Volume 7, Issue 12 S A M B A T A L K S - PAGE 2 May, 2008

JOIN THE DISCUSSION - TOP

Need advice about a problem case in ambulatory anesthesia? Suggestions about a difficult situation in your ambulatory surgery center? A reply to questions others have raised about ambulatory anesthesia issues?

If you answered "yes" to any of these questions, or would like to share with other professionals a comment or opinion on a topic related to ambulatory anesthesia then please "Join the Discussion".

Your question, reply or comment will be published in the next available issue of SAMBA TALKS. Include your name (or initials), email address, city, and state, if you would like these published. Please note that because of the high volume of questions we receive, there is often a delay of 1 to 2 months before publication.

SAMBA Talks will include all discussion questions we receive considered of interest to the membership at large. We will endeavor to publish a response to at least one of these questions. The response will be from experts in the field, and from those willing to express a view on a particular topic, backed by experience and/or published evidence. Where email addresses are published, those individuals have indicated their interest in discussing the published questions.

Questions and responses from previous months are now available at the eNewsletter Discussion Archive. If you have any comments regarding the previous questions, please submit them to SAMBA Discussion, and they will be published here next month.

Please note: The information presented in the replies below does not represent SAMBA policy. The replies are solely the opinions of the individuals who wrote them.

?? - LAST MONTH'S QUESTION WITH REPLIES - ?? - TOP

What rationale, if any, exists for routine use of vancomycin for prophylactic antibiosis in patients receiving implanted sacral nerve stimulators? You could characterise this as a low risk, but "high consequence" (of infection) procedure.

Does vancomycin actually have greater prophylactic efficacy compared with cefazolin against MRSA? Or any other organism for that matter? 

-- From: Anonymous

REPLY 1

Great question. Vancomycin certainly has acquired the reputation of being the prophylactic antibiotic of choice in high risk situations e.g. cardiac surgery.

Given the higher cost and difficulties associated with the administration and timing of vancomycin it would certainly be worthwhile establishing whether this reputation is deserved. It is also becoming important to limit the use of vancomycin because overuse has contributed to the emergence of multidrug resistant organisms.

I am not aware of any clinical evidence that vancomycin has greater prophylactic efficacy against MRSA. But who is brave enough to mount such a trial?

The crucial initial step in invasive microbial disease is tissue adherence. There is a view that the prevention of tissue adherence is accomplished equally well by almost any antibiotic that has a spectrum of efficacy that includes the likely infective organisms. The important thing is to get the antibiotic in at the appropriate time to achieve adequate tissue levels. However this view has not been put to the test clinically.

There is evidence that universal surveillance of hospital patients for MRSA can reduce the incidence of MRSA infection. Selective testing has been less successful. Nevertheless, in areas of high MRSA prevalence it would be worthwhile considering the screening of patients about to undergo implanted sacral nerve stimulators that would help guide the rational choice of antimicrobial prophylaxis. New assays have a 24 hour turnaround time.

-- From: Gary Kantor, M.D., Cleveland, OH

Reply 2

It would seem to me that you need skin coverage for this surgery (staph and strep). The problem with Vancomycin is that it is not as effective an antibiotic. It is more a static agent than cidal. Granted it has a broader range of coverage for resistant staph. Unless you have a huge problem with community MRSA (which will require consulting with the local infection control people) than a Beta Lactam is a better antibiotic. The ID people obviously hate the routine use of Vanco for fear of loss of efficacy due to increased resistance.

-- From: Robert Helfand, M.D., Cleveland, OH

Reply 3

Antibiotic prophylaxis for surgery is indicated to reduce the risk of infection at the time of the operation. The use of vancomycin as a prophylaxis agent in patients not allergic to beta lactams (e.g. cefazolin) should be directed toward those surgical procedures where there is a high risk of MRSA infection (or known carriage of MRSA) preoperatively. As more patients are being screened for the presence of Staphylococcal aureus carriage prior to surgical procedures it is important to “match” the appropriate systemic antimicrobial agent with the antimicrobial susceptibility of the S. aureus detected in the screening cultures (if done).

-- From: Steven M. Gordon, M.D., Cleveland, OH

?? -- THIS MONTH'S QUESTION -- ?? - TOP

I would like to receive your input on the following two part question in regards to ACE inhibitors:

1. Does your institution have a policy to have patients hold the intake of ACE inhibitors on the day of surgery?
2. If so, does the policy differ in regards to type of anesthetic (local or MAC) or inpatient vs outpatient procedures?

Thanks

-- From: Doug Merrill, M.D., Iowa City, Iowa

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