ANTIBIOTIC USE Ensuring the proper timing of antibiotic prophylaxis is increasingly complex in outpatient surgery.

ANTIBIOTIC PROPHYLAXIS When's It Best to Administer Antibiotics?

Phenelle Segal, RN, CIC, president of Infection Control Consulting Services, shares her thoughts on the optimal timing of pre-op antibiotics:

• 1 or 2 hours? SCIP measures say you should start prophylactic antibiotics within 1 hour before incision and within 2 hours for vancomycin and quinolones. But what is the definition of "within 1 or 2 hours," and what about cases that aren't ready for IV infusion 2 hours beforehand? Many times, 1 hour is stretching it depending on the type of procedure. I refer to the SCIP guideline tool developed by Quality Net/CMS to interpret this measure. "For antibiotics with less than 1-hour infusion times, anesthesia will start the antibiotic in the OR. The longer-infusing antibiotics (vancomycin and quinolones) may be started in same-day surgery (2-hour timeframe to incision)."
• Give cephalosporin 30 to 60 minutes before incision. The most common antibiotic agent in the outpatient setting is a 1st or 2nd generation cephalosporin, reserving the use of vancomycin and fluoroquinolones for patients with documented ????-lactam allergies. A 2009 article in the Annals of Surgery reports that administration of a non-vancomycin/non-quinolone antibiotic such as a cephalosporin provides the most prophylaxis when administered within 30 minutes of incision. The article states that the infection risk with antibiotic administered within 30 minutes of incision was 1.6%, compared with 2.4% when antibiotics were administered between 31 to 60 minutes before surgery. To avoid confusion regarding administering of cephalosporins, it appears that optimal timing is 30 to 60 minutes before surgical incision. As long as it is within 1 hour, you're meeting the SCIP measure. Studies have not proven any advantage in administering the antibiotic in less than 30 minutes.
• Give vancomycin and fluoroquinolone 90 to 120 minutes before incision. This is more complex. You must infuse these agents within 2 hours before incision, as there are non-infection-related risks involved with too rapid an administration schedule with these agents. For example, "red man syndrome," a potential adverse effect that may occur after vancomycin administration, has been thought to be a result in some patients of too rapid administration of the medication. This is not true for all patients, but the pharmaceutical companies recommend that you infuse the drug over the course of 90 to 120 minutes. This poses a significant issue in outpatient surgery, as patients aren't always in the center and ready for IV infusion at the optimal time for vancomycin and fluoroquinolones to be administered.

— Dan O'Connor