantly reduced the rates of both postoperative bacteriuria (9 versus 26 percent) and clinical septicemia (0.7 versus 4.4 percent)

Effective antibiotics included quinolones, cephalosporins, trimethoprim-sulfamethoxazole, and aminoglycosides

The Medical Letter recommends ciprofloxacin (500 mg PO or 400 mg IV) or trimethoprim-sulfamethoxazole (1 DS tablet orally) in these settings (table 3)

No specific recommendations are given for prophylaxis prior to implantation of a penile prosthesis

One randomized controlled trial demonstrated that outcomes and antibiotic tissue concentrations in the corpora cavernosa were similar among patients receiving either ofloxacin or cefazolin/gentamicin prior to penile prosthesis implantation

In the absence of an indwelling catheter, antimicrobial therapy can be discontinued promptly following the procedure

When an indwelling catheter must remain in place following prostatic resection, some advocate continuing antimicrobial therapy until the catheter is removed

Finally, cefazolin (1 to 2 g IV) should be given prior to open or laparoscopic genitourinary procedures (including percutaneous renal surgery or procedures with entry into the urinary tract)

Neurosurgery Antimicrobial prophylaxis can reduce the incidence of infection, mostly due to

Staphylococcus aureus or S. epidermidis, after craniotomy and spinal surgery, including low-risk procedures

Efficacy in clean neurosurgical operations was illustrated in a trial in which 846 patients were randomly assigned to cefazolin and gentamicin or no therapy

The treated group had a significantly lower rate of wound infection (1.0 versus 3.6 percent).

All infections that occurred involved gram-positive organisms

Although no individual trial demonstrated a statistically significant benefit from prophylaxis in patients undergoing spinal surgery, a significant reduction in infection rate was noted in the pooled analysis (2.2 versus 5.9 percent, pooled odds ratio 0.37, 95% CI 0.17-0.78).

The recommended antibiotics are cefazolin (1 to 2 g IV) or, in selected patients, vancomycin (1 g IV) (table 4) .

The indications for vancomycin are previous colonization with MRSA, hospitals in which MRSA and/or coagulase-negative staphylococci are a common cause of postoperative infection, and allergy to penicillins or cephalosporins. 

Clindamycin is an alternative to vancomycin in patients with beta-lactam allergy

Head and neck surgery 

The 2009 Medical Letter guidelines recommended antimicrobial prophylaxis for head and neck surgery involving an incision through the oral or pharyngeal mucosa

Areas of controversy The efficacy of antimicrobial prophylaxis is

controversial in breast surgery and other "clean" procedures

The 2009 Medical Letter guideline consultants do not recommend prophylaxis for such procedures due to:

the low rate of infection low morbidity if infection does occur the potential adverse effect of antimicrobial therapy

However, some experts recommend prophylaxis for breast or reconstructive procedures that involve placement of prosthetic material such as synthetic mesh or saline implants

antimicrobial prophylaxis for the prevention of infective endocarditis

Despite the devastating consequences of bacterial endocarditis, evidence to support antimicrobial prophylaxis as an effective preventative measure is weak and inconclusive

The 2007 AHA guideline for the prevention of infective endocarditis has narrowed the indications for bacterial endocarditis prophylaxis, compared with prior versions, in recognition of the absence of strong supportive evidence

Similar indications by the Working Party of the British Society for Antimicrobial Chemotherapy

Despite a lack of evidence supporting the necessity of antimicrobial prophylaxis for IE, it is reasonable to prescribe antimicrobial prophylaxis for patients with:

the highest risk medical conditions which undergoing procedures likely to result in bacteremia with a microorganism that has the potential

ability to cause bacterial endocarditis (Grade 2C).

Which patients — The following are the highest risk conditions: Prosthetic heart valves, including bioprosthetic and homograft valves A prior history of IE Unrepaired cyanotic congenital heart disease, including palliative shunts and conduits Completely repaired congenital heart defects with prosthetic material or device, whether placed by

surgery or by catheter intervention, during the first six months after the procedure Repaired congenital heart disease with residual defects at the site or adjacent to the site of the prosthetic

device Cardiac valvulopathy in a transplanted heart

The following are the highest risk procedures: All dental procedures that involve manipulation of either gingival tissue or the periapical region of teeth

or perforation of the oral mucosa Procedures of the respiratory tract that involve incision or biopsy of the respiratory mucosa Procedures in patients with ongoing GI or GU tract infection Procedures on infected skin, skin structure, or musculoskeletal tissue Surgery to place prosthetic heart valves or prosthetic intravascular or intracardiac materials

Which antibiotic 

The choice of antibiotic is patient and procedure specific

For patients undergoing a dental procedure, who will be the majority of individuals for whom prophylaxis is appropriate, the preferred regimen is oral amoxicillin two grams given 30 to 60 minutes before the procedure

Alternative regimens for patients with penicillin allergy or who are unable to take oral medication are shown above

Regimens for non-dental procedures are described in detail above

Patients with skin or musculoskeletal infections undergoing procedures should receive agents active against staphylococci and beta-hemolytic streptococci

In patients with GI or GU tract infection, antibiotic therapy to prevent associated wound infection or sepsis should include an agent active against enterococci 

antimicrobial prophylaxis for the prevention of infective endocarditis

American Heart Association guideline The 2009 European Society of Cardiology (ESC) guidelines are largely in agreement with the American

guidelines(2007-2008)

The recommendation for antimicrobial prophylaxis for dental and other procedures (and others) is now limited to those patients with cardiac conditions with the highest risk of adverse outcome from IE

The following points were made by the AHA in support of their recommendation for the important change

IE is much more likely to result from frequent exposure to random bacteremias associated with daily activities (eg, tooth brushing) than from bacteremia caused by a dental, gastrointestinal, or genitourinary procedure

Prophylaxis may prevent an exceedingly small number of cases of IE, if any, in individuals who undergo these procedures

The risk of antibiotic-associated adverse events exceeds the benefit, if any, from prophylactic antibiotic therapy

Maintenance of optimal oral health and hygiene may reduce the incidence of bacteremia from daily activities and is therefore more important than prophylactic antibiotics for a dental procedure to reduce the risk of IE

The guidelines are not intended to be the standard of care in all instances in which prophylactic antibiotic therapy might be considered

Clinicians can exercise their own judgment in selecting the dose and duration of antibiotic therapy in individual cases or in special circumstances

Among the selected patients for whom antimicrobial prophylaxis is suggested, the antimicrobial regimen recommended by the AHA guidelines varies with the procedure being performed (table 1) 

CHOICE OF ANTIMICROBIAL AGENT Dental, oral, or upper respiratory tract procedures — The primary antibiotic regimen for most patients, including

those with prosthetic valves, is amoxicillin, 2 g orally 30 to 60 minutes before the procedure; a second dose is not necessary

A different regimen is warranted in the following circumstances; all drugs are given 30 to 60 minutes before the procedure:

Patients who are allergic to penicillins or ampicillin can be treated with cephalexin (2 g) or azithromycin or clarithromycin (500 mg) or clindamycin (600 mg)

Patients who are unable to take oral medications can be treated with 2 g of intravenous or intramuscular ampicillin

Patients allergic to penicillin can be given cefazolin or ceftriaxone (1 g intravenously) OR 600 mg of intravenous or intramuscular clindamycin

Genitourinary or gastrointestinal procedures — For those high risk patients who undergo gastrointestinal or genitourinary procedures at a time of ongoing gastrointestinal or genitourinary infection, antibiotic coverage for enterococcal bacteremia should be provided with amoxicillin orampicillin or, in the patient unable to tolerate these drugs, vancomycin

Skin and musculoskeletal tissue — Although infection of the skin or musculoskeletal tissue is often polymicrobial, only staphylococcal or beta-hemolytic streptococcal bacteremia is likely to cause endocarditis in such circumstances

Thus, an antistaphylococcal penicillin or a cephalosporin is appropriate (table 1).

In patients undergoing procedures involving infected skin and musculoskeletal tissue (eg, incision and drainage of skin abscess), the treatment regimen should include drugs active against these organisms

 Clindamycin or vancomycin may be used when the patient is unable to take a beta-lactam or is known or suspected to have an infection caused by a methicillin-resistant staphylococcus

Pregnancy — Uncomplicated vaginal or cesarean delivery is not a routine indication for antibiotic prophylaxis although

prophylaxis may be considered in certain circumstances

If antibiotic prophylaxis is given to prevent enterococcal endocarditis, amoxicillin, ampicillin, and vancomycin are appropriate agents and they should be administered at the time of delivery

Children prophylaxis

Children given endocarditis prophylaxis should receive the same antibiotic regimens and dosing intervals as noted above

Equivalent pediatric doses for oral therapy are as follows: Amoxicillin — 50 mg/kg to a maximum dose of 2 g Azithromycin or clarithromycin — 15 mg/kg to a maximum dose

of 500 mg Clindamycin —20 mg/kg to a maximum dose of 600 mg Cephalexin — 50 mg/kg to a maximum dose of 2 g Equivalent pediatric doses for intramuscular or intravenous

therapy are as follows: Ampicillin — 50 mg/kg to a maximum dose of 2 g Cefazolin or ceftriaxone — 50 mg/kg to a maximum dose of 1 g Clindamycin — 20 mg/kg to a maximum dose of 600 mg

Vancomycin — 15 mg/kg to a maximum dose of 1 g

SPECIAL CIRCUMSTANCES  The following four situations require special attention:

Patients on antibiotics   If patients are receiving antibiotics for other indications at the time that dental or invasive

procedures are undertaken, an alternate antibiotic of a different class is often chosen As an example, if a patient receiving penicillin for rheumatic fever prophylaxis undergoes

an invasive dental procedure and requires IE prophylaxis, clindamycin, cephalexin, or azithromycin is often chosen.

Patients receiving anticoagulants    Intramuscular injections of antibiotics should be avoided in patients receiving

anticoagulation therapy Oral antibiotic regimens are preferred, and intravenous therapy should be used when oral

treatment is not possible

Surgery for placement of prosthetic valves or intracardiac/ intravascular materials

  Patients undergoing surgery for placement of prosthetic valves or intracardiac or intravascular materials are at risk for the development of bacterial endocarditis

In this setting the morbidity and mortality of infection is high and antimicrobial

prophylaxis directed against staphylococci is advisable

First generation cephalosporins are often used, but local hospital susceptibility patterns need to be taken into account, and if methicillin-resistant staphylococci are common or prevalent local pathogens, vancomycin should be substituted for cephalosporins

Recommendations for the prevention of perinatal group B streptococcal (GBS) disease

Since The CDC revised guidelines that recommended universal antenatal GBS screening the incidence of early-onset GBS disease in neonates has decreased by an estimated 80%

However, in 2010, GBS disease remained the leading cause of early-onset neonatal sepsis

The CDC issued revised guidelines in 2010 based on evaluation of data generated after 2002

These revised and comprehensive guidelines, which have been endorsed by the AAP, reaffirm the major prevention strategy

universal antenatal GBS screening and intrapartum antibiotic prophylaxis for culture positive and high-risk women

and include new recommendations for laboratory methods for identification of GBS colonization during pregnancy

algorithms for screening and intrapartum prophylaxis for women with preterm labor and premature rupture of membranes,

updated prophylaxis recommendations for women with a penicillin allergy, and a revised

algorithm for the care of newborn infants

The purpose of this policy statement is to review and discuss the differences between the 2002 and 2010 CDC guidelines that are most relevant for the practice of pediatrics

Algorithm for the prevention of early-onset GBS infection in the newborn

Committee on Infectious Diseases and Committee on Fetus and Newborn Pediatrics 2011;128:611-616

©2011 by American Academy of Pediatrics

Algorithm for the prevention of early-onset GBS infection in the newborn

Full diagnostic evaluation includes; a blood culture; CBC count, including white blood cell differential and platelet counts; chest radiograph (if respiratory abnormalities are present); and lumbar puncture (if the patient is stable enough to tolerate procedure and sepsis is suspected).

Antibiotic therapy should be directed toward the most common causes of neonatal sepsis, including intravenous ampicillin for GBS and coverage for other organisms (including Escherichia coli and other Gram-negative pathogens) and should take into account local antibiotic-resistance patterns.

Consultation with obstetric providers is important in determining the level of clinical suspicion for chorioamnionitis. Chorioamnionitis is diagnosed clinically, and some of the signs are nonspecific.

Limited evaluation includes blood culture (at birth) and CBC count with differential and platelets (at birth and/or at 6–12 hours of life).

GBS prophylaxis is indicated if 1 or more of the following is true: (1) mother is GBS-positive within the preceding 5 weeks (2) GBS status is unknown and there are 1 or more intrapartum risk factors, including <37 weeks' gestation, rupture of

membranes for ≥18 hours, or temperature of ≥100.4°F (38.0°C); (3) GBS bacteriuria during current pregnancy; or (4) history of a previous infant with GBS disease

If signs of sepsis develop, a full diagnostic evaluation should be performed, and antibiotic therapy should be initiated.

If at ≥37 weeks' gestation, observation may occur at home after 24 hours if other discharge criteria have been met, there is ready access to medical care, and a person who is able to comply fully with instructions for home observation will be present

If any of these conditions is not met, the infant should be observed in the hospital for at least 48 hours and until discharge criteria have been achieved.

Some experts recommend a CBC count with differential and platelets at 6 to 12 hours of age.

CDC, 2010. MMWR Recomm Rep. 2010;59[RR-10]:1–32.)

INTRAPARTUM ANTIBIOTIC PROPHYLAXIS Penicillin remains the agent of choice for IAP, and ampicillin is an

acceptable alternative (AI)

Penicillin-allergic women who do not have a history of anaphylaxis, angioedema, respiratory distress, or urticaria after administration of penicillin or a cephalosporin should receive cefazolin (BII)

Penicillin-allergic women at high risk of anaphylaxis should receive

clindamycin if their GBS isolate is susceptible or vancomycin if their GBS isolate is intrinsically resistant to clindamycin (CIII)

The definition of adequate IAP has been clarified to be at least 4

hours of penicillin, ampicillin, or cefazolin.(before delivery)

The initial intravenous dose of penicillin is 5 million units; for ampicillin and cefazolin, the initial dose is 2 g (AIII)

All other antibiotics, doses, or durations are considered inadequate

for the purposes of neonatal management (AIII).

LABORATORY DIAGNOSIS OF GBS COLONIZATION

Recommendations Options for GBS identification from culture of

maternal vaginal/rectal swabs have been expanded to include a positive identification from chromogenic agar media.

Identification of GBS directly by nucleic acid amplification tests (NAATs), such as commercially available polymerase chain reaction assays, can also be used after broth enrichment if laboratories have validated their NAAT performance and instituted appropriate quality controls (CII).

Novel Methods of Antibiotic Prophylaxis Newer methods for delivery of antimicrobial prophylaxis have expanded the available armamentarium for the prevention

of SSls.

First introduced in 1939,132 antibiotic-impregnated cement placed directly into the operative wound (as a local antimicrobial brachytherapy) is increasingly being used as a method of antibiotic prophylaxis and treatment, particularly in procedures involving the replacement of infected prosthetic joints

Brachytherapy uses powdered antibiotic mixed with a cement polymer (such as polymerized polymethylmethacrylate) to form a compound that may be directly applied onto prosthetic material or manufactured into beads (usually 3 to 10 mm in diameter) that are placed into the wound.

Candidate antibiotics for use as brachytherapy must be available as a pharmaceutical-grade powder, must be heat stable (because of the exothermic reaction induced with polymerization), and must have an appropriate microbiologic spectrum of activity for the predominant pathogens at the operative site

The aminoglycosides and vancomycin are the compounds most commonly used for brachytherapy; oxacillinand cefazolin have comparable elution characteristics but are less frequently used because of concerns regarding ~-lactam allergy.

The majority of antibiotic elution occurs in the first days after implantation, but elution from impregnated cement has been detected years following surgery

The use of antibiotic-impregnated cement (in conjunction with systemic prophylaxis) was significantly associated with a reduction in SSls in studies from several large clinical registries in Europe

Concerns remain, however, regarding routine use of this mode of prophylaxis because of possible adverse effects,such as allergicreactions.

Systemic absorption of antibiotic brachytherapy is also a concern because potentially high boluses of antibiotic may lead to toxicity.

In one series of 14 subjects, I patient developed permanent and 2 others temporary high-frequency hearing loss following implantation of gentamicin-impregnated beads

Renal failure attributed to impregnated cement, while rare, has also been reported.137 Further studies into the systemic absorption, efficacy,and adverse effects of these brachytherapeutic compounds appear warranted.

Use of antibacterial prophylaxis for patients with neutropenia. Australian Consensus Guidelines 2011 Steering Committee

The use of oral prophylactic antibiotics in patients with neutropenia is controversial and not recommended by this group because of a lack of evidence showing a reduction in mortality and concerns that such practice promotes antimicrobial resistance.

Recent evidence has demonstrated non-significant but consistent, improvement in all-cause mortality when fluoroquinolones (FQs) are used as primary prophylaxis

However, the consensus was that this evidence was not strong enough to recommend prophylaxis

The evidence base for FQ prophylaxis is presented alongside current consensus opinion to guide the appropriate and judicious use of these agents

Due consideration is given to patient risk, as it pertains to specific patient populations, as well as the net effect on selective pressure from antibiotics if FQ prophylaxis is routinely used in a target population.

The potential costs and consequences of emerging FQ resistance, particularly among Escherichia coli, Clostridium difficile and Gram-positive organisms, are considered.

As FQ prophylaxis has been advocated in some chemotherapy protocols, specific regard is given to whether FQ prophylaxis should be used to support these regimens.

The group also provides recommendations for monitoring and surveillance of emerging resistance in those centres that have adopted FQ prophylaxis.

Intern Med J. 2011 Jan;41(1b):102-9. doi: 10.1111/j.1445-5994.2010.02341.x.. Slavin MA, Lingaratnam S, Mileshkin L, Booth DL, Cain MJ, Ritchie DS, Wei A, Thursky KA;

Australian Consensus Guidelines 2011 Steering Committee.

Table 1.  Key practice points – prophylaxis SCT, stem cell transplant; FQ, fluoroquinolone. • There is currently insufficient evidence to recommend routine

use of FQ prophylaxis in patients at low risk of developing neutropenic fever (grade C)• FQ prophylaxis should also not be routinely used in high-risk haematology patients (grade C)• FQ prophylaxis could be considered in outpatient SCT and palliative patients with bone marrow failure (grade C)• Appropriate surveillance (detailed within text) should be undertaken by centres using FQ prophylaxis (grade C)• When the prevalence of FQ resistance in E. coli in internal medicine patients at an institution approaches 20%, FQ prophylaxis is unlikely to be effective (grade C)

Mandel surgical site

Journal of Infection and Chemotherapy April 2008, Volume 14, Issue 2, pp 172-177 Guidelines for implementation of clinical studies on

surgical antimicrobial prophylaxis (2007) Yoshio Takesue, Hiroshige Mikamo, Soichi Arakawa, Kenji Suzuki, Haruo Sakamoto, Takashi Okubo, Junzo Shimizu, Takashi Yokoyama

Antibiotic prophylaxis in gynaecologic procedures

J Obstet Gynaecol Can. 2012 Apr;34(4):382-91.

Van Eyk N, van Schalkwyk J; Infectious Diseases Committee. COLLABORATORS (12) Yudin MH, Allen VM, Bouchard C, Boucher M, Caddy S, Castillo E, Money DM, Murphy KE, Ogilvie G, Paquet C, van Schalkwyk J, Senikas V. Abstract OBJECTIVE: To review the evidence and provide recommendations on antibiotic prophylaxis for gynaecologic procedures. OUTCOMES: Outcomes evaluated include need and effectiveness of antibiotics to prevent infections in gynaecologic procedures. EVIDENCE: Medline and The Cochrane Library were searched for articles published between January 1978 and January 2011 on the topic of antibiotic

prophylaxis in gynaecologic procedures. Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. Searches were updated on a regular basis and incorporated in the guideline to June 2011. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

VALUES: The quality of evidence obtained was rated using the criteria described in the Report of the Canadian Task Force on Preventative Health Care (Table

1). BENEFITS, HARMS, AND COSTS: Guideline implementation should result in a reduction of cost and related harm of administering antibiotics when not required and a reduction of

infection and related morbidities when antibiotics have demonstrated a proven benefit. RECOMMENDATIONS: (1) All women undergoing an abdominal or vaginal hysterectomy should receive antibiotic prophylaxis. (I-A) (2) All women undergoing laparoscopic

hysterectomy or laparoscopically assisted vaginal hysterectomy should receive prophylactic antibiotics. (III-B) (3) The choice of antibiotic for hysterectomy should be a single dose of a first-generation cephalosporin. If patients are allergic to cephalosporin, then clindamycin, erythromycin, or metronidazole should be used. (I-A) (4) Prophylactic antibiotics should be administered 15 to 60 minutes prior to skin incision. No additional doses are recommended. (I-A) (5) If an open abdominal procedure is lengthy (e.g., > 3 hours), or if the estimated blood loss is > 1500 mL, an additional dose of the prophylactic antibiotic may be given 3 to 4 hours after the initial dose. (III-C) (6) Antibiotic prophylaxis is not recommended for laparoscopic procedures that involve no direct access from the abdominal cavity to the uterine cavity or vagina. (l-E) (7) All women undergoing surgery for pelvic organ prolapse and/or stress urinary incontinence should receive a single dose of first-generation cephalosporin. (III-B) (8) Antibiotic prophylaxis is not recommended for hysteroscopic surgery. (II-2D) (9) All women undergoing an induced (therapeutic) surgical abortion should receive prophylactic antibiotics to reduce the risk of post-abortal infection. (I-A) (10) Prophylactic antibiotics are not suggested to reduce infectious morbidity following surgery for a missed or incomplete abortion. (I-E) (11) Antibiotic prophylaxis is not recommended for insertion of an intrauterine device. (I-E) However, health care professionals could consider screening for sexually transmitted infections in high-risk populations. (III-C) (12) There is insufficient evidence to support the use of antibiotic prophylaxis for an endometrial biopsy. (III-L) (13) The best method to prevent infection after hysterosalpingography is unknown. Women with dilated tubes found at the time of hysterosalpingography are at highest risk, and prophylactic antibiotics (e.g., doxycycline) should be given. (II-3B) (14) Antibiotic prophylaxis is not recommended for urodynamic studies in women at low risk, unless the incidence of urinary tract infection post-urodynamics is > 10%. (1-E) (15) In patients with morbid obesity (BMI > 35 kg/m²), doubling the antibiotic dose may be considered. (III-B) (16) Administration of antibiotics solely to prevent endocarditis is not recommended for patients who undergo a genitourinary procedure. (III-E).

Pediatrics. 2011 Sep;128(3):611-6. Epub 2011 Aug 1. Policy statement—Recommendations for the prevention of perinatal group B streptococcal (GBS) disease. Committee on Infectious Diseases; Committee on Fetus and Newborn, Baker CJ, Byington CL, Polin RA. COLLABORATORS (45) Brady MT, Bernstein HH, Byington CL, Edwards KM, Fisher MC, Glode MP, Jackson MA, Keyserling HL,

Kimberlin DW, Maldonado YA, Orenstein WA, Schutze GE, Willoughby RE, Bell B, Bortolussi R, Fischer MA, Gellin B, Gorman RL, Lee L, Pratt R, Read JS, Starke JR, Swanson J, Tan TQ, Baker CJ, Long SS, Meissner H, Pickering LK, Rubin LG, Frantz J, Cummings J, Baley JE, Bhutani VK, Carlo WA, Kumar P, Polin RA, Tan RC, Wang KS, Watterberg KL, Barfield WD, Barth WH Jr, Jefferies AL, Mainous RO, Raju TN, Couto J.

Abstract The Centers for Disease Control and Prevention (CDC) guidelines for the prevention of perinatal group B

streptococcal (GBS) disease were initially published in 1996. The American Academy of Pediatrics (AAP) also published a policy statement on this topic in 1997. In 2002, the CDC published revised guidelines that recommended universal antenatal GBS screening; the AAP endorsed these guidelines and published recommendations based on them in the 2003 Red Book. Since then, the incidence of early-onset GBS disease in neonates has decreased by an estimated 80%. However, in 2010, GBS disease remained the leading cause of early-onset neonatal sepsis. The CDC issued revised guidelines in 2010 based on evaluation of data generated after 2002. These revised and comprehensive guidelines, which have been endorsed by the AAP, reaffirm the major prevention strategy--universal antenatal GBS screening and intrapartum antibiotic prophylaxis for culture-positive and high-risk women--and include new recommendations for laboratory methods for identification of GBS colonization during pregnancy, algorithms for screening and intrapartum prophylaxis for women with preterm labor and premature rupture of membranes, updated prophylaxis recommendations for women with a penicillin allergy, and a revised algorithm for the care of newborn infants. The purpose of this policy statement is to review and discuss the differences between the 2002 and 2010 CDC guidelines that are most relevant for the practice of pediatrics

Circulation. 2007 Oct 9;116(15):1736-54. Epub 2007 Apr 19. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association

Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group.

Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M, Bolger A, Cabell CH, Takahashi M, Baltimore RS, Newburger JW, Strom BL, Tani LY, Gerber M, Bonow RO, Pallasch T, Shulman ST, Rowley AH, Burns JC, Ferrieri P, Gardner T, Goff D, Durack DT; American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee; American Heart Association Council on Cardiovascular Disease in the Young; American Heart Association Council on Clinical Cardiology; American Heart Association Council on Cardiovascular Surgery and Anesthesia; Quality of Care and Outcomes Research Interdisciplinary Working Group.

Source Mayo Clinic, USA. Erratum in Circulation. 2007 Oct 9;116(15):e376-7. Abstract BACKGROUND: The purpose of this statement is to update the recommendations by the American Heart Association (AHA) for the prevention of

infective endocarditis that were last published in 1997. METHODS AND RESULTS: A writing group was appointed by the AHA for their expertise in prevention and treatment of infective endocarditis, with liaison

members representing the American Dental Association, the Infectious Diseases Society of America, and the American Academy of Pediatrics. The writing group reviewed input from national and international experts on infective endocarditis. The recommendations in this document reflect analyses of relevant literature regarding procedure-related bacteremia and infective endocarditis, in vitro susceptibility data of the most common microorganisms that cause infective endocarditis, results of prophylactic studies in animal models of experimental endocarditis, and retrospective and prospective studies of prevention of infective endocarditis. MEDLINE database searches from 1950 to 2006 were done for English-language papers using the following search terms: endocarditis, infective endocarditis, prophylaxis, prevention, antibiotic, antimicrobial, pathogens, organisms, dental, gastrointestinal, genitourinary, streptococcus, enterococcus, staphylococcus, respiratory, dental surgery, pathogenesis, vaccine, immunization, and bacteremia. The reference lists of the identified papers were also searched. We also searched the AHA online library. The American College of Cardiology/AHA classification of recommendations and levels of evidence for practice guidelines were used. The paper was subsequently reviewed by outside experts not affiliated with the writing group and by the AHA Science Advisory and Coordinating Committee.

CONCLUSIONS: The major changes in the updated recommendations include the following: (1) The Committee concluded that only an extremely

small number of cases of infective endocarditis might be prevented by antibiotic prophylaxis for dental procedures even if such prophylactic therapy were 100% effective. (2) Infective endocarditis prophylaxis for dental procedures is reasonable only for patients with underlying cardiac conditions associated with the highest risk of adverse outcome from infective endocarditis. (3) For patients with these underlying cardiac conditions, prophylaxis is reasonable for all dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa. (4) Prophylaxis is not recommended based solely on an increased lifetime risk of acquisition of infective endocarditis. (5) Administration of antibiotics solely to prevent endocarditis is not recommended for patients who undergo a genitourinary or gastrointestinal tract procedure. These changes are intended to define more clearly when infective endocarditis prophylaxis is or is not recommended and to provide more uniform and consistent global recommendations.

American Heart Association guideline The 2007 AHA guideline for the prevention of infective endocarditis (IE) made major revisions to the 1997 AHA guideline, the 2005

update of those guidelines published by the Medical Letter, and the 2006 ACC/AHA guideline on the management of valvular heart disease

Since the publication of the 2007 AHA guideline, the ACC/AHA guideline was updated in 2008 .

The 2009 European Society of Cardiology (ESC) guidelines are largely in agreement with the American guidelines(2007-2008)

The recommendation for antimicrobial prophylaxis for dental and other procedures (and others) is now limited to those patients with cardiac conditions with the highest risk of adverse outcome from IE

In contrast, the prior guidelines recommended prophylaxis for patients at moderate to high risk of IE, a much larger population

The rationale for this change was to make guidelines more evidence-based since, there is no convincing evidence that antimicrobial prophylaxis provides significant benefit in most patients in terms of prevention of IE.

This change has the added advantage of simplifying care for practitioners and patients

The following points were made by the AHA in support of their recommendation for the important change :

IE is much more likely to result from frequent exposure to random bacteremias associated with daily activities (eg, tooth brushing) than from bacteremia caused by a dental, gastrointestinal, or genitourinary procedure

Prophylaxis may prevent an exceedingly small number of cases of IE, if any, in individuals who undergo these procedures

The risk of antibiotic-associated adverse events exceeds the benefit, if any, from prophylactic antibiotic therapy

Maintenance of optimal oral health and hygiene may reduce the incidence of bacteremia from daily activities and is therefore more important than prophylactic antibiotics for a dental procedure to reduce the risk of IE.

The guideline recommendations were based upon results of in vitro studies, clinical experience, data from experimental animal models, and assessment of both the bacteria most likely to produce bacteremia from a given site and those most likely to result in endocarditis

The guidelines are not intended to be the standard of care in all instances in which prophylactic antibiotic therapy might be considered

Clinicians can exercise their own judgment in selecting the dose and duration of antibiotic therapy in individual cases or in special circumstances

Recommendations for the prevention of perinatal group B streptococcal (GBS) disease

The Centers for Disease Control and Prevention (CDC) guidelines for the prevention of perinatal group B streptococcal (GBS) disease were initially published in 1996

The American Academy of Pediatrics (AAP) also published a policy statement on this topic in 1997

In 2002, the CDC published revised guidelines that recommended universal antenatal GBS screening; the AAP endorsed these guidelines and published recommendations based on them in the 2003 Red Book

Since The CDC revised guidelines that recommended universal antenatal GBS screening the incidence of early-onset GBS disease in neonates has decreased by an estimated 80%

However, in 2010, GBS disease remained the leading cause of early-onset neonatal sepsis

The CDC issued revised guidelines in 2010 based on evaluation of data generated after 2002

These revised and comprehensive guidelines, which have been endorsed by the AAP, reaffirm the major prevention strategy

universal antenatal GBS screening and intrapartum antibiotic prophylaxis for culture positive and high-risk women

and include new recommendations for laboratory methods for identification of GBS colonization during pregnancy, algorithms for screening and intrapartum prophylaxis for women with preterm labor and premature rupture of membranes,

updated prophylaxis recommendations for women with a penicillin allergy, and a revised algorithm for the care of newborn

infants

The purpose of this policy statement is to review and discuss the differences between the 2002 and 2010 CDC guidelines that are most relevant for the practice of pediatrics

Recommendations for Management of Newborn Infants

All newborn infants with signs of sepsis should undergo a full diagnostic evaluation (including a lumbar puncture) and receive empirical antimicrobial therapy (AII).

All well-appearing newborn infants born to women given a diagnosis of chorioamnionitis by

their obstetrical provider should undergo a limited diagnostic evaluation (no lumbar puncture) and receive empirical antimicrobial therapy (AII).

For all women who received adequate IAP defined as penicillin (preferred), ampicillin, or cefazolin (penicillin-allergic women at low risk of anaphylaxis) for 4 or more hours before delivery, their newborn infants require only routine care and observation in the hospital for 48 hours (BIII).

If these infants meet other discharge criteria, including term birth and ready access to medical care, discharge can occur as early as 24 hours after birth with follow-up care by a care provider within 48 to 72 hours (CII).

Well-appearing term newborn infants whose mothers received no or inadequate IAP (including clindamycin or vancomycin) and had rupture of membranes for less than 18 hours require only observation for 48 hours (BIII).

Well-appearing term infants born to women with no or inadequate IAP and rupture of membranes for 18 or more hours before delivery should undergo a “limited evaluation” (ie, blood culture and CBC count with differential and platelets at birth) and observation for at least 48 hours (BIII).

All preterm infants born to women with no or inadequate IAP should undergo a “limited

evaluation” (ie, blood culture and CBC count with differential and platelets at birth) and observation for at least 48 hours (BIII).