ADMINISTRATION ROUTE For safety, consider pre-mixed products or those that facilitate closed system dilution.

If you haven't already, I suggest you download the new clinical guidelines for antimicrobial prophylaxis in surgery (www.ajhp.org/content/70/3/195.full). In handy chart form, the evidence-based guidelines provide recommendations for timing as well as antibiotic type and dosage for each surgery type. Here are 9 practical pearls to keep in mind as you implement the new guidelines.

Administer antibiotics within 60 minutes before surgical incision. That is the time frame that best ensures adequate tissue and serum concentrations during the period of potential contamination.

Routine use of vancomycin prophylaxis is not recommended for any procedure. Use this drug only in patients with known MRSA colonization or at high risk for MRSA colonization (if it's within your facility policy to accept these patients).

Begin administration of vancomycin and fluoroquinolone within 120 minutes of the surgical incision; prolonged infusion times are required for these drugs.

While the dosing of pediatric patients is based on weight, the dosing of most antimicrobials in adults isn't, because it's safe, effective and convenient to use standardized doses. Exceptions, such as aminoglycosides, should be evaluated, but the new guidelines state that "when used as a single dose for prophylaxis, the risk of toxicity from gentamicin is very low."

For patients weighing more than 264 lbs., you should be using the new standard recommended doses: 3g cephazolin (compared with 2g for adults under that threshold).

The American Society for Gastrointestinal Endoscopy no longer considers any gastrointestinal procedure high risk for bacterial endocarditis, and you therefore needn't routinely use endocarditis prophylaxis, even in patients with the highest-risk cardiac conditions (such as prosthetic valves or prior endocarditis).

For the common antibiotics used in outpatient surgery — cefazolin, gentamicin, ampicillin, vancomycin and ciprofloxacin — regularly review the recommendations of a nursing implications text, such as the annual Mosby's Nursing Drug Reference.

Antibiotics are best prepared as close to the time of administration as possible.

If you're not giving the patient antibiotics by bolus, it's recommended that you consider "pre-mixed products" or those that facilitate closed-system dilution.

Antibiotic stewardship
Using antibiotics prophylactically in surgery should be done with careful attention to each clinical situation. For ambulatory surgical centers, it's even more important now because you need to be tracking antibiotics administered for prophylactic purposes before the surgery or procedure for G-Code reporting to CMS. There are 3 codes — patient with order received antibiotics on time (G8916), patient with order didn't receive on time (G8917), and patient didn't have an order for antibiotics (G8918) — and CMS has indicated that, if antibiotics were ordered, their administration should begin within 60 minutes of incision. Take care and track closely: Your payments in 2014 depend on it.