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Perioperative Antimicrobial Prophylaxis Adjustment – Adult/Pediatric – Inpatient/Ambulatory/Emergency Department [75]

Perioperative Antimicrobial Prophylaxis Adjustment – Adult/Pediatric – Inpatient/Ambulatory/Emergency Department [75] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Delegation/Practice Protocols, Inpatient Delegation Protocols


1

Delegation Protocol Number: 75

Delegation Protocol Title:
Perioperative Antimicrobial Prophylaxis Adjustment - Adult/Pediatric - Inpatient/Ambulatory/Emergency
Department

Delegation Protocol Applies To:
All preoperative and preprocedural antibiotic orders excepting those for neonates (younger than 30
days old), ENT, Oncology, and patients with indwelling CSF catheters

Target Patient Population:
Surgical patients with prophylactic perioperative antimicrobial orders.

Delegation Protocol Champion:
Barry C. Fox, MD - Clinical Professor of Medicine, Division of Infectious Disease

Delegation Protocol Workgroup:
Megan Donovan, PharmD - Perioperative Pharmacy Services
Joshua Vanderloo, Clinical Pharmacist - Drug Policy Program
Lucas Schulz, PharmD, BCPS, - Critical Care and Infectious Disease Pharmacist

Responsible Department:
Department of Pharmacy

Purpose Statement:
To delegate authority from the surgical provider for the case to pharmacists to adjust perioperative
surgical prophylactic antimicrobial therapy to an appropriate weight-based dose, dosing interval, and
duration of antimicrobial coverage as outlined in the UW Health Surgical and Interventional Radiology
Antimicrobial Prophylaxis – Adult/Pediatric - Inpatient/Ambulatory/Emergency Department - Clinical
Practice Guideline.

This protocol also delegates authority from the surgical provider to pharmacists to choose an alternative
prophylactic perioperative antimicrobial, if necessary, for patients with a reported or documented
allergy, intolerance, or contraindication to the ordered antimicrobial.

Who May Carry Out This Delegation Protocol:
Pharmacists who are trained in the use of this delegation protocol.

Guidelines for Implementation:
1. This protocol is initiated when a patient is scheduled for a procedure with orders for prophylactic
antimicrobial therapy.
2. If a procedure is not included Surgical and Interventional Radiology Antimicrobial Prophylaxis –
Pediatric/Adult – Inpatient – Clinical Practice Guideline the pharmacist will contact the surgical
provider for antimicrobial order.
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

2

3. If an appropriate antibiotic cannot be selected due to a patient’s allergy/intolerance list despite
pharmacist evaluation following the Surgical and Interventional Radiology Antimicrobial Prophylaxis
– Pediatric/Adult – Inpatient – Clinical Practice Guideline, or there are other remaining uncertainties,
the pharmacist will contact the surgical provider for antimicrobial order.
4. Prior to order validation of prophylactic perioperative antimicrobials, the pharmacist will verify the
patient’s weight and review the need for a weight-based dose adjustment based on UW Health
Surgical and Interventional Radiology Antimicrobial Prophylaxis – Adult/Pediatric -
Inpatient/Ambulatory/Emergency Department - Clinical Practice Guideline and Surgical Care
Improvement Project measures (SCIP). A weight documented in Health Link within the past 30 days
may be used for this protocol. If a dose adjustment is required, the pharmacist re-enters an order
for the appropriate dose of antimicrobial.
5. The pharmacist will schedule the prophylactic antimicrobial "on call" and assign the correct phase of
care such that it is available for administration prior to incision.
6. The pharmacist reviews the overall duration of the prophylactic perioperative antimicrobial
coverage for a duration. If antimicrobial coverage is ordered for 72 hours or less, but greater than 24
hours post incision closure (time is documented in the Surgical Encounter for that procedure), or 48
hours for cardiothoracic surgery, then the pharmacist will re-enter the order for a duration not to
exceed 24 hours, or 48 hours for cardiothoracic surgery.
7. The pharmacist will review the patient’s medication allergies and medical history. If the patient has
a documented or reported allergy, intolerance, or contraindication to the ordered antimicrobial or
an antimicrobial in the same chemical classification, the pharmacist will contact the patient, as
needed, for clarification of the reaction. If necessary, an appropriate alternative is chosen based on
the UW Health Surgical and Interventional Radiology Antimicrobial Prophylaxis – Adult/Pediatric -
Inpatient/Ambulatory/Emergency Department - Clinical Practice Guideline and Beta-Lactam Allergy
– Adult - Inpatient - Clinical Practice Guideline. The alternate regimen will be ordered in Health Link.
Changes to the ordered medication for any reason other than an allergy or contraindication will
require an order from the prescriber.
8. Prior to order validation of the selected prophylactic postoperative antimicrobial, the pharmacist
will check the time of the last dose of the same antimicrobial, or an antimicrobial with the same
antimicrobial coverage based on the UW Health Surgical and Interventional Radiology Antimicrobial
Prophylaxis – Adult/Pediatric - Inpatient/Ambulatory/Emergency Department - Clinical Practice
Guideline.
8.1. The pharmacist reviews the UW Health Surgical and Interventional Radiology Antimicrobial
Prophylaxis – Adult/Pediatric - Inpatient/Ambulatory/Emergency Department - Clinical Practice
Guideline dosing interval guidelines and the anesthesia intra-procedure record or brief
operative note for documentation of blood loss supporting the need for a dose of antimicrobial
at the time ordered.
8.2. If a dose of antimicrobial is not required at the time ordered per UW Health Surgical and
Interventional Radiology Antimicrobial Prophylaxis – Adult/Pediatric -
Inpatient/Ambulatory/Emergency Department - Clinical Practice Guideline interval guidelines
or intra-operative blood loss, the pharmacist will reschedule the dose for the appropriate time
(keeping in mind the 24- or 48-hour duration of coverage limit as applicable).
9. If the provider does not want the pharmacist to initiate dose and interval adjustments to
perioperative prophylactic antimicrobials based on the UW Health Surgical and Interventional
Radiology Antimicrobial Prophylaxis – Adult/Pediatric - Inpatient/Ambulatory/Emergency
Department - Clinical Practice Guideline, then the order must indicate “do not adjust per protocol”
in the administration instructions.
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

3

10. If a change in dosage, duration, or medication is indicated, then the pharmacist will discontinue the
current order and re-enter an order for the appropriate dosage with order mode “Protocol/Policy
without cosign”.
11. If any change in dose, duration or medication occurs, the pharmacist will document that the change
is made per protocol in the electronic medical record.

Order Mode: Medications: Protocol/Policy without cosign

References: UW Health. UW Health Surgical and Interventional Radiology Antimicrobial Prophylaxis –
Adult/Pediatric - Inpatient/Ambulatory/Emergency Department - Clinical Practice Guideline. December
2014. https://uconnect.wisc.edu/clinical/cckm-tools/content/cpg/infection-and-isolation/name-97542-
en.cckm.

Collateral Documents/Tools:
UW Health Surgical and Interventional Radiology Antimicrobial Prophylaxis – Adult/Pediatric -
Inpatient/Ambulatory/Emergency Department - Clinical Practice Guideline

Approved By:
UWHC Pharmacy Practice Committee: April 2011, February 2015
UWHC Pharmacy Practice Infectious Disease Subcommittee: October 2012, February 2015
UWHC Antimicrobial Use Subcommittee: November 2012, February 2015
UWHC Pharmacy & Therapeutics Committee: December 2012, March 2015
UWHC Medical Board: January 2013, April 2015

Effective Date: April 2015

Scheduled for Review: April 2017


Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

4

Antimicrobial selection in patients with reported β-lactam allergy or intolerance (from Surgical and Interventional Radiology
Antimicrobial Prophylaxis Clinical Practice Guideline)








Surgical Prophylaxis
No
Yes
Order, process and / or
administer beta-lactam
antibiotic
Type of reaction?
Clean Procedures: Vancomycin is preferred.
Clindamycin can be utilized, but currently not preferred due to: 1) risk of Clostridium difficile
infection and 2) increasing rates of Staphylococcal resistance to clindamycin.
If additional gram-negative coverage is desired, Gentamicin 5mg/kg x1* is preferred.
Alternatively Ciprofloxacin 600mg IV can be given for patients with renal impairment, balancing
the increased risk for Clostridium difficile infection.

Clean / Contaminated or Contaminated Procedures:
Gentamicin 5mg/kg x1* PLUS Metronidazole 500mg IV is preferred.


Alternatively, Ciprofloxacin 600mg IV PLUS Metronidazole 500mg IV can be given for patients
with renal impairment, balancing the increased risk for Clostridium difficile infection.

Clindamycin PLUS Gentamicin OR Ciprofloxacin can be utilized, but currently not preferred
due to: 1) risk of Clostridium difficile and 2) increasing rates of Staph resistance to clindamycin
*Intraop redosing and post-op dosing are not usually necessary with 5mg/kg dosing

Add vancomycin if patient has history of or documented MRSA
Penicillin or Carbapenem
allergy
Has patient received antibiotic
in same class in the past
without reaction?
Yes
No
History of beta-
lactam allergy /
adverse reaction?
Penicillin Allergy:
First Line: Cephalosporin
Second Line: Carbapenem
Carbapenem Allergy:
First Line: Penicillin or
Cephalosporin

Adverse Reaction / Side
Effect
(examples: GI intolerance,
headache)
Unable to ascertain type of reaction from patient,
family or medical record

OR

Non-severe, Non-IgE mediated reaction
(for example: delayed macular popular rash)

OR

Possible IgE mediated reaction occurring WITHIN
72 hours
(for example: Rash + hives)

OR

IgE mediated reaction occurring WITHIN 24 hours
(for example: angioedema, anaphylaxis

OR

Severe, Non-IgE mediated reaction
(for example: hemolysis, Stevens-Johnson
syndrome)


Prescribe beta-
lactam antibiotic
from different class
based on class of
beta-lactam allergy
Unable to ascertain type of
reaction from patient, family
or medical record

OR

Non-Severe, Non-IgE
mediated reaction occurring
AFTER 72 hours
(for example: delayed
macular papular rash)
Possible IgE mediated
reaction occurring WITHIN
72 hours
(for example: Rash + hives)

OR

IgE mediated reaction
occurring WITHIN 24 hours
(for example: angioedema,
anaphylaxis

OR
Severe, Non-IgE mediated
reaction
(for example: hemolysis,
Stevens-Johnson
syndrome)


Cephalosporin
allergy

Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org