Evidence-Based Surgery (PCS CPGs)

Question 1

Antibiotic prophylaxis for:

Biliary, breast and gastroduodenal surgery

Answer 1

Cefazolin 1g IV single dose

Alt: Cefuroxime 1.5 g IV

Question 2

Antibiotic prophylaxis for:

Colorectal surgery

Answer 2

1. Co-amoxiclav 1.2g IV
2. Cefoxitin 2g IV
3. Ampi-sul 1.5g IV

Question 3

Antibiotic prophylaxis for:

CSF shunting

Answer 3

Cloxacillin 1g IV

Alt: Oxacillin 1g IV

Question 4

Antibiotic prophylaxis for:

Cranial procedures other than CSF shunting

Answer 4

Cefuroxime 1.5g IV

Alt: Cefazolin 1g IV + Genta 80 mg

Question 5

Antibiotic prophylaxis for:

TCV Surgeries

Answer 5

Cefazolin 1g IV

Question 6

Antibiotic prophylaxis for:

Orthopedic procedures

Answer 6

Ceftraxone 2g IV

Question 7

Antibiotic prophylaxis for:

Transurethral resection of the prostrate

Answer 7

Gentamicin 80mg IV within 2 hours before surgery

Question 8

Antibiotic prophylaxis for:

Elective groin hernia sugery and groin hernia repair

Answer 8

NO prophylaxis recommended!

A TRAP!

Question 9

in adult patients not undergoing immediate laparotomy, ___ is the imaging modality of choice to determine presence of an intra-abdominal infection.

Answer 9

CT scan

Question 10

Patient was diagnosed to have a periappendiceal phlegmon. Patient has stable vital signs. Is there room for conservative management, i.e. antimicrobial tx without source control?

Answer 10

HIGHLY selected patients with MINIMAL physiologic derangement and a WELL-CIRCUMSCRIBED focus of infection may be treated conservatively.

Question 11

Are blood cultures routinely ordered in patients presenting with community-acquired intraabdominal abscess?

Answer 11

NO. They do NOT provide additional clinically relevant information.

Question 12

Which antibiotic is NOT to be used in the local setting in the management of intraabdominal abscess, due to high resistance rates? Which antibiotics that are traditionally used to cover for anaerobes are NOT recommended locally?

Answer 12

Ampicillin-sulbactam
Aminoglycosides also NOT recommended (too toxic when safer alternatives exist)

NOT recommended anti-anaerobes:
Cefotetan
Clindamycin

Question 13

What are antibiotics of choice for adult patients with mild to moderate community acquired intraabdominal abscesses?

Answer 13

As single agents:
Ticarcillin-clavulanic acid
Cefoxitin
Ertapenem
Moxifloxacin
Tigecycline

Combinations of Metronidazole +
Cefax/Cefu/Cefot/Levo/Cipro

Question 14

For community-acquired infections, do we need to cover for:

1. Enterococcus
2. Candida

Answer 14

NO!

Question 15

If the following are isolated in high risk intra-abdominal infections, what is the antibiotic of choice?

1. Candida albicans
2. Candida albicans in a critically ill patient
3. Enterococci

Answer 15

1. Fluconazole
2. Echinocandins
3. Ampi, Pip-Tazo, Vanco

Question 16

How long is antimicrobial therapy for intraabdominal infections?

Answer 16

4 - 7 days

Question 17

What is the “recommended imaging procedure for patients with suspected appendicitis”

Answer 17

Helical CT of the abdomen and pelvis with IV (not oral or rectal) contrast

Question 18

What is the management of a patient with “well-circumscribed periaapendiceal abscess”?

Answer 18

Percutaneous drainage or operative drainage. Appendectomy is DEFERRED.

Question 19

What is the first imaging technique used for suspected acute cholecystitis or cholangitis?

Answer 19

Ultrasonography

Question 20

Recommended agennts for uncomplicated acute cholecystitis

Answer 20

Cefazolin 1g IV q8
Cefuroxime 1.5g IV q8
Cefoxitin 2g IV q8

FOXy URO got some AZz.

If allergic, FQ + Metro

Question 21

Antibiotic of choice for patient with cholangitis

Answer 21

Ciprofloxacin 200mg IV BID

Ceftazidime 1g IV + Ampi 500mg IV QID + Metronidazole 500mg IV

Question 22

When to give prophylactic antibiotics?

Answer 22

Within 1 hour prior to surgical incision

Question 23

When to give additional doses of prophylactic antibiotics?

Answer 23

1-2x the half life of the drug

Cefox: 3h
Metro/Cipro: 6h

Question 24

Preoperative glucose should be <__.

Answer 24

200mg/dL

Question 25

What is the recommendation re: hair removal prior to surgery?

Answer 25

CLIPPING PRIOR to surgery ONLY if hair interferes with incision

Question 26

To reduce infection, operative time for colorectal surgery should be less than ____ hr.

Answer 26

3 hours

Question 27

Treatment of Skin and Soft Tissue Infections Impetigo / Cutaneous Abscess

Answer 27

Incision and breaking of pus; breaking up of loculations

Question 28

Treatment of Skin and Soft Tissue Infections Furuncles (Boils) / Carbuncles

Answer 28

Small furuncles: Moist heat Large furuncles / All carbuncles: Incision and drainage NO antibiotics unless with: 1. Cellulitis 2. Fever

Question 29

Treatment of Skin and Soft Tissue Infections Cellulitis / Erysipelas

Answer 29

Penicillin | Roxithromycin is equivalent.

Question 30

Treatment of Skin and Soft Tissue Infections MRSA infection

Answer 30

Doxycycline Clindamycin TMP-SMX Rifampin Always culture lesions and perform susceptibility testing.

Question 31

Treatment of Skin and Soft Tissue Infections Necrotizing infections / Fourniere's gangrene

Answer 31

Surgical debridement! Do repeat debridement 24 - 36h after initial and daily thereafter. Antibiotics: Ampi - aerobic, E. coli, G+ Clinda - anaerobes, aerobic G+ cocci Metro - enteric G- anaerobes For Streptococcal TSS: Clinda + Pen

Question 32

Treatment of Skin and Soft Tissue Infections Surgical site infections

Answer 32

``` Open incision. Evacuate infected material. Change dressing. Let wound heal by secondary intention NO antibiotics! ```

Question 33

Treatment of Skin and Soft Tissue Infections Antibiotic of choice in px with neutropenia with G+ organisms

Answer 33

Vancomycin

Question 34

Which of the following are accepted routine local maneuvers to prevent catheter-associated UTI? ( A. Daily meatal cleansing with povidone iodine solution B. Polyantibiotic ointment C. Green soap or water D. Catheter irrigation with antimicrobials

Answer 34

NONE of the above! There are no generally accepted routine local maneuvers.

Question 35

Recommended site for central venous catheter placement

Answer 35

Subclavian | > Femoral, jugular

Question 36

Is antibiotics prophylaxis needed for intubated patients requiring tracheostomy

Answer 36

YES!

Question 37

What is the appropriate timing of tracheostomy in patients on prolonged mechanical ventilation

Answer 37

Within the FIRST WEEK in critically ill adult patients

Question 38

What signs on physical examination have been documented to be associated with increased perioperative cardiac morbidity and mortality?

Answer 38

S3 heart sound Neck vein engorgement Rales (Signs of CHF)

Question 39

Which of the following confers the higher cardiac risk? A. Thoracic surgery B. Emergency surgery C. Vascular surgery D. Abdominal surgery

Answer 39

B and C