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 George.Diaz@providence.org. 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