Antibiotics in surgery

1. ANTIBIOTICS IN SURGERY
BY AMIRAH IZZATI

2. OUTLINES
• INTRODUCTIONS
• ANTIBIOTICS CLASSIFICATION
• TYPE OF SURGICAL WOUND
• USES OF ANTIBIOTICS IN SURGERY
• PROPHYLAXIS
• THERAPEUTIC
• TAKE HOME MESSAGES

3. ANTIBIOTICS
• DEFINITIONS:
SUBSTANCES PRODUCED BY MICROORGANISMS WHICH
SELECTIVELY SUPPRESS THE GROWTH OF OR KILL OTHER
MICROORGANISMS AT VERY LOW CONCENTRATIONS.

4. ANTIBIOTICS CLASSIFICATIONS
• CHEMICAL STRUCTURES
• MODE OF ACTION
• INHIBIT CELL WALL SYNTHESIS
• INHIBIT PROTEIN SYNTHESIS
• INHIBIT DNA GYRASE
• INHIBIT RNA SYNTHESIS
• LEAKAGE FROM CELL MEMBRANE
• INTERFERE WITH DNA SYNTHESIS
• TYPES OF ORGANISMS
• SPECTRUM ACTIVITY
• TYPES OF ACTION(BACTERIA STATIC,BACTERIACIDAL)

8. CHEMOPROPHYLAXIS
• GOAL OF ANTIMICROBIAL PROPHYLAXIS IS TO PREVENT
SURGICAL SITE INFECTION (SSI) BY REDUCING THE BURDEN
OF MICROORGANISMS AT THE SURGICAL SITE DURING THE
OPERATIVE PROCEDURE
• SINGLE DOSE PROPHYLAXIS IS USUALLY SUFFICIENT. IF
PROPHYLAXIS IS CONTINUED POST-OPERATIVELY,
DURATION SHOULD BE LESS THAN 24 HOURS (UP TO 48
HOURS FOR CARDIAC SURGERY),REGARDLESS OF THE
PRESENCE OF INTRAVASCULAR CATHETERS OR INDWELLING
DRAINS.
• IF PRESENCE OF PRE-EXISTING INFECTIONS (KNOWN OR
SUSPECTED), USE APPROPRIATE TREATMENT REGIMEN
INSTEAD OF PROPHYLATIC REGIMEN FOR PROCEDURE.

9. • OPTIMAL TIME FOR ADMINISTRATION OF PRE-OPERATIVE
ANTIBIOTICS IS 60MINUTES PRIOR TO SURGICAL INCISION.
• SOMES AGENTS, E.G FLUROQUINOLONES AND
VANCOMYCIN, REQUIRE ADMINISTRATION OVER ONE TO
TWO HOURS, THEREFORE,ADMINISTARTION OF THESE
AGENTS SHOULD BEGIN WITHIN 120MINUTES BEFORE
SURGICAL INCISION
• AN ADDITIONAL DOSE OF PROPHYLATIC ANTIBIOTIC
DURING OPERATION IS INDICATED IF:
 EXCESSIVE BLOOD LOSS (>1500ML)
 PROCEDURES EXCEED TWO HALF-LIFE OF THE DRUG
 IF THERE ARE OTHER FACTORS THAT MAY SHORTEN THE
HALF-LIFE OF THE PROPHYLATIC AGENT( E.G EXTENSIVE
BURNS)

10. CHEMOPROPHYLAXIS –
GENERAL SURGERY
PREFERABLE ALTERNATIVE
It is either involve into lumen of
git (bariatic /
pancreaticoduodenectomy) or
not (anti reflux / high selective
vagotomy)
IV CEFAZOLIN IV CEFUROXIME
Appendectomy
@ colorectal
@ small intestine
IV CEFAZOLIN +
IV FLAGYL
OR
IV UNASYN
IV CEFUROXIME + IV
FLAGYL
NB: IN PENICILLIN
ALLERGY  IV
GENTAMICIN + IV
CLINDAMYCIN
Hernia repair with mesh
@ breast cancer surgery
@ breast reshaping procedure
@ breast surgery implant
IV CEFAZOLIN IV UNASYN
OR
IV AUGMENTIN

11. CHEMOPROPHYLAXIS –
UROLOGICAL SURGERY
(DIAGNOSTIC &
ENDOUROLOGICAL)
COMMON
ORGANISMS
PREFERABLE ALTERNATIVE
Transrectal US
guided and
Prostate Biopsy
E. Coli, Kliebsella,
Proteus,
Enterococcus,
Pseudomonas
T.
CIPROFLOXACIN
±
IV GENTAMICIN
Targeted abx
therapy based on
pre-op rectal swab
result
Cystoscopy /
urodynamic study
No need abx
Retrograde
pyelogram (RPG)
/ ureteric stent
T. CEFUROXIME
(stat)
Endourological
surgery
Eg. PCNL, URS,
E. Coli, Kliebsella,
Proteus,
Enterococcus,
IV AUGMENTIN
OR
IV UNASYN
IV CEFUROXIME
OR IV FORTUM (if
urine grew

12. CHEMOPROPHYLAXIS –
UROLOGICAL SURGERY(OPEN
SURGERY)
COMMON
ORGANISM
S
PREFERABLE ALTERNATIVE
Clear op
Eg. Orchidectomy,
orchidopexy,
varicocelectomy,
deroofing renal cyst
No need abx
Clean contaminated
(with opening of urinary
tract)
Eg. Nephrectomy,
prostatectomy, open
stone surgery
E. Coli,
Kliebsella,
Proteus,
Enterococc
us,
Pseudomo
nas
IV AUGMENTIN
OR
IV UNASYN
IV CEFOBID
OR
IV FORTUM
Clean contaminated
(with opening of bowel
segment)
Eg. Cystectomy +
Same as
above
IV CEFOBID + IV
FLAGYL
IV GENTAMICIN +
IV FLAGYL

13. CHEMOPROPHYLAXIS –
HEPATOBILIARY SURGERY
PREFERABLE
Laparoscopic & Open surgery (low risk) IV CEFAZOLIN
Laparoscopic (high risk)
eg. Stent insertion, biliary obstruction (high direct
bilirubin)
IV CEFAZOLIN
+ IV GENTAMICIN
Open surgery (high risk)
Eg. Multiple ERCP (≥2) done with stenting , biliary
obstruction , biliary infection surgery w/in <30days
IV CEFAZOLIN
+ IV GENTAMICIN
Pre-existing infection before surgery, gall bladder
empyema, ascending cholangitis
Initiate abx
according to culture
result

14. CHEMOPROPHYLAXIS –
VASCULAR SURGERY
COMMON
ORGANISMS
PREFERABLE ALTERNATIVE
Amputation of
ischemic limb
Staphylococcus,
Anaerobe
IV UNASYN IV AUGMENTIN
Open &
endovascular
repair of abd
aneurysm
@ bypass
surgery
@ AV graft
IV AUGMENTIN
If high risk for
MRSA / allergic
to penicillin 
IV VANCOMYCIN

15. CHEMOPROPHYLAXIS –
SPONTANEOUS BACTERIAL
PERITONOTIS
COMMON
ORGANSIMS
PREFERABLE ALTERNATIVE
1ry SBP Enterobacterice
ae, K.
Pneumonia,
Strep
IV CEFOTAXIME
OR
IV ROCEPHINE
IV AUGMENTIN
In cirrhotic +
UGIB
IV CEFOTAXIME
OR
IV ROCEPHINE
T.
NORFLOXACIN

16. ANTIBIOTICS FOR
SURGICAL INFECTIONS

17. GENERAL SURGERY
COMMON
MICROORGANISMS
PREFERABLE ALERNATIVE
Acute pancreatitis
(mild-moderate)
No need abx Given abx
when extra-
pancreatic
infections
Acute pancreatitis
(severe)
NB: abx indicated for
infected pancreatic
necrosis
Enterobactericeae,
Enterococci, S.
Aureus, Strep., S.
Epidermis,
Anaerobe,
Candida
IV TAZOCIN IV CEFOBID
+ IV FLAGYL
Diverticulitis (not
undergoing a source
control procedure)
T.
AUGMENTIN
OR
IV UNASYN
IV CEFOBID
+ IV FLAGYL
Diverticulitis (severe
infection/ life
threatening)
IV TAZOCIN
Appendicitis @ Enterobactericeae, IV IV UNASYN

18. NECROTISING FASCIITIS
COMMON
ORGANISMS
PREFERABLE ALTERNATIVE
Type 1
(polymicrobial
infection)
NB: in
comorbid pt
IV TAZOCIN
± IV
CLINDAMYCIN
IV CEFOTAXIME
+ IV FLAGYL/IV
CLINDAMYCIN
OR
IV UNASYN
± IV
CLINDAMYCIN
Type 2
(monomicrobia
l infection= gp
A strep)
IV
BENZYLPENICILIN
+ IV
CLINDAMYCIN
Fournier
gangrene
E. Coli, Kliebsella,
Proteus,
Enterococcus,
Pseudomonas,
Anaerobes
IV TAZOCIN
OR
IV ROCEPHINE
+ IV FLAGYL
IV CEFOTAXIME
+ IV
CLINDAMYCIN

19. UROLOGY
COMMON
ORGANISMS
PREFERABLE ALTERNATIVE
Pyonephrosis /
perinephric
abscess/ renal
abscess
Acute & chronic
prostatis
Testicular
abscess
Enterobactericeae
, Enterococci,
Pseudomonas,
Staph. Aureus
IV AUGMENTIN
OR
IV UNASYN
OR
IV CEFUROXIME
± IV GENTAMICIN
IV ROCEPHINE
± IV GENTAMICIN

20. UROLOGY & UTI
COMMON
ORGANISMS
PREFERABLE ALTERNATIVE
Pyonephrosis /
perinephric
abscess/ renal
abscess
Acute & chronic
prostatis
Testicular
abscess
Enterobactericeae
, Enterococci,
Pseudomonas,
Staph. Aureus
IV AUGMENTIN
OR
IV UNASYN
OR
IV CEFUROXIME
± IV GENTAMICIN
IV ROCEPHINE
± IV GENTAMICIN
Cystitis E. Coli,
Enterobactericeae
, Staph.
Saprophyticus,
Proteus
T. CEPHALEXIN T. CEFUROXIME
OR T.
AUGMENTIN
OR T.
AUGMENTIN
OR T.
FOSFOMYCON
(for MDR pt)

21. SKIN AND SOFT TISSUE
INFECTION
COMMON
ORGANISMS
PREFERABLE ALTERNATIVE
Furuncle /
Carbuncles
Staph.
Aureus
IV CLOXACILLIN IV AUGMENTIN
Cellulitis Staph.
Aureus,
Strep.
Pyogene
T. CEPHALEXINE
(mild)
IV CLOXACILLIN
(moderate)
IV UNASYN
± IV CLINDAMYCIN
(severe)
IV TAZOCIN
± IV
CLINDAMYCIN
(severe)
Peripheral
phlebitis /
thrombophlebitis
Staph.
Aureus,
coagulase –
ve, staph,
gram –ve
rods
Early stage – remove
IV cannula
Moderate – advanced
stage:
T. CEPHALEXIN
OR IV CLOXACILLIN
Bed sore IV UNASYN

22. ESCALATE AD DESCALATE
ATIBIOTICS
• ONCE CULTURE AND SENSITIVITY ARE AVAILABLE
• CAN ESCALATE AND DEESCALATE BASE ON CULTURE AND
SENSITIVITY
• IF THE DOSAGE WAS INITIALLY HIGH, IT CAN BE DE-
ESCALATE TO A STANDARD DOSAGE FOR A SUSCEPTIBLE
ORGANISM
• PATIENT CLINICAL CONDITION

23. INTRAVENOUS TO ORAL ANTIBIOTICS
CONVERSION
• BEFORE SWITCH TO ORAL ANTIMICROBIAL A PATIENT
MUST:
• DISPLAY SIGNS OF CLINICAL IMPROVEMENT AND
• ABLE TO TOLERATE ORAL THERAPY
• NOT HAVE A CONDITION IN WHICH HIGHER CONCENTRATIONS
OF ANTIBIOTIC ARE REQUIRED IN THE TISSUE OR A PROLONGED
COURSE OF IV THERAPY IS ESSENTIAL.

24. • ABLE TO TOLERATE ORAL THERAPY
• PATIENT IS NOT NBM
• PATIENT TOLERATE ORAL FOOD OR ENERAL FEEDING. FOR
ENTERAL FEEDING PLS CONSULT PHARMACY ON SUITABLE
FORMULATION AND ADMINISTARTION METHOD.
• ORAL ABSORPTION IS NOT COMPROMISED (E.G DIARRHOEA,
VOMITTING, MALABSORPTION DISORDER, PARTIAL OR TOTAL
REMOVAL OF THE STOMACH, SHORT BOWEL SNYDROME ,
UNCONCIOUS ,SWALLOWING DISORDER.

25. • THERE ARE NUMBER OF CONDITIONS IN WHICH TO ORAL
THERAPY SHOULD BE CONSIDERED E.G:
• PNEUMONIA
• SKIN AND SOFT TISSUE INFECTIONS
• UTI
• UNCOMPLICATED GRAM NEGATIVE BACTEREMIA
• INTRA-ABDOMINAL INFECTION WIHOUT DEEP SEATED
COLLECTIONS

26. CRITERIA FOR IV TOPOCONVERSION
• PATIENT DISPLAY SIGNS OF CLINICAL IMPROVEMENT
• AFEBRILE (TEMP >36C AND <38C FOR PAST 48HOURS)
• CRP TRENDING DOWN
• STABLE IMMUNE RESPONSE (WCC>4 AND <12X109CELLS/L OR
TRENDING TOWARDS NORMAL RANGE). IT IS IMPORTANT TO
EXAMINE THE PATIENT OTHER MEDICATION THERAPY THAT MAY
CAUSE INCREASE OR HIGH WBC COUNT E.G STEROID
• NO UNEXPLAINED TACYCARDIA
• NO UNEXPLAINED HYPOTEENSION
• NO TACYPNEA

27. THANK YOU