Antimicrobial prophylaxis for surgery

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Forwarding, copying or any other distribution of this material is strictly prohibited For further information call: 800-211-2769 Treatment Guidelines from The Medical Letter® Published by The Medical Letter, Inc • 145 Huguenot Street, New Rochelle, NY 10801 • A Nonprofit Publication Volume 10 (Issue 122) October 2012 (supercedes vol [Issue 82] June 2009) www.medicalletter.org Take CME Exams Tables Antimicrobial Prophylaxis for Surgery Pages 74-75 Antimicrobial Prophylaxis for Surgery Antimicrobial prophylaxis can decrease the incidence of postoperative infection, particularly surgical site infection, after some procedures Recommendations for such prophylaxis are listed in the table that begins on page 74 Antimicrobial prophylaxis for dental procedures to prevent endocarditis was recently discussed in The Medical Letter.1 CHOICE OF AGENT — Antimicrobial prophylaxis for surgery should be directed against the most likely infecting organisms, but it does not need to eradicate every potential pathogen to be effective Cefazolin (Ancef, and others), a first-generation cephalosporin active against many staphylococci and streptococci, can be used for most procedures For procedures that might involve exposure to bowel anaerobes, including Bacteroides fragilis, the secondgeneration cephalosporins cefoxitin (Mefoxin, and others) and cefotetan (Cefotan, and others) are more active than cefazolin, but anaerobic resistance to these drugs is increasing.2 Cefazolin plus metronidazole (Flagyl, and others) and ampicillin/sulbactam (Unasyn, and others) may be reasonable alternatives depending on local susceptibility patterns of Escherichia coli.3 In institutions where surgical site infections are frequently due to methicillin-resistant staphylococci, vancomycin (Vancocin, and others) could be used for prophylaxis, but such use could lead to emergence of vancomycin-resistant organisms If vancomycin is used for procedures in which gram negatives or anaerobes are also likely pathogens, an additional agent with activity against these organisms could be added.4 Most experts not recommend use of broadspectrum antibiotics such as ertapenem (Invanz) or extended-spectrum cephalosporins such as cefotaxime (Claforan, and others), ceftriaxone (Rocephin, and others), ceftazidime (Fortaz, and others), cefepime (Maxipime) or ceftaroline (Teflaro) for routine surgical prophylaxis because they are expensive, some are less active than first- or second-generation cephalosporins against staphylococci, and their spectrum of activity includes organisms rarely encountered in elective surgery.5 Pre-operative Screening and Decolonization – Preoperative identification of patients who are nasal carriers of methicillin-resistant Staphylococcus aureus (MRSA) or methicillin-sensitive S aureus (MSSA) and decolonization using intranasal mupirocin (Bactroban Nasal, and others) have been shown to decrease surgical site infections following some procedures (primarily cardiac and orthopedic), but resistance to mupirocin could become a problem if it is used routinely.6 One randomized, double-blind, placebocontrolled, multicenter trial found that combined use of mupirocin nasal ointment and chlorhexidine (Peridex, and others) baths within the first 24 hours after hospital admission in identified carriers reduced the risk of hospital-acquired MSSA infection.7 DOSAGE AND DURATION — Administration of the first dose of the prophylactic antibiotic within 60 minutes before the initial surgical incision is recommended to ensure adequate serum and tissue levels If vancomycin or a fluoroquinolone is used, the infusion should begin within 60-120 minutes before the incision because of the prolonged infusion times required for these drugs.8 The duration of antimicrobial prophylaxis should be 3 hours) or those with major blood loss, or in patients with extensive burns, additional intraoperative doses should be given at intervals 1-2 times the half-life of the drug (ampicillin/sulbactam q2 hours, cefazolin q4 hours, cefuroxime q4 hours, cefoxitin q2 hours, clindamycin q6 hours, vancomycin q12 hours) for the duration of the procedure in patients with normal renal function If vancomycin or a fluoroquinolone is used, the infusion should be started within 60-120 minutes before the initial incision to have adequate tissue levels at the time of incision and to minimize the possibility of an infusion reaction close to the time of induction of anesthesia The recommended dose of cefazolin is g for patients who weigh 80 kg Morbidly obese patients may need higher doses Some experts recommend an additional dose when patients are removed from bypass during open-heart surgery Vancomycin can be used in hospitals in which methicillin-resistant S aureus and S epidermidis are a frequent cause of postoperative wound infection, in patients previously colonized with MRSA, or for those who are allergic to penicillins or cephalosporins Rapid IV administration may cause CARDIAC SURGERY — Preoperative antibiotics can decrease the incidence of infection after cardiac surgery, and intraoperative redosing has decreased the risk of postoperative infection in procedures lasting >400 minutes.9 Various data support a duration ranging from a single dose to up to 24 hours postoperatively; there is no evidence of benefit beyond 48 hours 74 Antimicrobial prophylaxis for prevention of devicerelated infections is recommended before placement of electrophysiologic devices, ventricular assist devices, ventriculoatrial shunts and arterial patches Prophylaxis prior to implantation of permanent pacemakers and cardioverter-defibrillators has been shown to significantly reduce the incidence of wound infection, inflammation and skin erosion.10 Treatment Guidelines from The Medical Letter • Vol 10 ( Issue 122) • October 2012 Antimicrobial Prophylaxis for Surgery Table Antimicrobial Prophylaxis for Surgery (cont’d) Recommended Antimicrobials Usual Adult Dosage1 Anaerobes, enteric gramnegative bacilli, S aureus clindamycin OR cefazolin + metronidazole OR ampicillin/sulbactam10 600-900 mg IV 1-2 g IV2 0.5 g IV g IV S aureus, S epidermidis cefazolin OR vancomycin4 1-2 g IV2 g IV S epidermidis, S aureus, streptococci, enteric gramnegative bacilli, Pseudomonas spp gentamicin, tobramycin, ciprofloxacin, gatifloxacin levofloxacin, moxifloxacin, ofloxacin or neomycingramicidin-polymyxin B multiple drops topically over to 24 hours OR cefazolin 100 mg subconjunctivally S aureus, S epidermidis cefazolin16 OR vancomycin4,16 1-2 g IV2 g IV S aureus, S epidermidis, streptococci, enteric gramnegative bacilli cefazolin OR ampicillin/sulbactam10 OR vancomycin4 1-2 g IV2 g IV g IV Arterial surgery involving a prosthesis, the abdominal aorta, or a groin incision S aureus, S epidermidis, enteric gram-negative bacilli cefazolin OR vancomycin4 1-2 g IV2 g IV Lower extremity amputation for ischemia S aureus, S epidermidis, enteric gram-negative bacilli, clostridia cefazolin OR vancomycin4 1-2 g IV2 g IV Nature of Operation Common Pathogens Head and Neck Surgery Incisions through oral or pharyngeal mucosa Neurosurgery Ophthalmic Orthopedic Thoracic (Non-Cardiac) Vascular hypotension, which could be especially dangerous during induction of anesthesia Even when the drug is given over 60 minutes, hypotension may occur; treatment with diphenhydramine (Benadryl, and others) and further slowing of the infusion rate may be helpful Some experts would give 15 mg/kg of vancomycin to patients weighing more than 75 kg, up to a maximum of 1.5 g, with a slower infusion rate (90 minutes for 1.5 g) For procedures in which enteric gram-negative bacilli are common pathogens, many experts would add another drug such as an aminoglycoside (gentamicin, tobramycin or amikacin), aztreonam or a fluoroquinolone Morbid obesity, GI obstruction, decreased gastric acidity or GI motility, gastric bleeding, malignancy or perforation, or immunosuppression For patients allergic to penicillins and cephalosporins, clindamycin or vancomycin with either gentamicin, ciprofloxacin, levofloxacin or aztreonam is a reasonable alternative Fluoroquinolones should not be used for prophylaxis in cesarean section Age >70 years, acute cholecystitis, non-functioning gall bladder, obstructive jaundice or common bile duct stones Cefotetan, cefoxitin and ampicillin-sulbactam are reasonable alternatives In addition to mechanical bowel preparation, g of neomycin plus g of erythromycin at PM, PM and 11 PM or g of neomycin plus g of metronidazole at PM and 11 PM the day before an AM operation 10 Due to increasing resistance of E coli to fluoroquinolones and ampicillin/sulbactam, local sensitivity profiles should be reviewed prior to use 11 For a ruptured viscus, therapy is often continued for about five days 12 Urine culture positive or unavailable, preoperative catheter, transrectal prostatic biopsy, or placement of prosthetic material 13 Shock wave lithotripsy, ureteroscopy 14 Including percutaneous renal surgery, procedures with entry into the urinary tract, and those involving implantation of a prosthesis If manipulation of bowel is involved, prophylaxis is given according to colorectal guidelines 15 Divided into 100 mg before the procedure and 200 mg after 16 If a tourniquet is to be used in the procedure, the entire dose of antibiotic must be infused prior to its inflation GASTROINTESTINAL SURGERY — Antimicrobial prophylaxis is recommended for high-risk patients undergoing esophageal or gastroduodenal procedures Patients considered high-risk include those with GI obstruction, increased gastric pH, decreased GI motility, gastric bleeding, malignancy or perforation, and those with morbid obesity or immunosuppression Prophylaxis is not recommended for routine gastroesophageal endoscopy.11 Preoperative antibiotics are used routinely for bariatric surgery, including adjustable gastric banding, vertical banded gastroplasty, Roux-en-y gastric bypass and biliopancreatic diversion, but no controlled trials supporting such use are available Higher doses of antibiotics may be needed for adequate serum and tissue concentrations in morbidly obese patients.12 Treatment Guidelines from The Medical Letter • Vol 10 ( Issue 122) • October 2012 75 Antimicrobial Prophylaxis for Surgery Antimicrobial prophylaxis is recommended before biliary tract surgery for patients at high risk for infection, including those >70 years old and those with acute cholecystitis, a non-functioning gallbladder, obstructive jaundice, or common bile duct stones Antibiotic prophylaxis for endoscopic retrograde cholangiopancreatography (ERCP) is recommended only if complete biliary drainage is unlikely to be achieved.13 Prophylactic antibiotics are generally not necessary for low-risk patients undergoing elective laparoscopic cholecystectomy.14 Preoperative antibiotics can decrease the incidence of infection after colorectal surgery Many US surgeons use a combination of oral neomycin, either oral erythromycin or oral metronidazole, and parenteral agents; one meta-analysis suggests that combined intravenous and oral prophylaxis (with mechanical bowel preparation) is more effective than parenteral prophylaxis alone in preventing surgical site infection.15 Ertapenem (Invanz) is a broad-spectrum carbapenem that has been approved by the FDA for prevention of infection after elective colorectal procedures, but many experts advise against using it for this purpose Like other broad-spectrum agents, if ertapenem is to remain useful, it should be reserved for treatment of serious infections, particularly those caused by organisms resistant to other antimicrobials.5,16 Antimicrobial prophylaxis can decrease the incidence of infection after surgery for acute appendicitis.17,18 If perforation has occurred, antibiotics are often continued for >5 days GENITOURINARY SURGERY — Most experts not recommend antimicrobial prophylaxis before cystoscopy without manipulation in patients with sterile urine When cystoscopy with manipulation (dilation, biopsy, fulguration, resection or ureteral instrumentation) is planned, the urine culture is positive or unavailable, or an indwelling urinary catheter is present, patients should either be treated to sterilize the urine before surgery or receive a single preoperative dose of an agent that is usually active against the likely microorganisms Antimicrobial prophylaxis decreases the incidence of postoperative bacteriuria and septicemia in patients with sterile preoperative urine undergoing transurethral prostatectomy and transrectal prostatic biopsies.19-21 Prophylaxis is also recommended for ureteroscopy, shock wave lithotripsy, percutaneous renal surgery, open laparoscopic procedures, and for placement of a urologic prosthesis (penile implant, artificial sphincter, synthetic pubovaginal sling, bone anchors for pelvic floor reconstruction).22 While the efficacy of fluoroquinolones for prophylaxis in urologic procedures has 76 been well established, resistance has emerged.23 Local resistance patterns to the fluoroquinolones, particularly with E coli, should be evaluated to guide appropriate selection of antimicrobials GYNECOLOGY AND OBSTETRICS — Antimicrobial prophylaxis decreases the incidence of infection after vaginal or abdominal hysterectomy.24 Prophylaxis is also recommended for laparoscopic hysterectomies Antimicrobials can prevent infection after elective and non-elective cesarean section; administration of the dose prior to the initial skin incision appears to be more effective than giving it after cord clamping.25Antimicrobial prophylaxis can also prevent infection following elective abortion.26 HEAD AND NECK SURGERY — Prophylaxis with antimicrobials has decreased the incidence of surgical site infection after clean-contaminated oncologic head and neck operations that involve an incision through the oral or pharyngeal mucosa.27 Prophylaxis is not beneficial in tonsillectomy or nasal septoplasty.28,29 NEUROSURGERY — An antistaphylococcal antibiotic can decrease the incidence of infection after craniotomy.30 In spinal surgery, the infection rate after conventional lumbar discectomy is low, but the serious consequences of postoperative infection at this site have led many surgeons to use perioperative antibiotics Infection rates are higher after prolonged spinal surgery or spinal procedures involving fusion or insertion of foreign material, and prophylactic antibiotics are generally used for these.31 Studies have shown lower infection rates with use of prophylactic antibiotics for implantation of permanent cerebrospinal fluid shunts and for intrathecal pump placement.32 The benefits of antimicrobial prophylaxis for ventriculostomy placement remain uncertain.33 OPHTHALMIC SURGERY — There is no consensus supporting a particular choice, route or duration of antimicrobial prophylaxis for ophthalmic procedures, but based on available evidence, preoperative povidone-iodine applied to the skin and conjunctiva lowers the incidence of endophthalmitis.34 Other prophylactic strategies include pre- and post-operative topical antibiotic eye drops, addition of antibiotics to the irrigating solution, and subconjunctival injections Use of intracameral injections is limited by lack of commercial availability and potential toxicity if inaccurately dosed.35 There is no evidence that prophylactic antibiotics are needed for procedures that not invade the globe ORTHOPEDIC SURGERY — Antistaphylococcal drugs administered prophylactically can decrease the incidence of both early and delayed infection after Treatment Guidelines from The Medical Letter • Vol 10 ( Issue 122) • October 2012 Antimicrobial Prophylaxis for Surgery joint replacement and surgical repair of closed fractures.36-38 They also decrease the rate of infection when hip and other closed fractures are treated with internal fixation by nails, plates, screws or wires, and in compound or open fractures.39 Whether orthopedic prophylaxis should be with a single dose or with multiple doses for up to 24 hours is unclear.38-40 A retrospective review of patients undergoing arthroscopic surgery concluded that antibiotic prophylaxis is not indicated.41 THORACIC SURGERY — Antibiotic prophylaxis is used routinely in thoracic surgery, but supporting data are sparse In one study, a single preoperative dose of cefazolin before pulmonary resection led to a decrease in surgical site infection, but not in pneumonia or empyema.42 Insertion of chest tubes for non-traumatic indications, such as spontaneous pneumothorax, does not require antimicrobial prophylaxis 10 VASCULAR SURGERY — Preoperative prophylaxis decreases the incidence of postoperative surgical site infection after arterial reconstructive surgery on the abdominal aorta, vascular operations on the leg that include a groin incision, and amputation of the lower extremity for ischemia.43,44 Many experts also recommend prophylaxis for implantation of any vascular prosthetic material, such as grafts for vascular access in hemodialysis Prophylaxis is not indicated for carotid endarterectomy or brachial artery repair without prosthetic material Prophylactic antibiotics are not routinely recommended for endovascular stenting, but risk factors that may justify using them include repeat intervention within days, prolonged indwelling arterial sheath, prolonged procedure duration (>2 hours), presence of other infected implants or immunosuppression.45,46 OTHER PROCEDURES — Antimicrobial prophylaxis is generally not indicated for cardiac catheterization, varicose vein surgery, most dermatologic47 and plastic surgery, arterial puncture, thoracentesis, paracentesis, repair of simple lacerations, outpatient treatment of burns, or dental extractions or root canal therapy because the incidence of surgical site infections is low The need for prophylaxis in breast surgery (other than for breast cancer),48 hernia repair,49 and other “clean” surgical procedures has been controversial Most experts generally not recommend antibacterial prophylaxis for these procedures because of the low rate of infection and the potential for adverse effects with prophylaxis; it may be considered for procedures with high consequences of infection, such as those involving placement of prosthetic material (e.g., synthetic mesh, saline implants, tissue expanders) 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 Endocarditis prophylaxis for dental procedures Med Lett Drugs Ther 2012; 54:73 DR Snydman et al National survey on the susceptibility of Bacteroides fragilis group: report and analysis of trends in the United States from 1997 to 2004 Antimicrob Agents Chemother 2007; 51:1649 F Baquero et al In vitro susceptibilities of aerobic and facultatively anaerobic gram-negative bacilli isolated from patients with intraabdominal infections worldwide: 2005 results from Study for Monitoring Antimicrobial Resistance Trends (SMART) Surg Infect (Larchmt) 2009; 10:99 T Crawford et al Vancomycin for surgical prophylaxis? Clin Infect Dis 2012; 54:1474 Why not ertapenem for surgical prophylaxis? Med Lett Drugs Ther 2009; 51:72 C Hebert and A Robicsek Decolonization therapy in infection control Curr Opin Infect Dis 2010; 23:340 LG Bode et al Preventing surgical-site infections in nasal carriers of Staphylococcus aureus N Engl J Med 2010; 362:9 DW Bratzler et al Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project Clin Infect Dis 2004; 38:1706 G Zanetti et al Intraoperative redosing of cefazolin and risk for surgical site infection in cardiac surgery Emerg Infect Dis 2001; 7:828 JC de Oliveira et al Efficacy of antibiotic prophylaxis before the implantation of pacemakers and cardioverter-defibrillators: results of a large, prospective, randomized, double-blinded, placebo-controlled trial Circ Arrhythm Electrophysiol 2009; 2:29 S Banerjee et al Antibiotic prophylaxis for GI endoscopy Gastrointest Endosc 2008; 67:791 CE Edmiston et al Perioperative antibiotic prophylaxis in the gastric bypass patient: we achieve therapeutic levels? Surgery 2004; 136:738 MC Allison et al Antibiotic prophylaxis in gastrointestinal endoscopy Gut 2009; 58:869 RC Yan et al The role of prophylactic antibiotics in laparoscopic cholecystectomy in preventing postoperative infection: a meta analysis J Laparoendosc Adv Surg Tech A 2011; 21:301 RL Nelson et al Antimicrobial prophylaxis for colorectal surgery Cochrane Database Syst Rev 2009; (1):CD001181 KM Itani et al Ertapenem versus cefotetan prophylaxis in elective colorectal surgery N Engl J Med 2006; 355:2640 BR Andersen et al Antibiotics versus placebo for prevention of postoperative infection after appendicectomy Cochrane Database Syst Rev 2005; (3):CD001439 LM Mui et al Optimum duration of prophylactic antibiotics in acute non-perforated appendicitis ANZ J Surg 2005; 75:425 A Berry and A Barratt Prophylactic antibiotic use in transurethral prostatic resection: a meta-analysis J Urol 2002; 167:571 W Qiang et al Antibiotic prophylaxis for transurethral prostatic resection in men with preoperative urine containing less than 100,000 bacteria per ml: a systematic review J Urol 2005; 173:1175 M Aron et al Antibiotic prophylaxis for transrectal needle biopsy of the prostate: a randomized controlled study BJU Int 2000; 85:682 JS Wolf Jr et al Best practice policy statement on urologic surgery antimicrobial prophylaxis J Urol 2008; 179:1379 DA Williamson et al Escherichia coli bloodstream infection after transrectal ultrasound-guided prostate biopsy: implications of fluoroquinolone-resistant sequence type 131 as a major causative pathogen Clin Infect Dis 2012; 54:1406 ACOG Practice Bulletin no 104: antibiotic prophylaxis for gynecologic procedures Obstet Gynecol 2009; 113:1180 ACOG Committee Opinion no 465: antimicrobial prophylaxis for cesarean delivery: timing of administration Obstet Gynecol 2010; 116:791 SL Achilles and MF Reeves Prevention of infection after induced abortion: release date October 2010: SFP guideline 20102 Contraception 2011; 83:295 R Simo and G French The use of prophylactic antibiotics in head and neck oncological surgery Curr Opin Otolaryngol Head Neck Surg 2006; 14:55 Treatment Guidelines from The Medical Letter • Vol 10 ( Issue 122) • October 2012 77 Antimicrobial Prophylaxis for Surgery 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 BJ O’Reilly et al Is the routine use of antibiotics justified in adult tonsillectomy? J Laryngol Otol 2003; 117:382 M Caniello et al Antibiotics in septoplasty: is it necessary? Braz J Otorhinolaryngol 2005; 71:734 FG Barker 2nd Efficacy of prophylactic antibiotics against meningitis after craniotomy: a meta-analysis Neurosurgery 2007; 60:887 EM Brown et al Spine update: prevention of postoperative infection in patients undergoing spinal surgery Spine 2004; 29:938 KA Follett et al Prevention and management of intrathecal drug delivery and spinal cord stimulation system infections Anesthesiology 2004; 100:1582 PJ McCarthy et al International and specialty trends in the use of prophylactic antibiotics to prevent infectious complications after insertion of external ventricular drainage devices Neurocrit Care 2010; 12:220 TA Ciulla et al Bacterial endophthalmitis prophylaxis for cataract surgery: an evidence-based update Ophthalmology 2002; 109:13 G Yiu et al Prophylaxis against postoperative endophthalmitis in cataract surgery Int Ophthalmol Clin 2011; 51:67 B Al Buhairan et al Antibiotic prophylaxis for wound infections in total joint arthroplasty: a systematic review J Bone Joint Surg Br 2008; 90:915 L Prokuski Prophylactic antibiotics in orthopaedic surgery J Am Acad Orthop Surg 2008; 16:283 WJ Gillespie and GH Walenkamp Antibiotic prophylaxis for surgery for proximal femoral and other closed long bone fractures Cochrane Database Syst Rev 2010; (3):CD000244 JP Southwell-Keely et al Antibiotic prophylaxis in hip fracture surgery: a metaanalysis Clin Orthop Relat Res 2004; 419:179 GP Slobogean et al Single- versus multiple-dose antibiotic prophylaxis in the surgical treatment of closed fractures: a meta-analysis J Orthop Trauma 2008; 22:264 JM Bert et al Antibiotic prophylaxis for arthroscopy of the knee: is it necessary? Arthroscopy 2007; 23:4 R Aznar et al Antibiotic prophylaxis in non-cardiac thoracic surgery: cefazolin versus placebo Eur J Cardiothorac Surg 1991; 5:515 AH Stewart et al Prevention of infection in peripheral arterial reconstruction: a systematic review and meta-analysis J Vasc Surg 2007; 46:148 S Homer-Vanniasinkam Surgical site and vascular infections: treatment and prophylaxis Int J Infect Dis 2007; 11:S17 P Beddy and JM Ryan Antibiotic prophylaxis in interventional radiology—anything new? Tech Vasc Interv Radiol 2006; 9:69 AM Venkatesan et al Practice guidelines for adult antibiotic prophylaxis during vascular and interventional radiology procedures Written by the Standards of Practice Committee for the Society of Interventional Radiology and Endorsed by the Cardiovascular Interventional Radiological Society of Europe and Canadian Interventional Radiology Association [corrected] J Vasc Interv Radiol 2010; 21:1611 TI Wright et al Antibiotic prophylaxis in dermatologic surgery: advisory statement 2008 J Am Acad Dermatol 2008; 59:464 F Bunn et al Prophylactic antibiotics to prevent surgical site infection after breast cancer surgery Cochrane Database Syst Rev 2012; 1:CD005360 FJ Sanchez-Manuel et al Antibiotic prophylaxis for hernia repair Cochrane Database Syst Rev 2012; 2:CD003769 Coming Soon in Treatment Guidelines: Drugs Some Common Eye Disorders – Nov 2012 Screening Tests for Cancer – Dec 2012 Follow us on Twitter @MedicalLetter Coming soon: Our Facebook page 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Call us at 800-211-2769 or 914-235-0500 or e-mail us at: custserv@medicalletter.org Questions start on next page Treatment Guidelines from The Medical Letter • Vol 10 ( Issue 122) • October 2012 DO NOT FAX OR MAIL THIS EXAM To take CME exams and earn credit, go to: medicalletter.org/CMEstatus Issue 122 Questions To ensure adequate serum and tissue levels before surgery, the first dose of cefazolin should be administered: a >60 minutes after the incision b 2 hours after the incision d 70 years old b with acute acute cholecystitis c with common duct stones d all of the above Issue 122 ACPE UPN: 0379-0000-12-122-H01-P; Release: September 2012, Expire: September 2013 Treatment Guidelines from The Medical Letter • Vol 10 ( Issue 122) • October 2012 ... www.medicalletter.org Take CME Exams Tables Antimicrobial Prophylaxis for Surgery Pages 74-75 Antimicrobial Prophylaxis for Surgery Antimicrobial prophylaxis can decrease the incidence of postoperative... reproduction by any means and imposes severe fines 73 Antimicrobial Prophylaxis for Surgery Table Antimicrobial Prophylaxis for Surgery Recommended Antimicrobials Usual Adult Dosage1 Staphylococcus... Letter • Vol 10 ( Issue 122) • October 2012 Antimicrobial Prophylaxis for Surgery Table Antimicrobial Prophylaxis for Surgery (cont’d) Recommended Antimicrobials Usual Adult Dosage1 Anaerobes,