Antibiotic prophylaxis

1,939 views

Published on

Published in: Health & Medicine, Business
0 Comments
6 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
1,939
On SlideShare
0
From Embeds
0
Number of Embeds
2
Actions
Shares
0
Downloads
198
Comments
0
Likes
6
Embeds 0
No embeds

No notes for slide

Antibiotic prophylaxis

  1. 1. Antibiotic Prophylaxis in SurgeryAntibiotic Prophylaxis in Surgery Prevention of Surgical SitePrevention of Surgical Site InfectionInfection Dr sumer yadavDr sumer yadav
  2. 2. IntroductionIntroduction Background: Infection of the surgical site is aBackground: Infection of the surgical site is a common but avoidable complication of anycommon but avoidable complication of any surgical procedure.surgical procedure. Bacterial contamination of the surgical site isBacterial contamination of the surgical site is inevitable, from the patient’s own flora or theinevitable, from the patient’s own flora or the environment.environment. A U.K. study (1993) showed the prevalence ofA U.K. study (1993) showed the prevalence of wound infection to be 2.6% among 12947wound infection to be 2.6% among 12947 patients of different surgical specialties.patients of different surgical specialties.
  3. 3. It is based on the concept that bacterial contami-It is based on the concept that bacterial contami- nation occurs during surgery, and that thenation occurs during surgery, and that the administration ofadministration of the antibiotic used for prevention must be timed forthe antibiotic used for prevention must be timed for opti-opti- mum blood levels during the operationmum blood levels during the operation.. ..
  4. 4. Bacterial contamination of collections of blood or bodyBacterial contamination of collections of blood or body fluid introduces organisms to an excellent culture medium,fluid introduces organisms to an excellent culture medium, and abscess formation frequently follows. The administra-and abscess formation frequently follows. The administra- tion of antibiotics once an abscess has formed is seldomtion of antibiotics once an abscess has formed is seldom suf-suf- ficient definitive treatment. However, the complication canficient definitive treatment. However, the complication can be prevented if there are high concentrations of antibiotic inbe prevented if there are high concentrations of antibiotic in these collections, making them an unfavourable culturethese collections, making them an unfavourable culture medium. Antibiotic prophylaxis should therefore be admin-medium. Antibiotic prophylaxis should therefore be admin- istered immediately before, or during, surgery. Furtheristered immediately before, or during, surgery. Further prophylaxis for 48hours postoperatively is justified if oozingprophylaxis for 48hours postoperatively is justified if oozing of blood or tissue fluid from internal raw surfaces isof blood or tissue fluid from internal raw surfaces is expectedexpected to continue during this period. The choice of antibiotic isto continue during this period. The choice of antibiotic is dictated by the likely pathogenic contaminantsdictated by the likely pathogenic contaminants..
  5. 5. Goals of antibiotic prophylaxisGoals of antibiotic prophylaxis Reduce the incidence of surgical siteReduce the incidence of surgical site infection (SSI)infection (SSI) Minimize the effect on the patient’s normalMinimize the effect on the patient’s normal bacterial flora.bacterial flora. Minimize adverse side effects ofMinimize adverse side effects of antibiotics.antibiotics. Minimize the emergence of antibioticsMinimize the emergence of antibiotics resistant strains of bacteria.resistant strains of bacteria. Cost effectiveness.Cost effectiveness.
  6. 6. Criteria for defining a surgical siteCriteria for defining a surgical site infectioninfection Superficial incisional SSI: involving the skin and the subcutaneousSuperficial incisional SSI: involving the skin and the subcutaneous tissue. Occurs within 30 days after the operation and shows at leasttissue. Occurs within 30 days after the operation and shows at least one of the followings: A(1/ pain 2/ swelling 3/ redness 4/heat 5/one of the followings: A(1/ pain 2/ swelling 3/ redness 4/heat 5/ tenderness)tenderness) B Purulent drainageB Purulent drainage C Isolation of organismsC Isolation of organisms  Deep incisional SSI:1/ Purulent drainage from the deep incision butDeep incisional SSI:1/ Purulent drainage from the deep incision but not from organ or space component of the surgical site.not from organ or space component of the surgical site. 2/ Deep incision dehiscence or deliberate opening2/ Deep incision dehiscence or deliberate opening 3/ Fever, localized pain or tenderness3/ Fever, localized pain or tenderness 4/ An abscess formation4/ An abscess formation  Organ/space SSI: 1/ An abscess or infection found by radiological,Organ/space SSI: 1/ An abscess or infection found by radiological, histopathological means or at reoperationhistopathological means or at reoperation 2/ Purulent discharge from the drain or culture isolation.2/ Purulent discharge from the drain or culture isolation.
  7. 7. Site specific classification of organSite specific classification of organ space SSI infectionspace SSI infection 1/ Gastrointestinal tract 2/ Intraabdominal1/ Gastrointestinal tract 2/ Intraabdominal 1/ Male or female reproductive tract1/ Male or female reproductive tract 1/ Breast1/ Breast 1/ Upper respiratory tract 2/lower respiratory tract1/ Upper respiratory tract 2/lower respiratory tract 1/Sinusitis 2/ Ear,mastoiditis1/Sinusitis 2/ Ear,mastoiditis 1/Oral cavity1/Oral cavity 1/ Eye other than conjunctivitis1/ Eye other than conjunctivitis 1/ Mediastinitis 2/ Pericarditis 3/Myocarditis 4/ Endocarditis1/ Mediastinitis 2/ Pericarditis 3/Myocarditis 4/ Endocarditis 1/ Arterial or venous infection1/ Arterial or venous infection 1/ Osteomyelitis 2/ Joint or bursa 3/ Disc space1/ Osteomyelitis 2/ Joint or bursa 3/ Disc space 1/ Brain abscess 2/ Meningitis, ventriculitis 3/ Spinal abscess1/ Brain abscess 2/ Meningitis, ventriculitis 3/ Spinal abscess
  8. 8. Guidelines to antibiotic prophylaxisGuidelines to antibiotic prophylaxis of SSIof SSI Risk factors for SSIRisk factors for SSI Common pathogensCommon pathogens Benefits and risks of antibiotic prophylaxisBenefits and risks of antibiotic prophylaxis Administration of intravenous prophylacticAdministration of intravenous prophylactic antibioticantibiotic Cost effectivenessCost effectiveness Factors to be considered in auditing practiceFactors to be considered in auditing practice Antibiotic prophylaxis other than for SSI controlAntibiotic prophylaxis other than for SSI control
  9. 9. Risk factors for surgical siteRisk factors for surgical site infectioninfection Classification of operationClassification of operation Insertion of prosthetic implantsInsertion of prosthetic implants Duration of surgeryDuration of surgery Co morbiditiesCo morbidities
  10. 10. Classification of operationsClassification of operations Clean: No inflammation.Clean: No inflammation. Alimentary,genitourinary or respiratory notAlimentary,genitourinary or respiratory not entered. No break in aseptic technique.entered. No break in aseptic technique. Clean contaminated: Alimentary, genitourinaryClean contaminated: Alimentary, genitourinary or respiratory tracts entered but withoutor respiratory tracts entered but without significant spillage.significant spillage. Contaminated: There is acute inflammationContaminated: There is acute inflammation without pus, macroscopic spillage or openedwithout pus, macroscopic spillage or opened wounds operated within four hours.wounds operated within four hours. Dirty: The presence of pus, previous perforatedDirty: The presence of pus, previous perforated hollow viscous or open injuries more than fourhollow viscous or open injuries more than four hours.hours.
  11. 11. Insertion of prosthetic implantInsertion of prosthetic implant Implants has a detrimental effect on theImplants has a detrimental effect on the host defences. As a result a lowerhost defences. As a result a lower inoculum of bacteria is needed to causeinoculum of bacteria is needed to cause SSI of a prosthetic implant than a viableSSI of a prosthetic implant than a viable tissue, this increases the incidence of SSItissue, this increases the incidence of SSI
  12. 12. Duration of surgeryDuration of surgery The risk is additional to that ofThe risk is additional to that of classification of the operation.classification of the operation.
  13. 13. Co morbiditiesCo morbidities ASA score of >2 is associated with an increasedASA score of >2 is associated with an increased risk of SSI, and this is additional to therisk of SSI, and this is additional to the classification of the operation.classification of the operation. ASA: 1: Normal healthy personASA: 1: Normal healthy person 2: Mild systemic disease2: Mild systemic disease 3:Severe systemic disease that limits3:Severe systemic disease that limits activities of the patientactivities of the patient 4: Incapacitating disease with a constant4: Incapacitating disease with a constant threat to life.threat to life. 5: Not expected to survive more than 245: Not expected to survive more than 24 hours with or without an operation.hours with or without an operation.
  14. 14. Common pathogens antibioticCommon pathogens antibiotic susceptibilitysusceptibility SSI for a skin wound at any site: 1/ Staph aureus . 90% remainsSSI for a skin wound at any site: 1/ Staph aureus . 90% remains sensitive to flucloxacillin, macrolides and clindamycin. 2/ Betasensitive to flucloxacillin, macrolides and clindamycin. 2/ Beta haemolytic streptococci. 90% remains sensitive to penicillinhaemolytic streptococci. 90% remains sensitive to penicillin macrolides and clindamycinmacrolides and clindamycin Additional pathogens: Head and neck surgery: 1/Oral anaerobes.Additional pathogens: Head and neck surgery: 1/Oral anaerobes. 95% remains sensitive to metronidazole and co-amoxyclav95% remains sensitive to metronidazole and co-amoxyclav Additional pathogens: Operations below the waist: 1/ Anaerobes.Additional pathogens: Operations below the waist: 1/ Anaerobes. 95% remains sensitive to metronidazole and co-amoxyclav 2/ E. coli95% remains sensitive to metronidazole and co-amoxyclav 2/ E. coli and other entrobacteriaceae. Complex resistance, but 90% remainsand other entrobacteriaceae. Complex resistance, but 90% remains sensitive to second generation cephalosporins, gentamicin or betasensitive to second generation cephalosporins, gentamicin or beta lactam beta lactamase inhibitors.lactam beta lactamase inhibitors. Insertion of prosthesis, graft or shunt: 1/ Coagulase negativeInsertion of prosthesis, graft or shunt: 1/ Coagulase negative Staph.90% remains sensitive to flucloxacillin, clindamycin orStaph.90% remains sensitive to flucloxacillin, clindamycin or microlides. 2/Staph aureus. 2/3 are MRSA but beta lactammicrolides. 2/Staph aureus. 2/3 are MRSA but beta lactam antibiotics are still appropriate.antibiotics are still appropriate.
  15. 15. MRSE/MRSA antibiotic prophylaxisMRSE/MRSA antibiotic prophylaxis Beta lactam drugsBeta lactam drugs GlycopeptidesGlycopeptides
  16. 16. Benefits and risks of antibioticBenefits and risks of antibiotic prophylaxisprophylaxis Benefits of prophylaxis:1/ related to the severity of consequences ofBenefits of prophylaxis:1/ related to the severity of consequences of SSI e.g. in colonic anastomosis prophylaxis reduces the mortality. InSSI e.g. in colonic anastomosis prophylaxis reduces the mortality. In total hip replacement reduces the long term morbidity, however intotal hip replacement reduces the long term morbidity, however in most operation reduces the short term morbidity.most operation reduces the short term morbidity. 2/ surgical wound infection increases the length of hospital stay2/ surgical wound infection increases the length of hospital stay depends on the type of the operation.depends on the type of the operation.  Risks of prophylaxis:1/ Increased rates of antibiotic resistantRisks of prophylaxis:1/ Increased rates of antibiotic resistant bacteria. 2/ increased incidence of C. defficile carriage in patientsbacteria. 2/ increased incidence of C. defficile carriage in patients received > 24 hours prophylaxis.received > 24 hours prophylaxis.  The final decision depends on: 1/ The patient’s risk of SSI. 2/TheThe final decision depends on: 1/ The patient’s risk of SSI. 2/The potential severity of the consequences of SSI. 3/ The effectivenesspotential severity of the consequences of SSI. 3/ The effectiveness of prophylaxis in that operation. 4/ The consequences of prophylaxisof prophylaxis in that operation. 4/ The consequences of prophylaxis in that patient (e.g. risk of colitis)in that patient (e.g. risk of colitis)
  17. 17. Administration of intravenousAdministration of intravenous prophylactic antibioticsprophylactic antibiotics The choice of antibioticsThe choice of antibiotics Usually a small number of pathogens need to beUsually a small number of pathogens need to be covered. The antibiotic used must reflect thecovered. The antibiotic used must reflect the local information about common pathogens.local information about common pathogens. The choice should include economicThe choice should include economic considerations.considerations. Must be aware that if infection occurs, usually itMust be aware that if infection occurs, usually it remains sensitive to the antibiotic used forremains sensitive to the antibiotic used for prophylaxis.prophylaxis. Penicillin allergy( anaphylaxis, articaria andPenicillin allergy( anaphylaxis, articaria and rash): Do not use penicillin, challenge test forrash): Do not use penicillin, challenge test for cephalosporins and admit another antibiotic incephalosporins and admit another antibiotic in the regime.the regime.
  18. 18. Timing of administrationTiming of administration The risk begins at the time of incision soThe risk begins at the time of incision so effective tissue concentration must beeffective tissue concentration must be reached at that time.reached at that time. This depends on pharmacokinetic of theThis depends on pharmacokinetic of the drug and the route of administration.drug and the route of administration. Ideally 30 minutes within induction ofIdeally 30 minutes within induction of anaesthesia.anaesthesia. Considerations when use a tourniquet andConsiderations when use a tourniquet and in caesarian sections.in caesarian sections.
  19. 19. Additional dose during theAdditional dose during the operationoperation Using antibiotics of short half life(1_2 hours) itUsing antibiotics of short half life(1_2 hours) it seems logical to give an additional dose duringseems logical to give an additional dose during operations that last more than 4 hours.operations that last more than 4 hours. Controlled trials did not show any evidence toControlled trials did not show any evidence to support thissupport this All antibiotics should be administeredAll antibiotics should be administered intravenouslyintravenously Additional doses may be needed if there is bloodAdditional doses may be needed if there is blood loss and dilution by fluid replacementloss and dilution by fluid replacement Controlled trials did not show any benefit ofControlled trials did not show any benefit of further postoperative dosesfurther postoperative doses
  20. 20. Cost effectivenessCost effectiveness Rule 1: The number of patients needed to treatRule 1: The number of patients needed to treat to prevent one wound infection increases into prevent one wound infection increases in operations with low risk of wound infectionoperations with low risk of wound infection Rule 2: Prophylactic antibiotics are given if theyRule 2: Prophylactic antibiotics are given if they are likely to reduce the overall antibioticsare likely to reduce the overall antibiotics consumption (use NNT to compare the likelyconsumption (use NNT to compare the likely prophylactic and therapeutic consumption ofprophylactic and therapeutic consumption of antibiotics)antibiotics) Rule 3: Prophylactic antibiotics are given if theyRule 3: Prophylactic antibiotics are given if they are likely to reduce the overall hospital costsare likely to reduce the overall hospital costs
  21. 21. Factors to be considered in auditingFactors to be considered in auditing practicepractice Date and time of administration and surgicalDate and time of administration and surgical incisionincision Operation performed (elective or emergency)Operation performed (elective or emergency) Classification of operationClassification of operation Justification for prophylaxisJustification for prophylaxis Antibiotic name, dose and routeAntibiotic name, dose and route Number of doses given and indicationsNumber of doses given and indications Duration of operationDuration of operation Previous adverse reactions to antibioticsPrevious adverse reactions to antibiotics
  22. 22. Antibiotics prophylaxis other thanAntibiotics prophylaxis other than for SSI controlfor SSI control Prevention of urinary tract or respiratory tractPrevention of urinary tract or respiratory tract infections after surgeryinfections after surgery Prevention of endocarditisPrevention of endocarditis Topical antibioticsTopical antibiotics Treatment of anticipated infection in dirtyTreatment of anticipated infection in dirty emergency operationsemergency operations Oral antibiotics to achieve selectiveOral antibiotics to achieve selective decontamination of the gutdecontamination of the gut Patients with prosthetic implants undergoingPatients with prosthetic implants undergoing surgery that may cause bacteraemiasurgery that may cause bacteraemia Transplant surgeryTransplant surgery
  23. 23. THE END

×