手術預防性抗生素使用準則

選擇抗生素和替代品,用於常規手術

摘於台灣地區外科手術預防性抗生素之建議使用準則
J Microbiol Immunol Infect 2004; 37: 71-4.

適當使用手術預防性抗生素已證實能降低很多種手術的術後感染。這是很重要的,因為:

  • 全球抗生素的抗藥性危機﹝源於抗生素的過度濫用﹞
  • 自主管理的成本控制與品質保證

標準指引﹝standard guidelines﹞建議預防性抗生素只用在清潔污染傷口﹝Clean-Contaminated Wounds﹞ 與指定的清潔傷口﹝Clean-Wounds﹞手術,但條件為如此預防感染,其好處超過預防的成本和危險。目前醫師與指引的遵從性很差。

預防性抗生素施打的時間應該越靠近手術處置﹝切皮膚前﹞的時間越好,使下刀時與整個手術當中,組織的抗生素濃度都在有效的範圍。唯一的例外情況是剖腹產,第一劑預防性抗生素應延至新生兒生出臍帶夾緊後才給,以避免抗生素經胎盤流到胎兒體內。

抗生素的選擇應考慮抗菌範圍與成效,術前單劑﹝single dose﹞抗生素的使用對大部分的手術處置是足夠的。學理上,長時間的手術可以考慮在 1-2 個半衰期間追加抗生素,
病人離開手術室後施打的抗生素,並未帶來更大的益處
台灣地區外科手術預防性抗生素之建議使用準則
(僅成人)
部位/手術 可能病原體 推薦的抗生素 替代的抗生素 持續時間
Large skin (清潔) Staphylococcus aureus
CoNS
Streptococci
Nil

Cefazolin 1 gm IV at IA
Clindamycin 600 mg IV at IA 1 劑
耳鼻喉科手術
Head and neck (清潔) S. aureus
CoNS
Cefazolin 1-2 gm IV at IA Clindamycin 600 mg IV at IA <1 天
Head and neck (清潔污染) S. aureus
CoNS
Streptococci
Enteric GNB
Cefazolin 1-2 gm IV at IA Clindamycin 600 mg + gentamicin 2mg/kg IV at IA <1 天
Ear (清潔污染) S. aureus
Streptococci
Cefazolin 1-2 gm IV at IA Clindamycin 600 mg IV at IA <1 天
Nose and sinus (清潔污染) S. aureus
Enteric GNB
Anaerobes
Cefazolin 1-2 gm IV at IA Clindamycin 600 mg IV at IA <1 天
Tonsil (清潔污染) S. aureus
Enteric GNB
Anaerobes
Cefazolin 1-2 gm IV at IA Clindamycin 600 mg + gentamicin 2 mg/kg IV at IA <1 天
心血管手術
Coronary artery graft bypassing (清潔) S. aureus
CoNS
Cefazolin 1-2 gm IV at IA then 1 gm q8h Vancomycin 1 gm IV on call to OR <1 天
Prosthetic valve (清潔) S. aureus
CoNS
Cefazolin 1-2 gm IV at IA then 1 gm q8h Vancomycin 1 gm IV on call to OR <1 天
Large vessel in abdomen or lower limb (清潔) S. aureus
CoNS
Cefazolin 1-2 gm IV at IA then 1 gm q8h Vancomycin 1 gm IV on call to OR <1 天
胸腔科手術
Lung (清潔污染), pulmonary resection (lobectomy and pneumonectomy) S. aureus
CoNS
Streptococci
Cefazolin 1-2 gm IV at IA then 1 gm q8h Vancomycin 1 gm IV on call to OR
Clindamycin 600 mg IV + gentamicin 2 mg/kg IV at IA
2GC 1-2 gm
<2 天
Esophagus (清潔污染) S. aureus
CoNS
Enteric GNB
Cefazolin 1-2 gm IV at IA then 1 gm q8h Vancomycin 1 gm IV on call to OR
Clindamycin 600 mg IV + gentamicin 2 mg/kg IV at IA
2GC 1-2 gm IV at IA
<2 天
骨科手術
Total hip arthroplasty (清潔) S. aureus
CoNS
Cefazolin 1-2 gm IV at IA then 1 gm q8h Vancomycin 1 gm IV on call to OR <2 天
Total knee arthroplasty (清潔) S. aureus
CoNS
Cefazolin 1-2 gm IV at IA then 1 gm q8h Vancomycin 1 gm IV on call to OR <2 天
Internal fixation for close reduction (清潔) S. aureus
CoNS
Cefazolin 1-2 gm IV at IA then 1 gm q8h Vancomycin 1 gm IV on call to OR <1 天
Spine (清潔) S. aureus
CoNS
Cefazolin 1-2 gm IV at IA then 1 gm q8h Vancomycin 1 gm IV on call to OR <2 天
Other selective, non-prosthesis bone procedures (清潔) S. aureus
CoNS
Cefazolin 1-2 gm IV at IA then 1 gm q8h Vancomycin 1 gm IV on call to OR <1 天
神經科手術
Craniotomy (清潔) S. aureus
CoNS
Cefazolin 1-2 gm IV Oxacillin 2 gm IV at IA
Vancomycin 1 gm IV on call to OR
<1 天
Ventriculo-peritoneal shunting (清潔) S. aureus
CoNS
Cefazolin 1-2 gm IV Oxacillin 2 gm IV at IA
Vancomycin 1 gm IV on call to OR
<2 天
大腸直腸肛門外科
Colorectum (清潔污染) Enteric GNB
Anerobes
Oral:
Neomycin 1 gm qid + metronidazole 1 gm qid the day before operation
Tinidazole 1 gm the night before operation + Cefoxitin 1-2 gm IV at IA
Cefmetazole 1-2 gm IV at IA
or
Cefazolin 1 gm IV at IA ± gentamicin 2 mg/kg ± metronidazole 500 mg IV at IA
Clindamycin 600 mg IV + gentamicin 2 mg/kg IV at IA
Amoxicillin/clavulanate 750 mg IV at IA
Ampicillin/sulbactam 1.5 gm IV at IA
<1 天
一般外科
Non-complicated appendectomy ( infected) Enteric GNB
Anerobes
Cefoxitin 1-2 gm IV at IA
Cefmetazole 1-2 gm IV at IA
Cefazolin 1 gm + gentamicin 2 mg/kg + metronidazole 500 mg IV at IA
Clindamycin 600 mg IV + gentamicin 2 mg/kg IV at IA
Amoxicillin/clavulanate 750 mg IV at IA
Ampicillin/sulbactam 1.5 gm IV at IA
<1 天
Open biliary (清潔污染) Enteric GNB Cefazolin 1 gm IV at IA Clindamycin 600 mg IV + gentamicin 2 mg/kg IV at IA
2GC 1-2 gm IV at IA
<1 天
Open cholecystectomy (清潔污染) Enteric GNB Cefazolin 1 gm IV at IA Clindamycin 600 mg IV + gentamicin 2 mg/kg IV at IA
2GC 1-2 gm IV at IA
<1 天
Laparoscopic cholecystectomy (清潔污染) Enteric GNB Cefazolin 1 gm IV at IA Clindamycin 600 mg IV + gentamicin 2 mg/kg IV at IA
2GC 1-2 gm IV at IA
<1 天
Gastroduodenal (清潔污染) Gram-positive cocci
Enteric GNB
Cefazolin 1-2 gm IV at IA Clindamycin 600 mg IV + gentamicin 2 mg/kg IV at IA <1 天
Intestinal (清潔污染) Gram-positive cocci
Enteric GNB
Cefazolin 1-2 gm IV at IA Clindamycin 600 mg IV + gentamicin 2 mg/kg IV at IA <1 天
Laparoscopic or non-laparoscopic herniorrhaphy with mesh (清潔) S. aureus
CoNS
Cefazolin 1 gm IV at IA Clindamycin 600 mg IV at IA 1 劑
Laparoscopic or non-laparoscopic herniorrhaphy without mesh (清潔) S. aureus
CoNS
Nil or Cefazolin 1 gm IV at IA Clindamycin 600 mg IV at IA 1 劑
Breast (清潔) S. aureus
CoNS
Nil or Cefazolin 1-2 gm IV at IA Clindamycin 600 mg IV at IA 1 劑
Thyroid (清潔) S. aureus
CoNS
Nil or Cefazolin 1-2 gm IV at IA Clindamycin 600 mg IV at IA 1 劑
泌尿科手術
Transrectal prostate biopsy (清潔污染) Enteric GNB Cefazolin 1 gm IV at IA Gentamicin 2 mg/kg IV on call to OR
Ciprofloxacin 500 mg oral or 400 mg IV on call to OR
1 劑
Transurethral prostate biopsy (清潔污染) Enteric GNB Cefazolin 1 gm IV at IA Gentamicin 2 mg/kg IV on call to OR
Ciprofloxacin 500 mg oral or 400 mg IV on call to OR
<1 天
Transurethral bladder tumor resection (清潔污染) Enteric GNB Cefazolin 1 gm IV at IA Gentamicin 2 mg/kg IV on call to OR <1 天
婦科
Hysterectomy, abdominal or vaginal (清潔污染) Enteric GNB
Group B streptococcus
Anerobes
Cefazolin 1 gm IV at IA
Cefoxitin 1 gm IV at IA
Cefmetazole 1 gm IV at IA
Clindamycin 600 mg IV at IA + gentamicin 2 mg/kg IV at IA
Amoxicillin/clavulanate 750 mg IV at IA
Ampicillin/sulbactam 1.5 gm IV at IA
<1 天
Cesarean section (清潔污染) Enteric GNB
Group B streptococcus
Anerobes
Cefazolin 1-2 gm IV immediately after cord clamping Clindamycin 600 mg IV at IA + gentamicin 2 mg/kg IV at IA <1 天

縮寫名稱解釋

CoNS = coagulase-negative staphylococci; GNB = Gram-negative bacilli; IA = induction of anesthesia; IV = intravenous; 2GC = second-generation cephalosporins; OR = operating room.
vancomycin 只使用於: 1)對 penicillin 類藥物過敏的病患; 2) 施于手術的醫院為 MRSA 高盛行率者
對於 non-complicated appendicitis 的手術, 當被確立診斷時即應給予第一劑而在誘導麻醉時給予第二劑