From: Logan Whitfield
To: Pharmacists
Sent: Friday, November 16, 2018 12:19:25 PM
Subject: ANCEF Shortage and Pre/Post-OP Antimicrobial Prophylaxis Changes
Attachment: ANCEF Shortage Education
ANCEF alternatives for MSSA infections

Hello Pharmacists,

As you are all aware the ANCEF shortage is now in full swing and it is estimated that we have less than a weeks supply if we continue to utilize the drug at our current rate. You should have received an email recently regarding the recommendation of alternative therapies for non-surgical prophylaxis indications such as endocarditis, SSTIs, osteomyelitis, etc. This email is again posted below for your reference. This week various committees met to discuss options for surgical prophylaxis regarding cefazolin and the following was decided and approved to be effective immediately:

1. We as pharmacists are to inform providers that ANCEF is NOT available and cannot be ordered for pre/post-op management.

2. Pharmacists are approved to automatically convert all pre-op prophylaxis ANCEF orders to the non-beta-lactam alternative on the order set, most frequently clindamycin or vancomycin.

3. Pharmacists are approved to automatically convert all handwritten pre-op surgical prophylaxis orders for ANCEF to the non-beta-lactam alternative on the order set, most frequently clindamycin or vancomycin. This may require you to call and determine the appropriate pre-op order set to reference.

4. For all clean/clean-contaminated procedures where cefazolin, clindamycin, or vancomycin are listed on current pre/post-op orders, all post-op antibiotic orders will automatically be discontinued due to no supportive literature/guidelines. Exceptions include post-op orders with 'until drain removed' in neurosurgery patients, for CV surgery post-op orders ≤ 48 hours, and joint replacement post-op orders ≤ 24 hours. In these cases no automatic D/C will be made. In order to aid in the identification of procedures as clean/clean-contaminated versus contaminated/dirty the PACU and surgery nurses are currently being educated on the policy changes. They will be placing stickers on the post-op order sets indicating the surgery category I-IV. Category I and II correspond to clean and clean-contaminated respectively. The corresponding nursing education document is attached above for you to review.

5. The surgery department will no longer be utilizing antibiotics in irrigation solutions. There should be no action required by pharmacists for this change.

6. Pharmacists are approved to automatically discontinue pre-op antibiotic orders for percutaneous procedures involving venous puncture(e.g. tunneled lines, drain placements, etc.).

7. If intra-op wound infection or spillage of bile/bowel contents is discovered, then antibiotics need to be customized by the practitioner. Pharmacists should be aware that they may be presented with orders intra-operatively for antimicrobials, NOT including cefazolin. These orders are OK to be verified.

The AMT pharmacist will be on stand-by for any questions or difficulties encountered via SpectraLink (50286) or email. Please stay-tuned for further updates in this process. Thank you all for your patience.


Thank You,

Philip Logan Whitfield, PharmD
PGY2 Infectious Disease Pharmacy Resident

PREVIOUS EMAIL REGARDING ALTERNATIVES FOR NON-SURGICAL PROPHYLAXIS ORDERS:

Pharmacists,
 

As many of you may know we have just received word that cefazolin is on back-order and is expected to remain so until Fall of next year. At this time we are going to attempt to reserve our remaining supply for perioperative use.

For other indications (e.g. MSSA endocarditis/bacteremia, MSSA SSTI) we will need to recommend alternative therapies to our physicians when cefazolin is being ordered for indications other than surgical prophylaxis. This will require a phone call to the physician if you receive an order for cefazolin in order to recommend an alternative therapy.  Attached is a word document outlining recommended alternative therapies to cefazolin specifically when providing therapy for known/suspected MSSA infections as cefazolin is infrequently used empirically. AMT will be monitoring this as well through Sentri7.

If for any reason you feel uncomfortable making a recommendation to a physician based on the attached document, or are uncertain of the appropriate recommendation to make, please feel free to consult your AMT via SpectraLink (50286)or email.