What are the current Indian guidelines for surgical and perioperative antibiotic prophylaxis?

From the Guidelines

The current Indian guidelines for surgical and perioperative antibiotic prophylaxis recommend administering antibiotics within 60 minutes before surgical incision, with first-generation cephalosporins like cefazolin being the preferred agents for most clean and clean-contaminated surgeries.

Key Recommendations

• Administering antibiotics 15-30 minutes prior to surgical incision to achieve adequate tissue concentration during the procedure 1
• First-generation cephalosporins like cefazolin (1-2g IV) are the preferred agents for most clean and clean-contaminated surgeries due to their broad coverage against common skin flora
• For patients with beta-lactam allergies, alternatives include clindamycin (600-900mg IV) or vancomycin (15mg/kg IV)
• Specific procedures may require targeted coverage:
  • For colorectal surgery, additional anaerobic coverage with metronidazole (500mg IV) is recommended
  • For orthopedic implant surgeries, higher doses of cefazolin (2g IV) are advised

Duration and Redosing

• Prophylaxis should generally be discontinued within 24 hours post-surgery, with single-dose prophylaxis being sufficient for many procedures
• Extended prophylaxis beyond 24 hours increases the risk of antimicrobial resistance without providing additional benefit
• Redosing is necessary during prolonged procedures (over 4 hours) or in cases of significant blood loss

Rationale

These guidelines aim to prevent surgical site infections while minimizing antibiotic resistance by using the narrowest effective spectrum for the shortest appropriate duration, as supported by recent studies 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Current Indian Guidelines for Surgical and Perioperative Antibiotic Prophylaxis

• The Indian Council of Medical Research (ICMR) guidelines for surgical antibiotic prophylaxis are mentioned in the study 2, which assessed the appropriateness of surgical antibiotic prophylaxis in a tertiary care teaching hospital in Central India.
• According to the study 2, the overall compliance of surgical cases with respect to the American Society of Health-System Pharmacists (ASHP) and ICMR guidelines was less than 1%.
• The study 3 also mentions the hospital guidelines for surgical antibiotic prophylaxis in a tertiary care private hospital in India, which includes the choice of antibiotic, timing, and duration of administration.
• However, the study 4 notes that adherence to guidelines regarding perioperative prophylactic antibiotics is yet to translate to common practice in many parts of the world, including India.

Key Recommendations

• The choice of antibiotic should be based on the organism most commonly causing wound infection in the specific procedure, as well as the relative costs of available agents 5.
• The timing of antibiotic administration is critical to efficacy, with the first dose given before the procedure, preferably within 30 minutes before incision 5.
• Readministration of antibiotics at one to two half-lives is recommended for the duration of the procedure, but postoperative administration is not recommended in general 5.
• Cefazolin provides adequate coverage for most types of procedures, but ceftriaxone was the most commonly used antibiotic in the study 2.

Challenges and Limitations

• The study 2 identified major inappropriateness in the selection of antibiotics, which may be attributed to the non-availability of cefazolin in the institute.
• The study 4 notes that injudicious use of broad-spectrum antibiotics for surgical prophylaxis is prevalent in low- and middle-income countries such as India, posing the risk of emergence of resistant microorganisms.
• The study 6 highlights the lack of consensus guidelines for local antimicrobial administration for prophylaxis of surgical site infections, and the uncertainty surrounding the efficacy of this practice.