Antibiotic Therapy

Original Date: 02/2010 | Supersedes: 10/2020 | Last Review Date: 02/2022
Purpose: To standardize antibiotic therapy in the Division of Acute Care Surgery

EXTREMITY WOUNDS & OPEN FRACTURES 1-5

  1. Skin, soft tissue with open fractures, exposed bone or open joints:
    • The initial dose of antibiotics should be administered immediately and no later than 60 minutes after arrival
      Gustilo-Anderson Classification of Open Fractures Description Treatment
      Type I Open fracture with a wound <1cm long, low energy, without gross contamination Cefazolin 2g IV q8 hours x3 total doses

      If penicillin allergy: Clindamycin 900mg IV q8 hours x3 total doses

      *Initial dose should be given immediately and no later than 60 minutes after arrival
      Type II Open fracture with a wound 1-10cm long, low energy, without gross contamination or extensive soft-tissue damage, flaps, or avulsions Cefazolin 2g IV q8 hours x3 total doses

      If penicillin allergy:  Clindamycin 900mg IV q8 hours x3 total doses

      *Initial dose should be given immediately and no later than 60 minutes after arrival
      Type III IIIA:  Open fracture with a wound greater than 10cm with adequate soft-tissue coverage, or any open fracture due to high-energy trauma or with gross contamination, regardless of the size of the wound

      IIIB:  Open fracture with extensive soft-tissue injury or loss, with periosteal stripping and bone exposure that requires soft-tissue coverage in the form of muscle rotation or transfer

      IIIC:  Open fracture associated with arterial injury requiring repair.

      		 Treatment for ALL Type III:

      Ceftriaxone 2g IV x1 total dose

      and

      Vancomycin 15mg/kg IV q12 hours x2 total doses

      If penicillin allergy: Ceftriaxone 2g IV x1, and vancomycin 15mg/kg IV q12 hours x2 total dose.

      *Initial dose should be given immediately and no later than 60 minutes after arrival

 

CHEST TUBES
No antibiotics indicated.

NEUROSURGICAL/CRANIOTOMY/SINUSES
CRANIOTOMY:  Cefazolin 2 g IV, one dose immediately pre-op

OPEN SKULL FX:  Nafcillin (2 g IV q 4 hours) and ceftriaxone (2 g IV q 12 hours) x 72 hours or 24 hours after washout and coverage, whichever comes first.

PENETRATING BRAIN/CNS INJURY:  All penetrating wounds will be washed out with a minimum of 1L of sterile saline and closed within 6 hours of arrival to the hospital (excluding injuries to the mouth or globe).  This may be done in the operating room or at the bedside. Nafcillin (2 g IV q 4 hours) and ceftriaxone (2 g IV q 12 hours) x 72 hours or 24 hours after washout and coverage, whichever comes first.

VENTRICULOSTOMY, ICP MONITOR:  No antibiotics.

CSF LEAK:  No antibiotics.

PNEUMOCEPHALY:  No antibiotics.

**When monitoring CSF for infection, if CSF develops pleocytosis or other evidence of infection, begin vancomycin and cefepime and adjust appropriately to culture growth.

FACIAL FRACTURES
MANDIBLE FRACTURES:  Unasyn 3g IV q 6 hours upon admission and continued x 72 hours or 24 hours after fixation, whichever comes first. If penicillin allergy, substitute clindamycin 600 mg IV q 8 hours for same duration.

CLOSED FACIAL FRACTURES (NON-MANDIBLE FRACTURES):  No prophylactic antibiotics for non-operative fractures. For fractures requiring operative therapy, 24 hours of perioperative antibiotics

GU TRAUMA

  • Perioperative coverage as for abdominal trauma.
  • No need for antibiotics for drains, or suprapubic catheters.
  • Scrotal or Penile Trauma: Immediate debridement and cefazolin (2g IV q 8 hours) x 24 hours.

URINARY TRACT INFECTION (EMPIRIC)

If PO access available/functional: TMP/SMX DS (160 mg/800 mg q 12 hours)
If NPO or non-functional gut: ceftriaxone 1 g q 24 hours.

***Treatment for complicated UTI (all males, females with previous catheter) should receive 7 days of antibiotic therapy tailored to susceptibility.

SINUSITIS6

  • Afrin and normal saline lavage for 5 days
  • D/C all nasal tubes
  • If persistent, obtain CT of sinuses. If positive for sinusitis, amoxicillin/clavulanic acid 875 mg PO q 12 hours for 5 days (Alternative for penicillin allergy, azithromycin 500 mg X 1, then 250 mg q 24 hours)

PNEUMONIA (empiric)7

Gram positive (vancomycin 2 g loading dose once, then pharmacy consult for additional dosing based on body mass and renal function) and Gram negative coverage (cefepime 1 gm IV q 6 hours).

ABDOMINAL SURGERY8,9

PROPHYLACTIC ANTIBIOTICS10,11

  1. Prophylactic antibiotics with appropriate coverage for the most common SSI pathogens for that surgery should be administered prior to surgical incision and no longer than 60 minutes prior to incision (2 hours for vancomycin or fluoroquinolones).
  2. Prophylactic antibiotics should be re-dosed during surgery to maintain adequate tissue levels in accordance with the following:
    1. Every half-life of the antibiotic
    2. Every 1,500mL blood loss
  3. Prophylactic antibiotics should be discontinued at the end of the procedure and no later than 24 hours following surgery.
No Data Antibiotic Dose Re-Dosing Alternatives (PCN Allergy)
Neck Cases Cefazolin 2g (if ≥ 120kg: 3g) – Every 4 hours
– Every 1,500mL blood loss		  
Cardiac & Thoracic Cases Cefazolin 2g (if ≥ 120kg: 3g) – Every 4 hours
– Every 1,500mL blood loss		 Clindamycin, Vancomycin
Abdominal Cases Cefazolin
and
Metronidazole		 Cefazolin:  2g (if ≥ 120kg: 3g)
Metronidazole:  500mg		 – Cefazolin:  Every 4 hrs
– Metronidazole:  None
– Every 1,500mL blood loss		 Levofloxacin and Metronidazole
Vascular Cases Cefazolin 2g (if ≥ 120kg: 3g)   Clindamycin, Vancomycin
Skin & Soft Tissue Cases Cefazolin 2g (if ³ 120kg: 3g)   Clindamycin, Vancomycin

SOURCE CONTROL

  1. Source control should be obtained within 24 hours, or more emergently in the presence of sepsis, to prevent ongoing contamination unless clear evidence exists to support good outcomes with non-interventional treatment.
  2. Use the lease invasive mode of effective source control.
  3. Do not use temporary abdominal closure for contamination if adequate source control is achieved at the initial operation and there is not another indication for temporary abdominal closure.

CULTURES

  • Intra-peritoneal fluid cultures should only be taken for suspected peritonitis/abscesses, not simple enteric contamination

EMPIRIC ANTIBIOTICS 8,9,12-14

  1. Empiric antibiotic therapy should be initiated within 1 hour of diagnosis for patients with sepsis or septic shock.
  2. Re-administer antibiotics within 1 hour prior to start of source control procedure if two half-lives have passed since the last dosing.
  3. Antibiotics should be routinely de-escalated to the narrowest spectrum drug based on culture results, if available.
    1. Do not modify antibiotic regimen based on cultures in low risk patients who have had clinical improvement.
    2. Do modify antibiotics based on cultures in high risk patients if culture reveals organisms resistant to initial antibiotic regimen.
  4. Limit antibiotic treatment to 24 hours for the following:
    1. Traumatic bowel perforations controlled within 12 hours
    2. Gastroduodenal perforations controlled within 24 hours
    3. Acute of gangrenous appendicitis without perforation
    4. Acute or gangrenous cholecystitis without perforation
    5. Ischemic, non-perforated bowel
  5. Limit antibiotic treatment to 4 days (96 hours) following definitive source control in the setting of complex intra-abdominal infection with the following exceptions:
    1. There is clinical evidence of treatment failure and radiographic evidence of persistent inflammation/infection.
    2. The patient has clinical evidence of treatment failure and cannot undergo further source control.
  6. Limit antibiotic treatment to 5-7 days in patients who have not had definitive source control of intra-abdominal infection.

 

Community Acquired   Low Risk High Risk
Empiric regimen cefoxitin and metronidazole piperacillin-tazobactam, or cefepime/metronidazole, or meropenem
β-lactam allergy ceftriaxone and metronidazole metronidazole, and vancomycin
Anti-pseudomonal coverage Not recommended covered in empiric regimen
Anti-enterococcal Not recommended piperacillin-tazobactam, or meropenem, or adjunctive ampicillin or vancomycin
Antifungal coverage Not recommended Not recommended
Extended Spectrum B-lactamase coverage meropenem meropenem
 
Hospital Acquired Empiric Regimen piperacillin-tazobactam, or cefepime/metronidazole, or meropenem
β-lactam allergy cefepime/metronidazole, or aztreonam and metronidazole
Anti-enterococcal coverage No known VRE: vancomycin
VRE: linezolid or daptomycin
Risk factors: recent exposure to broad spectrum antibiotics, post-operative infections, severe sepsis/septic shock, known VRE colonization
Anti-staphylococcal coverage vancomycin, or linezolid or daptomycin (neither commonly used)
Risk factors: known MRSA colonization, advanced age, co-morbid medical conditions, previous hospitalization or operation, recent exposure to antibiotics
Antifungal coverage Severe sepsis/septic shock: micafungin
Non-severe illness: fluconazole
Risk factors: upper GI perforation, recurrent bowel perforation, surgically debrided pancreas, recent prolonged course of broad spectrum antibiotics, positive cultures

 

References

  1. Garner MR, Sethuraman SA, Schade MA, Boateng H. Antibiotic Prophylaxis in Open Fractures: Evidence, Evolving Issues, and Recommendations. J Am Acad Orthop Surg. 2020;28(8):309-315.
  2. Hauser CJ, Adams CA, Jr., Eachempati SR, Council of the Surgical Infection S. Surgical Infection Society guideline: prophylactic antibiotic use in open fractures: an evidence-based guideline. Surgical infections. 2006;7(4):379-405.
  3. Hospenthal DR, Murray CK, Andersen RC, et al. Guidelines for the prevention of infections associated with combat-related injuries: 2011 update: endorsed by the Infectious Diseases Society of America and the Surgical Infection Society. The Journal of trauma. 2011;71(2 Suppl 2):S210-234.
  4. Martin GJ, Dunne JR, Cho JM, Solomkin JS, Prevention of Combat-Related Infections Guidelines P. Prevention of infections associated with combat-related thoracic and abdominal cavity injuries. The Journal of trauma. 2011;71(2 Suppl 2):S270-281.
  5. Rodriguez L, Jung HS, Goulet JA, Cicalo A, Machado-Aranda DA, Napolitano LM. Evidence-based protocol for prophylactic antibiotics in open fractures: improved antibiotic stewardship with no increase in infection rates. The journal of trauma and acute care surgery. 2014;77(3):400-407; discussion 407-408; quiz 524.
  6. Benninger MS. Rhinosinusitis. In: Gleeson M BG, Burton MJ, Clarke R, ed. Scott-Brown’s Otorhinolaryngology, Head and Neck Surgery. Vol 2. 7th ed. London: Hodder Arnold; 2008.
  7. Chastre J, Wolff M, Fagon JY, et al. Comparison of 8 vs 15 days of antibiotic therapy for ventilator-associated pneumonia in adults: a randomized trial. JAMA : the journal of the American Medical Association. 2003;290(19):2588-2598.
  8. Mazuski JE, Tessier JM, May AK, et al. The Surgical Infection Society Revised Guidelines on the Management of Intra-Abdominal Infection. Surgical infections. 2017;18(1):1-76.
  9. Rhodes A, Evans LE, Alhazzani W, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Crit Care Med. 2017;45(3):486-552.
  10. Ban KA, Minei JP, Laronga C, et al. American College of Surgeons and Surgical Infection Society: Surgical Site Infection Guidelines, 2016 Update. Journal of the American College of Surgeons. 2017;224(1):59-74.
  11. Rosenberger LH, Politano AD, Sawyer RG. The surgical care improvement project and prevention of post-operative infection, including surgical site infection. Surgical infections. 2011;12(3):163-168.
  12. Rattan R, Allen CJ, Sawyer RG, et al. Percutaneously drained intra-abdominal infections do not require longer duration of antimicrobial therapy. The journal of trauma and acute care surgery. 2016;81(1):108-113.
  13. Rattan R, Namias N, Sawyer RG. Patients with Complicated Intra-Abdominal Infection Presenting with Sepsis Do Not Require Longer Duration of Antimicrobial Therapy: In reply to Spartalis and colleagues. Journal of the American College of Surgeons. 2016;223(1):206-207.
  14. Sawyer RG, Claridge JA, Nathens AB, et al. Trial of short-course antimicrobial therapy for intraabdominal infection. N Engl J Med. 2015;372(21):1996-2005