Cardiac Surgery in Adults - Guideline for antimicrobial prophylaxis

Publication: 16/03/2009  
Last review: 13/03/2019  
Next review: 13/03/2022  
Clinical Guideline
CURRENT 
ID: 1497 
Approved By: Improving Antimicrobial Prescribing Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2019  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Guideline for antimicrobial prophylaxis during cardiac surgery

  1. Summary table of routine recommendations
  2. Background information
  3. Special antimicrobial prophylaxis recommendations
  4. Appendix

1. Summary table of routine recommendations

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Procedure

Prophylaxis recommended?

Evidence level

Prophylaxis aims to reduce

NNT

Give antibiotics within 1 hour of skin incision and before insertion of the central venous catheter and urinary catheter.

Routine

MRSA risk factors or penicillin allergic

Coronary artery bypass grafting

YES

C (1-4)  

Wound infection

5,-27, 3

Flucloxacillin electronic Medicines Compendium information on Flucloxacillin 1g iv plus Gentamicin 2mg/kg iv plus Flucloxacillin electronic Medicines Compendium information on Flucloxacillin 1g iv at the end of bypass.

Teicoplanin electronic Medicines Compendium information on Teicoplanin 400mg iv plus Gentamicin 2mg/kg iv plus Teicoplanin electronic Medicines Compendium information on Teicoplanin 400mg at the end of bypass.

Heart valve replacement or repair or placement of other prosthetic material

YES

C (3, 4)

Any infection
(prosthetic valve endocarditis)

5,-27, 3

Teicoplanin electronic Medicines Compendium information on Teicoplanin 400mg iv plus Gentamicin 2mg/kg iv plus Teicoplanin electronic Medicines Compendium information on Teicoplanin 400mg at the end of bypass.

Teicoplanin electronic Medicines Compendium information on Teicoplanin 400mg iv plus Gentamicin 2mg/kg iv plus Teicoplanin electronic Medicines Compendium information on Teicoplanin 400mg at the end of bypass.

Other open cardiac surgery

YES

C (3, 4)

Wound infection

5,-27, 3

Flucloxacillin electronic Medicines Compendium information on Flucloxacillin 1g iv plus Gentamicin 2mg/kg iv plus Flucloxacillin electronic Medicines Compendium information on Flucloxacillin 1g iv at the end of bypass.

Teicoplanin electronic Medicines Compendium information on Teicoplanin 400mg iv plus Gentamicin 2mg/kg iv plus Teicoplanin electronic Medicines Compendium information on Teicoplanin 400mg at the end of bypass.

Resternotomy – same admission

YES

 

Wound infection

 

Teicoplanin electronic Medicines Compendium information on Teicoplanin 400mg iv plus Gentamicin 2mg/kg iv single dose

Teicoplanin electronic Medicines Compendium information on Teicoplanin 400mg iv plus Gentamicin 2mg/kg iv single dose

2. Background information

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The aim of antimicrobial prophylaxis when used in cardiac surgery is a reduction in surgical site infection (SSI) - a potentially life-threatening complication.

A review of antimicrobial prophylaxis recommendations for cardiac surgery procedures in Leeds has been prompted by several recent severe wound and mediastinal infections caused by meticillin susceptible Staphylococcus aureus (MSSA), the continued presence of meticillin-resistant Staphylococcus aureus (MRSA) in the Trust and the ongoing problem of Clostridium difficile infection. It is appropriate to use a single pre-operative dose of prophylaxis in most situations to reduce the risks related to antimicrobial use while gaining maximum benefit from prophylaxis (3).

These guidelines should be applicable to the majority of patients. Where the recommendations in these guidelines do not seem appropriate for a particular patient, the surgeon or cardiologist is advised to discuss the case with a microbiologist.

3. Special antimicrobial prophylaxis recommendations

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Microbiology.
Antimicrobial prophylaxis should cover the organisms most likely to cause surgical site infection. Staphylococci appear to be the most common cause of wound infection in cardiac surgical patients in Leeds, but a lack of surveillance data means that this is anecdotal. Both Staphylococcus aureus and coagulase negative staphylococci can cause sternal infections and Gram negative organisms are occasionally implicated.

Early prosthetic valve endocarditis (EPVE) is most commonly caused by staphylococci (Staphylococcus aureus and coagulase negative staphylococci) but enterococci are also an important cause.

Antimicrobial prophylaxis should therefore cover these organisms.

Choice of antimicrobial agents
In view of the increased risk of Clostridium difficile infection with cephalosporins and anecdotal failures with cephalosporin prophylaxis alternatives have been explored.

The favoured options are a return to a previous regimen of Flucloxacillin electronic Medicines Compendium information on Flucloxacillin plus Gentamicin and/or a glycopeptide in combination with Gentamicin.

MRSA isolates are resistant to all beta-lactams (penicillins and cephalosporins), by definition MSSA are susceptible.

The vast majority of MRSA and MSSA isolates that are tested in Leeds are susceptible to Gentamicin (see appendix, Tables 1 and 2).

The majority (60-80%) of coagulase negative staphylococci are resistant to beta-lactams. Relatively few coagulase negative staphylococci are tested for susceptibility to Gentamicin but approximately 70% are susceptible (see appendix, Table 3).

A meta-analysis of antimicrobial prophylaxis for cardiac surgical procedures showed that there was no difference in surgical site infection when either beta-lactams or glycopepetides were used (5). “Blanket” use of glycopeptides is not recommended and it would therefore seem prudent to use the safer, cheaper beta-lactam when there is no known MRSA risk.

Vancomycin electronic Medicines Compendium information on Vancomycin needs to be given by prolonged intravenous infusion and timing of its administration is unlikely to be optimal, particularly if the infusion is started around the time of induction. In addition, the combination of Vancomycin electronic Medicines Compendium information on Vancomycin and Gentamicin can enhance the nephrotoxicity of these drugs.

Teicoplanin electronic Medicines Compendium information on Teicoplanin can be given as a bolus, achieves satisfactory serum levels and bone levels during cardiac surgery but lower levels in fat (6). Teicoplanin electronic Medicines Compendium information on Teicoplanin was however, overall less effective than a Flucloxacillin electronic Medicines Compendium information on Flucloxacillin/aminoglycoside combination in one study (7).

It is noteworthy that Teicoplanin electronic Medicines Compendium information on Teicoplanin is at least as effective (and sometimes more effective) than Vancomycin electronic Medicines Compendium information on Vancomycin in protecting animals against development of experimental endocarditis due to enterococci or Staphylococcus aureus (8, 9).

The half life of Flucloxacillin electronic Medicines Compendium information on Flucloxacillin was actually increased by bypass compared to normal subjects and serum concentrations were above the MIC for MSSA but bone and fat concentrations were lower than those achieved with Teicoplanin electronic Medicines Compendium information on Teicoplanin (6). In view of low serum levels of Flucloxacillin electronic Medicines Compendium information on Flucloxacillin (after a 500mg dose) at the end of the operation in 57% of cases in one study (6) and low wound fluid concentrations at the end of the operation in another (10), we have recommended a second dose of Flucloxacillin electronic Medicines Compendium information on Flucloxacillin at the end of bypass and a higher dose of 1g.

A meta-analysis concluded that glycopeptides were more effective at preventing surgical site infection caused by MRSA (5) this supports an alternative regimen for patients with high risk of MRSA infection (11). SIGN guidelines recommend use of a glycopeptide for MRSA colonised patients (3).

Several factors justify the routine addition of Gentamicin to prophylaxis regimen.

  1. The vast majority of staphylococci (tested) in Leeds are Gentamicin-susceptible (inc. MRSA).
  2. Not every patient who develops MRSA SSI is identified as at risk of MRSA pre-procedure.
  3. Some serious MSSA infections have occurred in spite of beta-lactam prophylaxis.
  4. Teicoplanin electronic Medicines Compendium information on Teicoplanin may be inferior to Flucloxacillin electronic Medicines Compendium information on Flucloxacillin/aminoglycoside combinations (7).

EPVE is an uncommon infection and therefore clinical studies are underpowered to detect a reduction in its incidence. Never-the-less it is reasonable to consider EPVE prevention because of the devastating consequences of this infection. In view of the poor activity of beta-lactams against coagulase negative staphylococci, their unpredictable susceptibility to Gentamicin and the lack of activity of Flucloxacillin electronic Medicines Compendium information on Flucloxacillin/Gentamicin combinations against enterococci we are recommending a combination of Teicoplanin electronic Medicines Compendium information on Teicoplanin plus Gentamicin for all valve replacements.

Topical prophylaxis
SIGN guidelines recommend nasal mupirocin for cardiothoracic surgical patients identified as colonised with Staphylococcus aureus (MSSA or MRSA) (3).

SIGN guidelines note that there is level 1+ evidence for the use of Gentamicin-collagen implants between the halves of the sternum reduces SSI, but they do not make specific recommendations (3). NICE guidelines acknowledge the same evidence but had reservations (4). Decisions regarding the routine or selected use of Gentamicin-collagen implants have been deferred pending a review of the effectiveness of this update of systemic prophylaxis.

Duration of prophylaxis
Multiple dosing regimens are currently used without evidence of increased effectiveness and with significant potential for adverse consequences for the patient (adverse drug reactions, Clostridium difficile infection etc). In a cohort study, single dose cefazolin prophylaxis was as effective a two-dose prophylaxis for procedures <4 hours duration (12). In addition to guidelines produced by NICE and SIGN, American Heart Association guidelines also advocate single dose prophylaxis (13). A three dose regimen of Teicoplanin electronic Medicines Compendium information on Teicoplanin was not associated with fewer infections than a two dose regimen (7).

Appendix.

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Graph 1 showing susceptibility of MRSA blood culture isolates to Gentamicin 2006-08.


Graph 2. Susceptibility of all meticillin-susceptible Staphylococcus aureus isolates to Gentamicin 2006-08.


Graph 3. Susceptibility of coagulase-negative staphylococci to Gentamicin 2006-08.


Graph 3. Susceptibility of coagulase-negative staphylococci to Flucloxacillin electronic Medicines Compendium information on Flucloxacillin 2006-08

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Provenance

Record: 1497
Objective:
Clinical condition:

Cardiac surgery prophylaxis

Target patient group: Patients undergoing cardiac surgery.
Target professional group(s): Secondary Care Doctors
Pharmacists
Adapted from:

Evidence base

Evidence levels
A. Meta-analyses, randomised controlled trials/systematic reviews of RCTs
B. Robust experimental or observational studies
C. Expert consensus.
D. LTHT Consensus [no national guidelines exist, guidelines from different learned bodies contradict each other, or no evidence exists]

References

  1. Fong IW, Baker CB, McKee DC. The value of prophylactic antibiotics in aorat-coronary bypass operations: a double-blind randomized trial. J Thorac Cardiovasc Surg. 1979 Dec; 78(6):908-13.
  2. Austin TW, Coles JC, Burnett R, Goldbach M. Aortocoronary bypass procedures and sternotomy infections: a study of antistaphylococcal prophylaxis. Can J Surg. 1980 Sep; 23(5):483-5.
  3. SIGN. Antibiotic Prophylaxis in Surgery. Scottish Intercollegiate Guideline Network Publication Number 104. Edinburgh; 2008.
  4. Leaper D, Collier M, Evans D, Farrington M, Gibbs E, Gould K, et al. Surgical site infection: prevention and treatment of surgical site infection. In: health NCcfwac, editor: Royal College of Obstetrics and Gynaecology, Press; 2008.
  5. Bolon MK, Morlote M, Weber SG, Koplan B, Carmeli Y, Wright SB. Glycopeptides are no more effective than beta-lactam agents for prevention of surgical site infection after cardiac surgery: a meta-analysis. Clinical Infectious Diseases. 2004 May 15; 38(10):1357-63.
  6. Wilson AP, Taylor B, Treasure T, Gruneberg RN, Patton K, Felmingham D, et al. Antibiotic prophylaxis in cardiac surgery: serum and tissue levels of teicoplanin, flucloxacillin and tobramycin. J Antimicrob Chemother. 1988 Feb; 21(2):201-12.
  7. Wilson AP, Treasure T, Gruneberg RN, Sturridge MF, Ross DN. Antibiotic prophylaxis in cardiac surgery: a prospective comparison of two dosage regimens of teicoplanin with a combination of flucloxacillin and tobramycin. J Antimicrob Chemother. 1988 Feb; 21(2):213-23.
  8. Perdikaris GS, Pefanis A, Giamarellou H, Nikolopoulos A, Margaris EP, Donta I, et al. Successful single-dose teicoplanin prophylaxis against experimental streptococcal, enterococcal, and staphylococcal aortic valve endocarditis. Antimicrobial Agents and Chemotherapy. 1997; 41(9):1916-21.
  9. Entenza JM, Calandra T, Moosmann Y, Malinverni R, Glauser MP. Teicoplanin versus vancomycin for prophylaxis of experimental Enterococcus faecalis endocarditis in rats. Antimicrobial Agents and Chemotherapy. 1992; 36(6):1256-62.
  10. Farrington M, Fenn A, Phillips I. Flucloxacillin concentration in serum and wound exudate during open heart surgery. J Antimicrob Chemother. 1985 Aug; 16(2):253-9.
  11. Gemmell CG, Edwards DI, Fraise AP, Gould FK, Ridgway GL, Warren RE, et al. Guidelines for the prophylaxis and treatment of methicillin-resistant Staphylococcus aureus (MRSA) infections in the UK. 2006. p. 589-608.
  12. Zanetti G, Giardina R, Platt R. Intraoperative redosing of cefazolin and risk for surgical site infection in cardiac surgery. Emerg Infect Dis. 2001 Sep-Oct; 7(5):828-31.
  13. Eagle KA, Guyton RA, Davidoff R, Edwards FH, Ewy GA, Gardner TJ, et al. ACC/AHA 2004 guideline update for coronary artery bypass graft surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1999 Guidelines for Coronary Artery Bypass Graft Surgery). Circulation. 2004 Oct 5; 110(14):e340-437.

Approved By

Improving Antimicrobial Prescribing Group

Document history

LHP version 1.0

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