What measures can be taken to prevent surgical site infection in a patient with a history of allergy to penicillin or cephalosporins, and underlying medical conditions such as diabetes, undergoing orthopedic or cardiovascular procedures?

Preventing Surgical Site Infection in Penicillin/Cephalosporin-Allergic Patients with Diabetes Undergoing Orthopedic or Cardiovascular Surgery

For patients with documented penicillin/cephalosporin allergy undergoing orthopedic or cardiovascular procedures, implement a comprehensive infection prevention bundle that includes: (1) allergy verification and potential de-labeling since 90-95% of reported allergies are false, (2) alternative antibiotic prophylaxis with vancomycin or clindamycin if allergy is confirmed, (3) intranasal mupirocin for staphylococcal decolonization, (4) strict glycemic control given diabetes, (5) hair clipping (not shaving) close to surgery time, (6) chlorhexidine-alcohol skin preparation, and (7) maintenance of normothermia. 1

Critical First Step: Verify the Penicillin Allergy

• Up to 98% of penicillin allergy labels are incorrect when tested, and using alternative antibiotics instead of beta-lactams increases surgical site infection odds by 50%. 1
• Low-risk patients who can safely receive cefazolin (the preferred agent for orthopedic and cardiovascular surgery) include those with: 2, 3
  • GI side effects only
  • Remote/childhood history with no details
  • Family history only
  • Unknown reaction type
  • Non-severe rash >10 years ago
• Consider preoperative allergy testing or direct oral challenge in appropriate patients, as this can enable use of superior first-line prophylaxis. 1

Antibiotic Prophylaxis for Confirmed Allergy

For Orthopedic Surgery:

• Vancomycin 15 mg/kg IV (maximum 2 grams) administered over 1-2 hours, beginning within 120 minutes before incision is the preferred alternative. 1, 3
• Clindamycin 600-900 mg IV is an acceptable alternative if vancomycin is contraindicated. 3
• Discontinue prophylaxis within 24 hours postoperatively—extended prophylaxis provides no benefit and increases C. difficile risk and antibiotic resistance. 3

For Cardiovascular Surgery:

• Vancomycin 15 mg/kg IV administered over 1-2 hours before incision is the standard alternative to cephalosporins. 1
• Continue prophylaxis for 48 hours after cardiac surgery completion, which differs from orthopedic procedures. 1
• For procedures >4 hours, redosing is required based on the half-life of the chosen antibiotic. 1

Staphylococcal Decolonization (Critical for All Patients)

• Apply intranasal mupirocin universally to all patients undergoing orthopedic or cardiovascular surgery, as 18-30% are S. aureus carriers with 3-fold increased infection risk. 1
• This intervention has Level IA evidence for reducing surgical site infections in cardiac surgery. 1

Glycemic Control (Essential for Diabetic Patients)

• Maintain strict perioperative glucose control as part of the infection prevention bundle, as hyperglycemia significantly increases SSI risk. 1
• Target normoglycemia throughout the perioperative period. 1

Hair Removal Protocol

• Use electric clippers for hair removal close to the time of surgery—never use razors. 1
• Shaving increases SSI risk, particularly in clean-contaminated surgeries and procedures <2 hours duration. 4
• Clipping should occur immediately before surgery, not the night before. 1

Skin Antisepsis

• Prepare skin with chlorhexidine-alcohol combination, which is optimal for reducing bacterial counts. 1, 5
• For patients with alcohol allergy, use chlorhexidine alone. 1
• Preoperative chlorhexidine showers reduce bacterial counts but have not been proven to significantly reduce SSI rates. 1, 6

Temperature Management

• Maintain perioperative normothermia and avoid both hypothermia and hyperthermia. 1
• In cardiac surgery, hyperthermia (core temperature >37.9°C) during rewarming on cardiopulmonary bypass is associated with cognitive deficits, infection, and renal dysfunction. 1
• Use continuous surface warming combined with controlled rewarming. 1

Intraoperative Measures

• Change gloves and instruments before wound closure, which reduces SSI by 13% in large trials. 1
• Use fascial abdominal wound protectors for abdominal procedures. 1
• Perform abdominal irrigation when indicated. 1

Postoperative Wound Care

• Remove sterile dressings within 48 hours and consider daily incision washing with chlorhexidine. 1
• These measures are potentially beneficial based on available evidence. 1

Critical Pitfalls to Avoid

• Do not assume all penicillin allergies are real—this leads to use of inferior antibiotics and 50% increased infection risk. 1, 2
• Do not extend antibiotic prophylaxis beyond 24 hours for orthopedic surgery (48 hours for cardiac surgery)—this increases C. difficile infection and resistance without benefit. 3, 1
• Do not administer vancomycin or fluoroquinolones <60 minutes before incision—these require 1-2 hours for infusion and should begin within 120 minutes of incision. 1
• Do not shave the surgical site—this creates microabrasions that increase infection risk. 1, 4
• Do not allow perioperative hyperglycemia in diabetic patients—this is a modifiable risk factor with strong evidence for SSI prevention. 1

Implementation as a Care Bundle

• Implement these measures as a bundled intervention rather than individual components, as care bundles of 3-5 evidence-based interventions have moderate-quality evidence for reducing SSI. 1
• The combination of interventions is more effective than any single measure alone. 1