Consensus statement
Executive summary of the Consensus Document of the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC) and of the Spanish Association of Surgeons (AEC) in antibiotic prophylaxis in surgeryResumen ejecutivo del Documento de Consenso de la Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica (SEIMC) y de la Asociación Española de Cirujanos (AEC) en profilaxis antibiótica en cirugía,☆☆

https://doi.org/10.1016/j.eimc.2020.02.017Get rights and content

Abstract

Antibiotic prophylaxis in surgery is one of the most effective measures for preventing surgical site infection, although its use is frequently inadequate and may even increase the risk of infection, toxicities and bacterial resistance. As a result of advances in surgical techniques and the emergence of multidrug-resistant organisms, the current guidelines for prophylaxis need to be revised.

La Sociedad Española de Enfermedades Infecciosas (Spanish Society of Infectious Diseases and Clinical Microbiology) (SEIMC) together with the Asociación Española de Cirujanos (Spanish Association of Surgeons) (AEC) have revised and updated the recommendations for antibiotic prophylaxis to adapt them to any type of surgical intervention and to current epidemiology. This document gathers together the recommendations on antimicrobial prophylaxis in the various procedures, with doses, duration, prophylaxis in special patient groups, and in epidemiological settings of multidrug resistance to facilitate standardized management and the safe, effective and rational use of antibiotics in elective surgery.

Resumen

La profilaxis antibiótica en cirugía es una de las medidas más eficaces para la prevención de la infección de localización quirúrgica, aunque su uso es con frecuencia inadecuado, pudiendo incrementar el riesgo de infección, toxicidades y resistencias bacterianas. Debido al avance en las técnicas quirúrgicas y la emergencia de microorganismos multirresistentes, las actuales pautas de profilaxis precisan ser revisadas.

La Sociedad Española de Enfermedades Infecciosas (SEIMC), conjuntamente con la Asociación Española de Cirujanos (AEC), ha revisado y actualizado las recomendaciones de profilaxis antimicrobiana para adaptarlas a cada tipo de intervención quirúrgica y a la epidemiología actual. En este documento se recogen las recomendaciones de los antimicrobianos utilizados en profilaxis en los diferentes procedimientos, las dosis, la duración, la profilaxis en huéspedes especiales, y en situación epidemiológica de multirresistencia, de tal forma que permitan un manejo estandarizado, un uso racional, seguro y efectivo de los mismos en la cirugía electiva.

Introduction

Antibiotic prophylaxis (AP) in surgery is one of the most effective measures for the prevention of surgical site infection (SSI). Despite this, its use is frequently inadequate, in general because it is not administered according to the guidelines, not started at the right time or because it is prolonged. Inadequate administration can increase the risk of SSIs, toxicities and bacterial resistance, control of which is a priority objective of the health authorities.

Advances in surgical techniques and the appearance of new ones, the increased number of transplants, and the emergence and expansion of multidrug-resistant organisms make it necessary to revise the AP guidelines that have been used in earlier decades.

The last consensus document on AP for Spain was published in 2002. The Sociedad Española de Enfermedades Infecciosas (SEIMC) together with the Asociación Española de Cirujanos (AEC) have revised and updated the recommendations for AP in order to adapt them to any type of surgical intervention and to current epidemiology. The recommendations made in this document are based on scientific evidence. Where it has not been possible to find high-quality evidence, the coordinators and authors of the document have made their recommendations based on knowledge of etiopathogenesis and risk factors for SSI found in pharmacokinetic studies of the antibiotics used in prophylaxis, and on clinical experience.

The main objective of this Consensus Document is to provide guidelines that will enable standardized management of AP in elective surgery, with a safe, effective and rational use of antimicrobials for the prevention of SSIs.

This document is focused exclusively on AP in surgery and does not address other measures that have been shown to be effective for prevention of SSI, such as decolonization of Staphylococcus aureus or skin antisepsis. The document provides general recommendations for AP and specific indications by type of surgical procedure, with graded recommendations based on scientific evidence. Antimicrobial agents and doses are provided, although excluding some that the committee considers to be unsuitable for prophylaxis because of currently very high rates of resistance, too broad a spectrum, ecological impact or ability to induce resistance (e.g. quinolones or ertapenem). Recommendations have also been provided for duration and prophylaxis in special patients and in epidemiological settings of multidrug resistance.

One of the major limitations of this document is that recommendations cannot always be supported by the highest strength of evidence owing to the design of most of the studies, the scarcity of comparative studies with placebo or different antimicrobials to study the effectiveness of AP, or the low incidence of infections in most procedures. On occasions, recommendations are inferred from evidence in other types of surgery in the same anatomical area or with a similar microbial spectrum. Although certain antibiotic types are recommended, the selection should be adapted to local epidemiology and the antimicrobial stewardship programs designed to optimize antimicrobial use at each center. It is not possible to make general indications in complicated situations, such as patients undergoing multiple surgeries who have received several antimicrobials, where prophylaxis would need to be individualized depending on the risk of infection and the colonization status of the patient.

The document is directed at professionals in specialized care involved in surgical procedures, such as anesthetists and surgeons, and at those who participate in prevention of surgical infection, such as infectologists, microbiologists, preventivists and pharmacists.

The two societies nominated project coordinators: an infectologist (MDT) and a surgeon (JMB), who selected the rest of the panel of experts, which includes surgeons, infectologists, internists and microbiologists. The final manuscript was made available to members of both societies for their review and suggestions.

This document is an updated version of the one published in 2002 and is based on recently published guidelines answering questions of clinical interest.

In order to answer each question, a systematic literature search was conducted for relevant studies published between 1970 and October 2018 using the following databases (Biblioteca Cochrane Plus (Cochrane Library), Medline, EMBASE, Scopus, Tryp database, DARE). Some relevant studies published while the document was being revised have also been included. The search terms used are specified in each section of the original document.

In accordance with SEIMC regulations, the criteria established by the SEIMC were used to determine the strength and quality of evidence (Table 2 of the original document). The methodological quality of the studies was evaluated in accordance with the Agree Collaboration (www.agreecollaboration.org).

The complete text was revised and approved by all authors and was made available to all members for review on the web page of the SEIMC. The conflicts of interest of all members of the panel of experts are specified at the end of the document.

Section snippets

When is prophylaxis indicated?

AP in surgery is recommended:

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    When there is a high probability of infection or when the consequences of postoperative infection are potentially serious for the patient (endocarditis, endophthalmitis, prosthetic joint infection) (A-III).

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    In surgery classified as clean-contaminated and contaminated (A-II).

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    In dirty surgery, when there is obvious suppuration or infection, antibiotics are administered as part of treatment (A-III).

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    In clean surgery, the indication for AP depends on the type of

Recommendations by type of surgery

The antibiotics indicated for each type of surgery are shown in Table 1 of this document, and the dosages in Tables 4 and 5 of the original document.

Conclusions

Antibiotic prophylaxis is one of the principal measures for prevention of SSI. Its objective is to achieve high concentrations of antibiotic in the relevant tissue before incision and maintain them throughout the procedure. In general, it is recommended when there is a very high likelihood of post-operative infection or when the consequences are potentially serious. It includes, at the very least, surgeries classed as clean-contaminated, contaminated, and clean surgery with prosthetic material

Financing

The present study was sponsored by the SEIMC and has not received specific funding from agencies in the public or private sectors or from other non-profit organizations.

Conflict of interests

The authors declare that they have no conflicts of interest related to this manuscript.

Acknowledgements

The authors would like to thank Antonio Gutierrez-Lizarraga for his assistance with the bibliographic support of this document, and to the SEIMC and AEC for entrusting us with the preparation of the manuscript.

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The complete consensus statement is available as Appendix in Supplementary Material.

☆☆

This document is published simultaneously in the journal: Cirugía Española. 2020: https://doi.org/XXXXXX with the consent of the authors and editors.

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