GUÍA PRÁCTICA CLÍNICA:
PARA LA PROFILAXIS ANTIBIÓTICA EN PROCEDIMIENTOS QUIRÚRGICOS (2017)

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RECOMENDACIONES Y FLUJOGRAMAS

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Ámbito
  • Esta guía debe ser usada en todos los establecimientos del seguro social del Perú (EsSalud), según lo correspondiente a su nivel de atención.
Población y alcance
  • Población: pacientes en quienes se planea un procedimiento quirúrgico.
  • Alcance: profilaxis antibiótica en procedimientos quirúrgicos.
Autores

Expertos clínicos:

  • Julio César Chamán Castillo
    Hospital Edgardo Rebagliati Martins, EsSalud

  • Hally Pacheco Oviedo
    Red Asistencial Apurímac, EsSalud

  • Henry Paucar Olivera
    Red Asistencial Madre de Dios, EsSalud

  • Fernando Villegas Paredes
    Red Asistencial Arequipa, EsSalud

  • Ysabel Chavez Santillán
    Hospital Nacional Alberto Sabogal Sologuren, EsSalud

  • Susana Aranzabal Durand
    Hospital Nacional Edgardo Rebagliati Martins, EsSalud

  • Martín Oyanguren Miranda
    Hospital Nacional Edgardo Rebagliati Martins, EsSalud

  • Ricardo Miguel Carpio Guzmán
    Hospital Nacional Edgardo Rebagliati Martins, EsSalud

  • Hugo Pedro Llerena Miranda
    Hospital Nacional Edgardo Rebagliati Martins, EsSalud

 Metodólogos:

  • César Ugarte Gil
    Consultor Metodológico IETSI, EsSalud

  • Maria Lazo Porras
    Consultor Metodológico IETSI, EsSalud

Coordinadores:

  • Víctor Suárez Moreno
    IETSI, EsSalud

  • Raúl Timaná Ruiz
    IETSI, EsSalud

Descargar PDF con más información sobre la filiación y rol de los autores.

Metodología

Resumen de la metodología:

  • Conformación del GEG: La Dirección de Guías de Práctica Clínica, Farmacovigilancia y Tecnovigilancia, del Instituto de Evaluación de Tecnologías en Salud e Investigación (IETSI) del Seguro Social del Perú (EsSalud), conformó un grupo elaborador de la guía (GEG), que incluyó médicos especialistas y metodólogos.
  • Planteamiento de preguntas clínicas: En concordancia con los objetivos y alcances de esta GPC, se formularon las preguntas clínicas.
  • Búsqueda de la evidencia para cada pregunta: Para cada pregunta clínica, se realizaron búsquedas de revisiones sistemáticas (publicadas como artículos científicos o guías de práctica clínica). De no encontrar revisiones de calidad, se buscaron estudios primarios, cuyo riesgo de sesgo fue evaluado usando herramientas estandarizadas.
  • Evaluación de la certeza de la evidencia: Para graduar la certeza de la evidencia, se siguió la metodología Grading of Recommendations Assessment, Development, and Evaluation (GRADE), y se usaron tablas de Summary of Findings (SoF).
  • Formulación de las recomendaciones: El GEG revisó la evidencia recolectada para cada una de las preguntas clínicas en reuniones periódicas, en las que formuló las recomendaciones usando la metodología GRADE, otorgándole una fuerza a cada una. Para ello, se tuvo en consideración los beneficios y daños de las opciones, valores y preferencias de los pacientes, aceptabilidad, factibilidad, equidad y uso de recursos. Estos criterios fueron presentados y discutidos, tomando una decisión por consenso o mayoría simple. Asimismo, el GEG emitió puntos de buenas prácticas clínicas (BPC) sin una evaluación formal de la evidencia, y mayormente en base a su experiencia clínica.
  • Revisión externa: La presente GPC fue revisada en reuniones con profesionales representantes de otras instituciones, tomadores de decisiones, y expertos externos.
    Recomendaciones que resumen el contenido de la GPC

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    1. Principios generales de la profilaxis

    Descargar PDF con el desarrollo de la pregunta.

    Recomendación 1:
    Una única dosis terapéutica estándar de antibiótico es suficiente para la profilaxis en la mayoría de circunstancias.
    (Recomendación D)

    BPC 1:
    La decisión final en relación a los beneficios y riesgos de la profilaxis en un paciente individual dependerá de:

    • el riesgo del paciente para la infección de sitio quirúrgico (ISQ)
    • la potencial severidad de las consecuencias de ISQ
    • la efectividad de la profilaxis para una cirugía específica
    • las consecuencias de profilaxis en el paciente (por ejemplo, incremento de las infecciones por Clostridium difficile y otros organismos multirresistentes, así como reacciones adversas a medicamentos).
    2. Administración de profilaxis con antibióticos

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    Recomendación 1:
    Los antibióticos elegidos para profilaxis deben cubrir los patógenos esperados en el sitio operatorio.
    (Recomendación C)

    Recomendación 2:
    Al prescribir profilaxis antibiótica a los pacientes que la requieran, siempre se debe considerar el riesgo de infección por Clostridium difficile; así como el mayor riesgo de infección por Clostridium difficile que se asocia a algunos antibióticos (cefalosporinas, fluoroquinolonas, clindamicina, carbapenems).
    (Recomendación C)

    Recomendación 3:
    No se recomienda la profilaxis antibiótica en procedimientos quirúrgicos como única medida de prevención de infecciones urinarias o del tracto respiratorio.
    (Recomendación A)

    Recomendación 4:
    Una dosis única de antibiótico tópico se recomienda para la inserción de un tubo de drenaje timpánico.
    (Recomendación B)

    Recomendación 5:
    Se recomienda profilaxis antibiótica intracámara para cirugía de cataratas.
    (Recomendación A)

    Recomendación 6:
    Se recomienda profilaxis intraocular intracámara o intravítrea al término de la cirugía para lesiones oculares penetrantes (dependiendo de la extensión de la lesión y la presencia o ausencia de un cuerpo extraño intraocular).
    (Recomendación B)

    Recomendación 7:
    No se recomienda el uso rutinario de dispositivos impregnados con antibiótico en neurocirugía.
    (Recomendación C)

    Recomendación 8:
    No se recomienda el uso rutinario de catéteres venosos centrales impregnados con antibióticos.
    (Recomendación A)

    Recomendación 9:
    Para procedimientos quirúrgicos, la profilaxis antibiótica endovenosa se debe administrar dentro de los 60 minutos previos a la incisión dérmica, y lo más cerca posible al momento de la incisión.
    (Recomendación B)

    Recomendación 10:
    En el caso de cesáreas, la profilaxis antibiótica se debe dar antes de la incisión dérmica para reducir complicaciones infecciosas maternas. (Recomendación B)

    Recomendación 11:
    Se recomienda una dosis única de antibiótico con vida media suficientemente prolongada para estar activo durante la cirugía.
    (Recomendación B)

    Recomendación 12:
    Se recomienda una dosis adicional intra-operatoria de antibiótico para cirugía cardiaca mayor de 4 horas, cuando se use un antibiótico con farmacocinética equivalente a cefazolina.
    (Recomendación C)

    Recomendación 13:
    Se debe considerar hasta 24 horas de profilaxis antibiótica en las artroplastías.
    (Recomendación B)

    BPC 1:
    La elección del antibiótico debe considerar los patrones de resistencia de los patógenos locales.

    BPC 2:
    Antibióticos de espectro reducido y de menor costo, deberían ser la primera elección para profilaxis durante una cirugía.

    BPC 3:
    En caso no exista patrones de resistencia de patógenos locales, se revisará las opciones terapéuticas disponibles en el Anexo N°11.

    BPC 4:
    La profilaxis antibiótica para procedimientos quirúrgicos debe ser administrada por vía endovenosa.

    BPC 5:
    El encargado de administrar la profilaxis antibiótica endovenosa es el anestesiólogo y debe realizarlo en sala de operaciones. (Considerar los aspectos contenidos en el ítem “Duración de la profilaxis – específico para cirugías”)

    BPC 6:
    Indicar dosis adicionales de antibiótico para una cirugía más extensa, o agentes de menor duración para mantener actividad durante la cirugía.

    3. Riesgos y beneficios de profilaxis con antibióticos

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    Recomendación 1:
    Pacientes con historia de anafilaxis, edema laríngeo, broncoespasmo, hipotensión, edema local, urticaria o rash inmediatamente después de terapia con penicilina están en mayor riesgo potencial de reacciones de sensibilidad inmediata a beta-lactámicos y no deberían recibir profilaxis con un antibiótico beta-lactámico.
    (Recomendación C)

    Recomendación 2:
    Considerar el uso de un glicopéptido para profilaxis antibiótica en pacientes de cirugía de alto riesgo que son portadores de MRSA.
    (Recomendación A)

    BPC 1:
    En pacientes con antecedente de alergia a la penicilina hay que descartar que hayan tenido una reacción adversa no-inmunológica, (diarrea, vómitos, rash maculopapular no específico) o un episodio erróneamente atribuido al antibiótico (ej. ampicilina e infección por virus Epstein-Barr).

    BPC 2:
    Las políticas locales para profilaxis quirúrgica que recomienden beta-lactámicos como agentes de primera línea deben también recomendar alternativas para pacientes alérgicos a penicilinas o cefalosporinas.

    BPC 3:
    El ser portador de bacterias multirresistentes debe ser identificado como un riesgo potencial para infección de sitio operatorio en cirugías de alto riesgo (ej. implante ortopédico, válvula cardiaca, injerto o shunt vascular o by-pass coronario).

    BPC 4:

    Ante sospecha de colonización por bacterias multirresistentes en pacientes programados para cirugía de alto riesgo, incluir las siguientes medidas:

    • Realizar evaluación con especialistas (infectólogo) o con el responsable de infecciones del establecimiento de salud
    • Tamizaje para los organismos relevantes
    • Cambiar el antibiótico de elección para profilaxis.

    BPC 5:
    Los pacientes portadores de MRSA deben llevar un curso de terapia de erradicación antes de cirugías de alto riesgo.

    BPC 6:
    En casos que requieren profilaxis antibiótica, los pacientes portadores de MRSA programados para cirugía de alto riesgo deberán recibir un antibiótico con actividad para cepas locales de MRSA.

    BPC 7:
    Ante pérdidas de volumen intraoperatoria significativa en adultos (> 1500 ml) considerar añadir una dosis de profilaxis antibiótica luego de la terapia de reemplazo de fluidos.

    BPC 8:
    En caso de pérdidas de volumen intraoperatoria significativa en niños (25 ml/kg) considerar añadir una dosis de profilaxis antibiótica luego de la terapia de reemplazo de fluidos.

    4. Implementación de la guía

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    Recomendación 1:
    Para reducir la prolongación inapropiada de la profilaxis antibiótica quirúrgica, se debe utilizar formularios de prescripción específicos.
    (Recomendación D)

    5. Auditoría de prácticas actuales

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    Recomendación 1:
    Se recomienda realizar auditorías en periodos cortos, a intervalos regulares, con retroalimentación de los partícipes del proceso.
    (Recomendación D)

    BCP 1:
    Todos los aspectos de la profilaxis antibiótica, por ejemplo, cuando no se utiliza la profilaxis a pesar de recomendaciones, debe ser claramente reportados en la historia clínica.

    BCP 2:
    Los protocolos locales deben indicar claramente dónde documentar la profilaxis antibiótica en la historia clínica (ej. la sección “dosis única” del registro de medicamentos, registro de anestesia, o historia clínica).

    BPC 3:
    Registre el mínimo de datos que sirvan para facilitar la auditoría de la adecuada indicación de profilaxis antibiótica quirúrgica.

    BPC 4:
    Debe considerarse el uso de procesos estadísticos de control para lograr cambios efectivos.

    BPC 5:
    Por motivos de auditoría, describir las infecciones de sitio operatorio de acuerdo a los criterios de la Normatividad Institucional vigente.

    6. Comunicación de información

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    BPC 1:
    Los profesionales de la salud deben proveer información adecuada a pacientes y proveedores de salud para incrementar el conocimiento y reducir la ansiedad en relación a ISQ.

    BPC 2:
    Los pacientes colonizados por MRSA u otros agentes multiresistentes deben recibir información sobre los riesgos asociados y sobre las modificaciones a los procedimientos que puedan minimizar estos riesgos.

    BPC 3:
    Todos los departamentos y servicios quirúrgicos deben tener hojas informativas sobre procedimientos quirúrgicos específicos, dirigidas a los pacientes.

    BPC 4:
    Los profesionales de la salud deben informar y dar consejería al paciente sobre los riesgos y beneficios de la profilaxis antibiótica para reducir el riesgo de ISQ.

    BPC 5:
    Los profesionales de la salud deben dar a los pacientes consejería e información sobre el cuidado de la herida operatoria y el monitoreo de signos de infección.

    BPC 6:
    Se debe contar con hojas informativas locales.

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