• Society of Thoracic Surgeons Workforce on Evidence Based Surgery. Antibiotic prophylaxis in cardiac surgery. Part 1, duration of prophylaxis. Chicago (IL): Society of Thoracic Surgeons; 2005. 20 p. [56 references]

This is the current release of the guideline.

Postoperative infection following cardiac surgery

Prevention

Cardiology
Infectious Diseases
Internal Medicine
Thoracic Surgery

Physicians

To provide guidelines on the duration of antibiotic prophylaxis in adult patients undergoing cardiac surgery by answering the following key questions:

• Does the duration of antibiotic prophylaxis influence the probability of developing antibiotic-resistant bacteria?
  • If so, at what postoperative time does this become clinically significant?
• Does the duration of antibiotic prophylaxis influence the incidence of surgical-site infection (SSI)?
  • If so, at what postoperative time does this become clinically significant?

Adult patients undergoing cardiac surgery

Note: The following patients are excluded from the analysis: patients with active preoperative infections, those undergoing cardiac transplantation, patients on immunosuppressive therapy, patients having aortic replacement surgery, and those undergoing off-pump cardiac surgery.

Prophylactic Intravenous Antibiotics

1. Single-dose (24 hour) or multiple dose (48 hour) prophylaxis
2. Duration of antibiotic administration (<48 hours; 48 hours; >48 hours)

• Surgical-site infections (SSI) including:
  • Soft tissue sternal infections
  • Suppurative mediastinitis
• Antibiotic resistance

Searches of Electronic Databases

Not stated

Not stated

Weighting According to a Rating Scheme (Scheme Given)

Levels of Evidence

Level A: Data derived from multiple randomized clinical trials

Level B: Data derived from a single randomized trial or from nonrandomized trials

Level C: Consensus expert opinion

Review of Published Meta-Analyses
Systematic Review with Evidence Tables

Not stated

Expert Consensus

Not stated

Classification of Recommendations

Class I: Conditions for which there is evidence and/or general agreement that a given procedure is useful and effective

Class II: Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure

IIa: Weight of evidence favors usefulness/efficacy

IIb: Usefulness/efficacy is less well established by evidence.

Class III: Conditions for which there is evidence and/or general agreement that the procedure is not useful/effective

A formal cost analysis was not performed and published cost analyses were not reviewed.

Peer Review

Not stated

The levels of evidence (A-C) and classification of recommendations (I-III) are defined at the end of the "Major Recommendations" field.

Antimicrobial Resistance

Guideline Panel Conclusion: The duration of a prophylactic antibiotic regimen is directly related to the probability of developing resistant microorganisms.

Optimal Practice: The duration of a prophylactic antibiotic regimen is limited to the shortest amount of time required to effectively minimize the probability of postoperative infection. Class IIa. Level B.

Surgical Site Infection

1. Chest Tubes and Antibiotic Prophylaxis
   • Guideline Panel Conclusion: The duration of antibiotic prophylaxis should not be dependent on indwelling catheters of any type.
   • Optimal Practice: Decisions regarding the continuation of antibiotic prophylaxis are not guided by the presence of indwelling catheters. Class IIb. Level C.
2. Single-dose prophylaxis
   • Guideline Panel Conclusion: Single dose antibiotic prophylaxis may be effective in cardiac surgery, but there are inconclusive data to confirm this effectiveness. There is insufficient evidence to recommend use of single-dose prophylaxis in cardiac surgery.
   • Optimal Practice: Single-dose prophylaxis is used in circumstances the surgeon considers optimal for patient care. Class IIa. Level B.
3. Prophylaxis for 48 hours
   • Guideline Panel Conclusion: Antibiotic prophylaxis of up to 48 hours duration is unlikely to produce antibiotic resistance.
   • Guideline Panel Conclusion: Antibiotic prophylaxis of 48 hours duration is clinically effective in minimizing infectious complications in cardiac surgery.
   • Guideline Panel Conclusion: Antibiotic prophylaxis of 48 hours duration may be as effective as prophylaxis administered for longer than 48 hours.

Summary Conclusions

There is evidence indicating that antibiotic prophylaxis of 48 hours duration is effective. There is some evidence that single-dose prophylaxis or 24-hour prophylaxis may be as effective as 48-hour prophylaxis, but additional studies are necessary before confirming the effectiveness of prophylaxis lasting less than 48 hours. There is no evidence that prophylaxis administered for longer than 48 hours is more effective than a 48-hour regimen.

Optimal Practice: Antibiotic prophylaxis is not continued for more than 48 hours postoperatively. Class IIa. Level B.

Definitions:

Levels of Evidence

Level A: Data derived from multiple randomized clinical trials

Level B: Data derived from a single randomized trial or from nonrandomized trials

Level C: Consensus expert opinion

Classification of Recommendations

Class I: Conditions for which there is evidence and/or general agreement that a given procedure is useful and effective

Class II: Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure

IIa: Weight of evidence favors usefulness/efficacy.

IIb: Usefulness/efficacy is less well established by evidence.

Class III: Conditions for which there is evidence and/or general agreement that the procedure is not useful/effective

None provided

The type of evidence is identified and graded for some recommendations (see "Major Recommendations" field).

Use of appropriate duration of a prophylactic antibiotic regimen in patients undergoing cardiac surgery will minimize surgical site infection and the development of antibiotic resistance.

Not stated

• These guidelines should not be considered inclusive of all proper methods of care or exclusive of other methods of care reasonably directed at obtaining the same results. Moreover, these guidelines are subject to change over time, without notice. The ultimate judgment regarding the care of a particular patient must be made by the physician in light of the individual circumstances presented by the patient.
• Members of The Society of Thoracic Surgeons (STS) have always placed the interests and welfare of their patients above all other considerations. Accordingly, the STS has an obligation to critically examine the evidence to ensure that the management decisions are consistent with optimal patient care. This is precisely the role of STS practice guidelines.

An implementation strategy was not provided.

Getting Better
Staying Healthy

Effectiveness

• Society of Thoracic Surgeons Workforce on Evidence Based Surgery. Antibiotic prophylaxis in cardiac surgery. Part 1, duration of prophylaxis. Chicago (IL): Society of Thoracic Surgeons; 2005. 20 p. [56 references]

Not applicable: The guideline was not adapted from another source.

2005

Society of Thoracic Surgeons - Medical Specialty Society

Society of Thoracic Surgeons

Workforce on Evidence Based Surgery

Not stated

Not stated

This is the current release of the guideline.

None available

None available

This NGC summary was completed by ECRI on July 28, 2005.

© 2005 The Society of Thoracic Surgeons
The Society of Thoracic Surgeons Practice Guidelines may be printed or downloaded for individual and personal use only. Guidelines may not be reproduced in any print or electronic publication or offered for sale or distribution in any format without the express written permission of the Society of thoracic Surgeons.