Some surgeons prefer cephalosporins of first or second generation, while other colleagues prefer wider spectrum antibiotics. The dosage and duration also differs in the practice of different hospitals.
Thank you, Alessandro, for your answer that coincides with my practical approach. However, if the operation's duration is longer - 5-6 hours, then we apply a second dosage in the afternoon.
Cefazolin is a good choice, clindamycin a plausible option for true beta-lactam allergic patients. Single dose is always preferable, unless the surgery is longer than drug's half-life or the patient needs more than 2 red cell packs transfusion. Timing is essential, half an hour before incision so proper tissue distribution is achieved. In my hospital, for total joint arthroplasties, we actively look for MRSA colonization. In a colonized patient, vancomycin is the drug of choice, remembering we must deliver it an hour before incision, due to its PK. Our objective must be reduce load of skin bacteria when the incision is made, minimizing risk of infection. Of course, those bacteria are gram positive cocci, that's why a first generation cephalosporin is recommended.
Thank you, Dr. Carvalho, for your interesting answer. Especially, the MSRA - SSI prevention is very important. In patients with MSRA colonization (very important issue for grand elective surgery as joint replacement, etc. !) or BL-allergic patients we prefer clindamycin instead of vancomycin for perioperative prophylaxis for pure economic reasons.
A convenient option is teicoplanin and gentamicin single dose as they don't have to be repeated
Dr. Kosmidis,
You consider this option in cases of MSRA-colonized patients, don't you? Or do you apply it routinely ?
Some trusts have moved to this combination as first option so they don't have to worry about repeat doses. With cefazolin of fluclox it is generally recommended that you continue with a few more doses to cover a 24h period.
I think cefalosporins ()1 and 2 generations) are generally used for prophylaxis, and the dose is usually only one which is given 30-45 minutes before the surgical incision. The combination of teicoplanin and gentamycin covers a wider spectrum of bacteria and it seems especially reasonable in MSRA-colonized cases. The problem is that not all patients are examined microbiologically ante operationem, even in planned surgery.
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