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Quality Standard for Antimicrobial Prophylaxis in Surgical Procedures

  • E. Patchen Dellinger (a1), Peter A. Gross (a2), Trisha L. Barrett (a3), Peter J. Krause (a4), William J. Martone (a5), John E. McGowan (a6), Richard L. Sweet (a7) and Richard P. Wenzel (a8)...



The objectives of this quality standard are 1) to provide an implementation mechanism that will facilitate the reliable administration of prophylactic antimicrobial agents to patients undergoing operative procedures in which such a practice is judged to be beneficial and 2) to provide a guideline that will help local hospital committees formulate policies and set up mechanisms for their implementation. Although standards in the medical literature spell out recommendations for specific procedures, agents, schedules, and doses, other reports document that these standards frequently are not followed in practice.


We have specified the procedures in which the administration of prophylactic antimicrobial agents has been shown to be beneficial, those in which this practice is widely thought to be beneficial but in which compelling evidence is lacking, and those in which this practice is controversial. We have examined the evidence regarding the optimal timing of drug administration, the optimal dose, and the optimal duration of prophylaxis.


The intended outcome is more uniform and reliable administration of prophylactic antibiotics in those circumstances where their value has been demonstrated or their use has been judged by the local practicing medical community to be desirable. The result should be a reduction in rates of postoperative wound infection with a limitation on the quantities of antimicrobial agents used in circumstances where they are not likely to help.


Many prospective, randomized, controlled trials comparing placebo with antibiotic and comparing one antibiotic with another have been conducted. In addition, some trials have compared the efficacy of different doses or methods of administration. Other papers have reported on the apparent efficacy of administration at different times and on actual practice in specific communities. Only a small group of relevant articles found through 1993 are cited herein. When authoritative reviews are available, these-rather than an exhaustive list of original references-are cited.


We assumed that reducing rates of postoperative infection was valuable but that reducing the total amount of antimicrobial agents employed was also worthwhile. The cost of and morbidity attributable to postoperative wound infections should be weighed against the cost and potential morbidity associated with excessive use of antimicrobial agents.

Benefits, Harms, and Costs:

More reliable administration of antimicrobial agents according to recognized guidelines should prevent some postoperative wound infections while lowering the total quantity of these drugs used. No harms are anticipated. The costs involved are those of the efforts needed on a local basis to design and implement the mechanism that supports uniform and reliable administration of prophylactic antibiotics.


All patients for whom prophylactic antimicrobial agents are recommended should receive them. The agents given should be appropriate in light of published guidelines. A short duration of prophylaxis (usually < 24 hours) is recommended.


More than 50 experts in infectious disease and 10 experts in surgical infectious disease and surgical subspecialties reviewed the standard. In addition, the methods for its implementation were reviewed by the American Society of Hospital Pharmacists.


The Quality Standards Subcommittee of the Clinical Affairs Committee of the Infectious Disease Society of America (IDSA) developed the standard. The subcommittee was composed of representatives of the IDSA (Drs. Gross and McGowan), the Society for Hospital Epidemiology of America (Dr. Wenzel), the Surgical Infection Society (Dr. Dellinger), the Pediatric Infectious Disease Society (Dr. Krause), the Centers for Disease Control and Prevention (Dr. Martone), the Obstetrics and Gynecology Infectious Diseases Society (Dr. Sweet), and the Association of Practitioners of Infection Control (Ms. Barrett). Funding was provided by the IDSA and the other cooperating organizations. The standard is endorsed by the IDSA.


Corresponding author

Department of Surgery, RF 25, University of Washington Medical Center, 1959 NE Pacific St., Seattle, WA 98195


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1.Horan, TC, White, JW, Jarvis, WR, et al. Nosocomial infection surveillance, 1984. MMWR 1986;35(SS-1):17SS29SS.
2.Haley, RW, Culver, DH, White, JW, Morgan, WM, Emori, TG. The nationwide nosocomial infection rate: a new need for vital statistics. Am J Epidemiol 1985;121:159167.
3.Hot-an, TC, White, JW, Jarvis, WR, et al. Nosocomial infection surveillance, 1984. MMWR 1986;35(SS-1):17SS29SS.
4.McGowan, JE Jr. Cost and benefit of perioperative antimicrobial prophylaxis: methods for economic analysis. Rev Infect Dis 1991; 13(suppl 10):S879S889.
5.Kaiser, AB. Antimicrobial prophylaxis in surgery. N Engl J Med 1986;315:11291138.
6.Nichols, RL. Postoperative infections and antimicrobial prophylaxis. In: Mandeli, GL, Douglas, RG Jr, Bennett, JE, eds. Principles and Practice of Infectious Diseases. 2nd ed. New York, NY: John Wiley, 1985:16371644.
7.Polk, HC Jr, Malangoni, MAChemoprophylaxis of wound infections. In: Howard, RJ, Simmons, RL, eds. Surgical Infectious Diseases. 2nd ed. Norwalk, CT: Appleton & Lange, 1988:351361.
8.Meakins, JL. Prophylactic antibiotics. In: Wilmore, DW, Brennan, MEHarken, AH, Holcroft, JW, Meakins, JL, eds. American College of Surgeons: Care of the Surgical Bxtient. Vol 2. New York, NY: Scientific American Medicine, 1991:110.
9. Anonymous. Antimicrobial prophylaxis in surgery. Med Lett Drugs Ther 1992;34:58. Letter.
10.Page, CP, Bohnen, JM, Fletcher, JR, McManus, AT, Solomkin, JS, Wittmann, DH. Antimicrobial prophylaxis for surgical wounds: guidelines for clinical care. Arch Surg 1993;128:7988.
11.ASHP Commission on Therapeutics. ASHP therapeutic guidelines on antimicrobial prophylaxis for surgery. Clin Pharm 1992;11:483513.
12.Baum, ML, Anish, DS, Chalmers, TC, Sacks, HS, Smith, J Jr, Fagerstron, RM. A survey of clinical trials of antibiotic prophylaxis in colon surgery: -evidence against further use of no-treatment controls. N Enel Wed 1981:305:795799.
13.Gorbach, SL. Antimicrobial prophylaxis for appendectomy and colorectal surgery. Rev Infect Dis 1991;13(suppl 10):S815S820.
14.Solla, JA, Rothenberger, DA. Preoperative bowel preparation: a survey of colon and rectal surgeons. Dis Colon Rectum 1990;33:154159.
15.Ad Hoc Committee of the Committee on Trauma, Division of Medical Sciences. National Academy of Sciences-National Research Council. Postoperative wound-infections: the influence of ultraviolet irradiation on the operating room and of various other factors. Ann Surg 1964;160(suppl):1196.
16.Platt, R, Zaleznik, DEHopkins, CC, et al. Perioperative antibiotic prophylaxis for herniorrhaphy and breast surgery. N Engl J Med 1990;322:253260.
17.Ergina, PL, Gold, S, Meakins, JL. Antibiotic prophylaxis for herniorrhaphy and breast surgery. N Engl J Med 1984;322:1884. Letter.
18.Rutkow, IM, Robbins, AW. Antibiotic prophylaxis for herniorrhaphy and breast surgery. N Engl JMed 1984;322:1884. Letter.
19.Byrd, RD, Brown, SW, Hohn, DC. Antibiotic prophylaxis for herniorrhaphy and breast surgery. N Engl J Med 1990;322:18841885. Letter.
20.Bencini, PL, Galimberti, M, Signorini, M, Crosti, C. Antibiotic prophylaxis of wound infections in skin surgery. Arch Dermatol 1991;127:13571360.
21.Dellinger, ERAntibiotic prophylaxis of wound infections in skin surgery: is four days too much? Arch Dermatol 1991;127:13941395. Editorial.
22.Hopkins, CC. Antibiotic prophylaxis in clean surgery. Peripheral vascular surgery, noncardiovascular thoracic surgery, herniorrhaphy, and mastectomy. Rev Infect Dis 1991;13(suppl 10):S869S873.
23.Platt, R, Zucker, JR, Zaleznik, DEet al. Prophylaxis against wound infection following herniorrhaphy or breast surgery J Infect Dis 1992;166:556560.
24.Platt, R, Zucker, JRZaleznik, DEet al. Perioperative antibiotic prophylaxis and wound infection following breast surgery. J Antimicrob Chemother 1993:31 (suppl B):4348.
25.Haley, RW, Culver, DH, Morgan, WM, White, JW, Emori, TG, Hooton, TM. Identifying patients at high risk of surgical wound infection: a simple multivariate index of patient susceptibility and wound contaminations. Am J Epidemiol 1985;121:206215.
26.Culver, DH, Horan, TC, Gaynes, RRet al. Surgical wound infection rates by wound class, operative procedure, and patient risk index. Am J Med 1991;91(suppl 3B):152S157S.
27.Dajani, AS, Bisno, AL, Chung, KJ, et al. Prevention of bacterial endocarditis: recommendations by the American Heart Association. JAMA 1990;264:29192922.
28.Classen, DC, Evans, RS, Pestotnik, SL, Menlove, RL, Burke, JRThe timing of prophylactic administration of antibiotics and the risk of surgicalwound infection. N Engl J Med 1992;326:281286.
29.DiPiro, JT, Vallner, JJ, Bowden, TA Jr, Clark, BA, Sisley, JEIntraoperative serum and tissue activity of cefazolin and cefoxitin. Arch Surg 1985;120:829832.
30.Galandiuk, S, Polk, HC Jr, Jagelman, DG, Fazio, VW. Re-emphasis of priorities in surgical antibiotic prophylaxis. Surg Gynecol Obstet 1989;169:219222.
31.Crossley, K, Gardner, LC, Task Force on Prophylactic Antibiotics in Surgery. Antimicrobial prophylaxis in surgical patients. JAMA 1985;245:722726.
32.Currier, JS, Campbell, H, Platt, R, Kaiser, AB. Perioperative antimicrobial prophylaxis in middle Tennessee, 1989-1990. Rev Infect Dis 1991;13(suppl 10):S874S878.
33.Shapiro, M, Townsend, TR, Rosner, B, Kass, EH. Use of antimicrobial drugs in general hospitals: patterns of prophylaxis. N Engl J Med 1979;301:351355.
34.Richet, HM, Chidiac, C, Prat, A, et al. Analysis of risk factors for surgical wound infections following vascular surgery. Am J Med 1991;91(suppl 3B):170S172S.
35.DiPiro, JT, Cheung, RPEBowden, TA Jr, Mansberger, JA. Single dose systemic antibiotic prophylaxis of surgical wound infections. Am J Surg 1986; 152:552559.
36.Consensus development of quality standards. Infect Control Hosp Epidemiol 1994;15:180181.
37.McGowan, JE Jr, Chesney, PJ, Crossley, KB, LaForce, FM. Guidelines for the use of systemic glucocorticosteroids in the management of selected infections. J Infect Dis 1992;165:113.
38.Hemsell, DL. Prophylactic antibiotics in gynecologic and obstetric surgery. Rev Infect Dis 1991;13(suppl 10):S821S841.
39.Shapiro, M, Schoenbaum, SC, Tager, IB, Munoz, A, Polk, BEBenefit-cost analysis of antimicrobial prophylaxis in abdominal and vaginal hysterectomy. JAMA 1983;249:12901294.
40.Ravbum, W. Vamer, M. Galask, R. Petzold, CR. Piehl, E. Comparison of moxalactam and cefazolin as prophylactic antibiotics during cesarean section. Antimicrob Agents Chemother 1985;27:337339.
41.Tuomala, RE, Fischer, SG, Munoz, A, Souney, PESteele, L, Polk, BEA comparative trial of cefazolin and moxalactam as prophylaxis for preventing infection after abdominal hysterectomy. Obstet Gynecol 1985;66:372376.
42.Morris, DL, Wilson, SR, Pain, J, et al. A comparison of aztreonam/metronidazole and cefotaxime/metronidazole in elective colorectal surgery: antimicrobial prophylaxis must include gram-positive cover. J Antimicrob Chemother 1990;25:673678.
43.Johnson, JT, Yu, VL. Antibiotic use during major head and neck surgery. Ann Surg 1988;207:108111.
44.Ariano, RE, Zhanel, GG. Antimicrobial prophylaxis in coronary bypass surgery: a critical appraisal. DICP 1991;25:478484.
45.Shapiro, M, Munoz, A, Xager, IB, Schoenbaum, SC, Polk, BERisk factors for infection at the operative site after abdominal or vaginal hysterectomy. N Engl J Med 1982;307:19611966.
46.Kaiser, AB, Herrington, JL, Jacobs, JK, Mulherin, JL Jr, Roach, AC, Sawyers, JL. Cefoxitin versus erythromycin, neomycin, and cefazolin in colorectal operations. Ann Surg 1983;198:525530.
47.Coppa, GEEng, K. Factors involved in antibiotic selection in elective colon and rectal surgery. Surgery 1988;104:853858.
48.Goldman, DA, Hopkins, CC, Karchmer, AW, et al. Cephalothin prophylaxis in cardiac valve surgery: a prospective, double-blind comparison of two-day and six-day regimens. J Thorac Cardio-vasc Surg 1977;73:470479.
49.Platt, R, Munoz, A, Stella, J, Van Devanter, S, Koster, JK Jr. Antibiotic prophylaxis for cardiovascular surgery: efficacy with coronary artery bypass. Ann Intern Med 1984;101:770774.

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Quality Standard for Antimicrobial Prophylaxis in Surgical Procedures

  • E. Patchen Dellinger (a1), Peter A. Gross (a2), Trisha L. Barrett (a3), Peter J. Krause (a4), William J. Martone (a5), John E. McGowan (a6), Richard L. Sweet (a7) and Richard P. Wenzel (a8)...


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