What is the recommended antibiotic prophylaxis for tracheostomy (surgical creation of an airway)

From the Guidelines

Antibiotic prophylaxis is not routinely recommended for tracheostomy procedures, as the quality of evidence is very poor and there is no randomized study that has assessed the usefulness of antibiotic prophylaxis for tracheotomy. However, a retrospective study by Hagiya et al. 1 reported a significantly lower rate of infection at the tracheotomy site in patients on antibiotic therapy. The 2010 SFAR update concerning antibiotic prophylaxis in surgery and interventional medicine advises against antibiotic prophylaxis for tracheotomy 1.

Key Considerations

• The rate of infection of the operative site ranges between 0 and 33% depending on the study, with percutaneous tracheotomy generally having a lower rate of infection (0-4%) compared to surgical tracheotomy 1.
• The use of ultrasound-guided localization before tracheotomy can reduce the risk of complications, including puncturing a blood vessel, and increase the success of the procedure at the first attempt 1.
• A recent expert panel report from the American College of Chest Physicians/American Association for Bronchology and Interventional Pulmonology/Association of Interventional Pulmonology Program Directors 1 does not provide specific recommendations on antibiotic prophylaxis for tracheostomy.

Recommendations

• The decision to use antibiotic prophylaxis for tracheostomy should be made on a case-by-case basis, taking into account the individual patient's risk factors and the potential benefits and harms of prophylaxis.
• If antibiotic prophylaxis is used, a single preoperative dose of a first-generation cephalosporin such as cefazolin or an alternative antibiotic should be administered within 60 minutes before surgical incision.
• The prophylaxis should be limited to this single preoperative dose unless the procedure is prolonged or involves significant blood loss, in which case a second dose may be warranted.

From the FDA Drug Label

To prevent postoperative infection in contaminated or potentially contaminated surgery, recommended doses are: 1 gram IV or IM administered 1/2 hour to 1 hour prior to the start of surgery. The recommended dose of cefazolin for antibiotic prophylaxis in tracheostomy, which can be considered a contaminated or potentially contaminated surgery, is 1 gram IV or IM administered 1/2 hour to 1 hour prior to the start of surgery 2.

• The dose may need to be repeated during lengthy operative procedures.
• Postoperative doses may also be necessary.

From the Research

Antibiotic Prophylaxis for Tracheostomy

• The use of antibiotic prophylaxis in tracheostomy has been studied to prevent wound infection and other complications 3.
• A preliminary randomized controlled trial found that antibiotic prophylaxis reduced tracheostomy wound infection rate from 23.3% to 6.7%, although the result was not statistically significant 3.
• The study also identified smoking and previous neck irradiation as significant risk factors for wound infection 3.
• Another study explored the use of inhaled antibiotics for the prevention of respiratory tract infections in children with a tracheostomy, and found that it may reduce the number of respiratory tract infections and exposure to broad-spectrum antibiotics 4.

Choice of Antibiotics

• The choice of antibiotics for tracheostomy prophylaxis depends on various factors, including the type of infection and patient allergies 5, 6.
• Clindamycin is a commonly used antibiotic for tracheostomy prophylaxis, especially in patients with penicillin allergy 3, 5.
• Cefazolin is also a suitable option for surgical prophylaxis in penicillin-allergic patients, with no significant difference in adverse events compared to other antibiotics 6.

Clinical Practice Guidelines

• The American Association for Respiratory Care (AARC) has developed clinical practice guidelines for the management of adult patients with tracheostomy in the acute care setting 7.
• The guidelines recommend the use of tracheostomy bundles, multidisciplinary tracheostomy teams, and weaning/decannulation protocols to improve patient outcomes and reduce tracheostomy-related complications 7.