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Ann Thorac Surg 2004;77:755-756
© 2004 The Society of Thoracic Surgeons

Correspondence

Cefazolin prophylaxis during cardiac operations

Jean-Jacques Lehot, MD, PhD

Service d'Anesthésie Réanimation, Hôpital Cardiovasculaire et Pneumologique Louis Pradel, BP Lyon Montchat, 69394 Lyon Cedex 3, France

e-mail: jean-jacques.lehot{at}chu-lyon.fr

To the Editor:

I read with interest the article on prophylactic cefazolin sodium for cardiac operations with cardiopulmonary bypass [1]. To guarantee serum antibiotic levels greater than the minimum inhibitory concentration during such surgical procedures at this institution, my colleagues and I performed similar studies with successive antibiotic prophylaxis regimens in adults [2, 3] and infants [4]. These studies probably contributed to the low rate of deep sternal wound infections (0.9% in 2001). In adults [3], the administration of a 30-minute infusion of cefazolin, 25 mg/kg, immediately after induction of anesthesia achieved serum levels consistently greater than the minimum inhibitory concentration for sensitive bacteria (4 µg/mL). In contrast, we recently observed an increased incidence of sternal infections when cefazolin, 1 g, was administered before the surgical incision was made. A case-control study suggested that weight greater than 70 kg was a risk factor for deep sternal infection (F. Vandenesch; personal communication). This case-control study confirmed that a standard dose of 1 g may be insufficient and that the antibiotic dose should be based on the patient's weight. The total dose can be administered either immediately after induction [3] or divided into two successive doses as proposed by Fellinger and co-authors [1].

The consequences of hemodilution at the onset of cardiopulmonary bypass depend on the amount and the nature of the priming volume. When only crystalloids are in the priming fluid, the proportion of free serum cefazolin increases and offsets the effects of hemodilution. An assumption that 80% of cefazolin is protein bound is true only if the plasma protein concentration remains stable [5]. In addition, temperature during cardiopulmonary bypass should be given in the report, and reference 9 in the study by Fellinger and associates does not correspond to the Centers for Disease Control.

Finally, as several authors [3, 5–7] have reported, "it is unclear if this cefazolin dosing regimen [1 to 2 g intravenously given on call to the operating room or at the induction of anesthesia] produces adequate blood levels" [1] during cardiac surgical procedures.

References

  1. Fellinger E.K., Leavitt B.J., Hebert J.C. Serum levels of prophylactic cefazolin during cardiopulmonary bypass surgery. Ann Thorac Surg 2002;74:1187-1190.[Abstract/Free Full Text]
  2. Lehot J.J., Reverdy M.E., Etienne J., et al. Oxacillin and tobramycin serum levels during cardiopulmonary bypass. J Cardiothorac Anesth 1989;3:163-167.[Medline]
  3. Lehot J.J., Reverdy M.E., Etienne J., et al. Cefazolin and netilmicin serum levels during and after cardiac surgery with cardiopulmonary bypass. J Cardiothorac Anesth 1990;4:204-209.[Medline]
  4. Haessler D., Reverdy M.E., Neidecker J., et al. Antibiotic prophylaxis with cefazolin and gentamicin in cardiac surgery for children less than ten kilograms. J Cardiothorac Vasc Anesth 2003;17:221-225.[Medline]
  5. Miller K.W., McCoy H.G., Chan K.K., et al. Effect of cardiopulmonary bypass on cefazolin disposition. Clin Pharmacol Ther 1980;27:550-556.[Medline]
  6. Akl B.F., Richardson G. Serum cefazolin levels during cardiopulmonary bypass. Ann Thorac Surg 1980;29:109-112.[Abstract]
  7. O'Rullian J.J., Wise R.K., McCoach R.M., Kingsley C.P., Williams D.R. The effects of haemofiltration on cefazolin levels during cardiopulmonary bypass. Perfusion 1998;13:176-180.[Abstract/Free Full Text]




This Article
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