Perioperative antibiotic prophylaxis in the gastric bypass patient: Do we achieve therapeutic levels?

Edmiston, Charles E.; Krepel, Candace J.; Kelly, Holly; Larson, Jeffery C.; Andris, Deborah A.; Hennen, Cindy; Nakeeb, Atilla; Wallace, James R.

doi:10.1016/j.surg.2004.06.022

Cited by 159 publications

(100 citation statements)

References 15 publications

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“…Furthermore, mean 60-min tissue concentrations were below the susceptibility breakpoint for S. aureus and E. coli, suggesting inadequate coverage in the event of intraoperative contamination. It is known that subcutaneous adipose tissue blood flow decreases in morbid obesity; similarly, antibiotic penetration has been inversely correlated to BMI (17,(38)(39)(40)(41). Our findings of an 8% cefoxitin penetration into pericolonic/perirectal adipose tissue are consistent with those of a previous study using 2-g i.v.…”

Section: Discussionsupporting

confidence: 89%

Pharmacokinetic and Pharmacodynamic Evaluation of a Weight-Based Dosing Regimen of Cefoxitin for Perioperative Surgical Prophylaxis in Obese and Morbidly Obese Patients

Moine

Mueller

Schoen

et al. 2016

Antimicrob Agents Chemother

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The objective of this study was to determine the pharmacokinetics and pharmacodynamics (PK/PD) of a weight-based cefoxitin dosing regimen for surgical prophylaxis in obese patients. Patients received a single dose of cefoxitin at 40 mg/kg based on total body weight. Cefoxitin samples were obtained over 3 h from serum and adipose tissue, and concentrations were determined by validated high-performance liquid chromatography. Noncompartmental pharmacokinetic analysis was performed, followed by Monte Carlo simulations to estimate probability of target attainment (PTA) for Staphylococcus aureus, Escherichia coli, and Bacteroides fragilis over 4-h periods postdose. Thirty patients undergoing bariatric procedures were enrolled. The body mass index (mean ؎ standard deviation [SD])was 45.9 ؎ 8.0 kg/m 2 (range, 35.0 to 76.7 kg/m 2 ); the median cefoxitin dose was 5 g (range, 4.0 to 7.5 g). The mean maximum concentrations were 216.15 ؎ 41.80 g/ml in serum and 12.62 ؎ 5.89 in tissue; the mean tissue/serum ratio was 8% ؎ 3%. In serum, weight-based regimens achieved >90% PTA (goal time during which free [unbound] drug concentrations exceed pathogen MICs [fT>MIC] of 100%) for E. coli and S. aureus over 2 h and for B. fragilis over 1 h; in tissue this regimen failed to achieve goal PTA at any time point. The 40-mg/kg regimens achieved higher PTAs over longer periods in both serum and tissue than did the standard 2-g doses. However, although weight-based cefoxitin regimens were better than fixed doses, achievement of desired pharmacodynamic targets was suboptimal in both serum and tissue. Alternative dosing regimens and agents should be explored in order to achieve more favorable antibiotic performance during surgical prophylaxis in obese patients. Surgical site infections (SSIs) are the leading cause of postoperative morbidity and mortality and add significantly to the cost of care (1). Perioperative antibiotic prophylaxis is therefore a standard of care and a keystone for the prevention of SSIs (2-6). Recommendations regarding the use of specific antibiotics for prophylaxis during surgical procedures have been published since the early 1990s and have been frequently revisited since that time (1, 2, 5-9). More recently, specific recommendations provided by the National Surgical Infection Prevention (SIP) Project have focused on appropriate timing of administration of prophylactic antibiotics, appropriate drug selection, and the discontinuation of prophylactic antibiotics within 24 h after surgery (2, 9). However, the actual recommended drugs and dosing regimens for surgical prophylaxis have been relatively unchanged over the past 20 years. Limited published data exist regarding appropriate dosing of antimicrobials for prophylaxis. It is generally stated that the drug should be given in an adequate dose based on patient weight, adjusted dosing weight, or body mass index (BMI) (2, 6, 9). Furthermore, antibiotic administration should be repeated intraoperatively if the procedure continues beyond one to two pharmacokinetic (PK) hal...

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Section: Discussionsupporting

confidence: 89%

Pharmacokinetic and Pharmacodynamic Evaluation of a Weight-Based Dosing Regimen of Cefoxitin for Perioperative Surgical Prophylaxis in Obese and Morbidly Obese Patients

Moine

Mueller

Schoen

et al. 2016

Antimicrob Agents Chemother

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“…The number of patients with elevated BMI undergoing spine procedures, therefore, is rising [67]. Patients with higher BMI have been found to have lower serum and tissue concentrations of prophylactic antibiotics and, thus, inadequate protection against SSI [68]. Evidence-based guidelines evaluating the prophylactic use of antibiotics in spine surgery published by the North American Spine Society [6] concluded that obese patients have a higher risk for SSI than non-obese patients when the standard doses of prophylactic antibiotic are given.…”

Section: Odds Ratiomentioning

confidence: 99%

Body mass index and risk of surgical site infection following spine surgery: a meta-analysis

2013

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Purpose Inconsistent results have been reported in the literature on the association between obesity, expressed as increased body mass index (BMI), and risk for surgical site infection (SSI) following spine surgery. The objective of this study was to review and quantify the association between increased BMI and risk of spinal SSI in adults. Methods We performed a comprehensive search for relevant studies using PubMed, Embase, and references of published manuscripts. Study-specific risk measures were transformed into slope estimates and combined using the random effects meta-analysis model to establish the risk of SSI associated with every 5-unit increase in BMI. Results Thirty-four articles underwent full-text review. Variations were noted among these studies in relation to SSI diagnosis criteria and BMI cut-off levels used to define obesity. Data from 12 retrospective studies were included in the analyses. Results showed that BMI was significantly positively associated with the risk of spinal SSI. Unadjusted risk estimates demonstrated that a 5-unit increase in BMI was associated with 13 % increased risk of SSI [Crude odds ratio (OR): 1.13; 95 % CI: 1.07-1.19, p\ 0.0001]. Pooling of risk estimates adjusted for diabetes and other confounders resulted in a 21 % increase in risk of spinal SSI for every 5-unit increase in BMI (adjusted OR: 1.21; 95 % CI 1.13-1.29, p \ 0.0001). ConclusionHigher BMI is associated with the increased risk of SSI following spine surgery. Prospective studies are needed to confirm this association and to determine whether other measures of fat distribution are better predictors of risk of SSI.

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“…Significantly lower concentrations of cefazolin were found in the adipose closure (P=0.04), initial (P=0.03) and omental flap closure (P=0.05) in groups B and C compared to group A. Therapeutic tissue levels were achieved in only 48.1%, 28.6% and 10.2% of the specimens in groups A, B and C, respectively (8) .…”

Section: Discussionmentioning

confidence: 87%

ANTIBIOTIC PROPHYLAXIS IN BARIATRIC SURGERY: a continuous infusion of cefazolin versus ampicillin/sulbactam and ertapenem

Ferraz

Siqueira

Campos

et al. 2015

Arq. Gastroenterol.

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-Background -The incidence of surgical site infection in bariatric patients is significant and the current recommendations for antibiotic prophylaxis are sometimes inadequate. Objective -The aim of this study was to analyze the effect of three prophylactic antibiotic regimens on the incidence of surgical site infection. Methods -A prospective, cross-sectional study was conducted between January 2009 and January 2013 in which 896 Roux-en-Y gastric bypasses were performed to treat obesity. The study compared three groups of patients according to the perioperative antibiotic prophylaxis administered intravenously and beginning at anesthesia induction: Group I consisting of 194 patients treated with two 3-g doses of ampicillin/sulbactam; Group II with 303 patients treated with a single 1-g dose of ertapenem; and Group III with 399 patients treated with a 2-g dose of cefazolin at anesthesia induction followed by a continuous infusion of cefazolin 1g throughout the surgical procedure. The rate of surgical site infection was analyzed, as well as its association with age, sex, preoperative weight, body mass index and comorbidities. Results -The rates of surgical site infection were 4.16% in the group treated prophylactically with ampicillin/sulbactam, 1.98% in the ertapenem group and 1.55% in the continuous cefazolin group. Conclusion -The prophylactic use of continuous cefazolin in surgeries for morbid obesity shows very promising results. These findings suggest that some prophylactic regimens need to be reconsidered and even substituted by more effective therapies for the prevention of surgical site infections in bariatric patients.

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Perioperative antibiotic prophylaxis in the gastric bypass patient: Do we achieve therapeutic levels?

Cited by 159 publications

References 15 publications

Pharmacokinetic and Pharmacodynamic Evaluation of a Weight-Based Dosing Regimen of Cefoxitin for Perioperative Surgical Prophylaxis in Obese and Morbidly Obese Patients

Pharmacokinetic and Pharmacodynamic Evaluation of a Weight-Based Dosing Regimen of Cefoxitin for Perioperative Surgical Prophylaxis in Obese and Morbidly Obese Patients

Body mass index and risk of surgical site infection following spine surgery: a meta-analysis

ANTIBIOTIC PROPHYLAXIS IN BARIATRIC SURGERY: a continuous infusion of cefazolin versus ampicillin/sulbactam and ertapenem

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