indiscriminate use of antibiotics in animal husbandry as well as human medicine is leading to ever increasing multi-drug resistance even pan-drug resistance. the situation is getting even grimmer in face of hardly any antibiotic developed in the last 25 years. WHO has published guidelines on infection control. it is the duty of every clinician to take situation in their hand, get oriented in judicious antibiotic usage and use sanitation in their clinical practice. principles of surgical antibiotic prophylaxis must be known to every surgeon and be adhered to strictly.

1. ​Dr Mayank Mohan Agarwal
MBBS, MS, MRCS(Ed), ​DNB, MCh (PGIMER, Chandigarh)
​VMMF and IAUA Fellowships Uro-Oncology, Pelvic Floor Reconstruction
(MSKCC, NY; UCLA, LA; WFUBMC, NC)​
Formerly Associate Professor of Urology PGIMER, Chandigarh
Formerly Consultant & Head of Urology, NMC specialty hospital, Abu Dhabi
Senior Consultant and Head of Urology
Aster Ramesh Hospital
Guntur (AP), India
<mayank.mohan@rameshhospitals.com>
ANTIBIOTIC RESISTANCE
Are we treating patients or our own fears

3. The road to destruction
Dr Tom Frieden, CDC

4. The road to destruction

5. Europe: E coli (R) to cephalosporins
da Costa ME, Machado HS. J Allerg Ther 2017

7. Kumar SG et al. J Nat sc Biol med 2013

8. Kumar SG et al. J Nat sc Biol med 2013

10. Where is it coming from?
• INAPPROPRIATE USAGE OF ANTIBIOTICS
• IN ANIMALS
• IN HUMANS

11. VETERINARY

12. • Livestock animals are fed antibiotics to “prevent” diseases  “promote”
growth
• Poor regulation leading to antibiotic usage in their food instead of
restricting to therapeutic usage

13. • Livestock animals are fed antibiotics to “prevent” diseases  “promote”
growth
• Poor regulation leading to antibiotic usage in their food instead of
restricting to therapeutic usage

15. Human medicine
• Similar thing happens in human medicine
• Inappropriate diagnosis –
• Contaminated sample
• Not performing gram staining
• Not performing culture
• Not performing sensitivity
PERCEIVED
WELL-WISH
FOR PATIENT
INCOMPLETE
KNOWLEDGE
PRESSURE
FROM
PATIENT
PRESSURE
FROM
INDUSTRY
PRESSURE
FROM
COLLEAGUES

16. • Inappropriate treatment –
• Unindicated prescription – e.g. for viral illness
• Broad spectrum antibiotics even when avoidable
• Low dose
• Incomplete duration
• Over-duration (e.g. surgical prophylaxis)
• Poor quality supply

17. • Not giving importance to hygiene and supportive measures –
• Hand hygiene
• Improving immunity in viral illness
• Trying to replace need for hygiene with higher antibiotics

20. OUR ROLE : practice

22. Hand hygiene
Semmelweis's reference to "cadaverous particles" were (in German) "an der Hand klebende Cadaverth
Hand hygiene with chlorinated water

23. Endourology – a clean contaminated surgery
• Just imagine –
• Sterilization is recommended
• Minimum High level disinfection is an absolute must
• There is no short cut to mechanical cleaning
• Enzymatic detergent

24. Sterilization and disinfection
Vegetative
Bacteria
Fungi Enveloped
viruses
Mycobacteria Nonenveloped
viruses
spores
Sterilizant + + + + + +
HL Disinfectant + + + + + -
IL Disinfectant + + + + - -
LL disinfectant + +/- + - - -
Rutala et al. CDC Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008

25. Cidex ® Cidex-OPA ® Perasafe ®
Level of disinfection HLD HLD HLD / Sterilizant
Contact time for HLD 20 min 10 min 10 min
Contact time for
sterilization
10 hours 24 hours 10-20 min
Specialized ventilation Required Required Not required
Toxic to environment +++ + -
Rutala et al. CDC Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008

26. Antibiotic prophylaxis in surgery
• Choose well – based on organism encountered, antibiogram, immunity
level of patient
• Avoid the one often used for ‘treatment’
• Long half life
• Loading dose – iv, double dose
• Within 60 minutes of incision / insertion (except vanco, FQ 120min)
• Repeat if procedure is long or blood loss significant
• Stop within 24 hours
• Don’t continue till drain / catheter removal
Haun et al. JAMA surg 2013

27. Antibiotic prophylaxis in surgery
• Choose well – based on organism encountered, antibiogram, immunity
level of patient
• Avoid the one often used for ‘treatment’
• Long half life
• Loading dose – iv, double dose
• Within 60 minutes of incision / insertion (except vanco, FQ 120min)
• Repeat if procedure is long or blood loss significant
• Stop within 24 hours
• Don’t continue till drain / catheter removal
Haun et al. JAMA surg 2013

28. Antibiotic prophylaxis in urology
Grabe M. Int J antimicrob ag 2004

29. TRANSURETHRAL RESECTION OF PROSTATE
• The most studied entity w.r.t antibiotics – over 32 RCT’s
• Antibiotics – yes or no? DEFINITELY YES
0
2
4
6
8
10
12
UTI sepsis
placebo antibiotic
Berry A, Barratt A. J urol 2002

30. TRANSURETHRAL RESECTION OF PROSTATE
• The most studied entity w.r.t antibiotics – over 32 RCT’s
• Antibiotics – yes or no? DEFINITELY YES
• How long? VARIABLE
• Single dose
• Upto 72 hours
• Extended
50
55
60
65
70
75
80
85
90
RRR all RRR ceph
single <72hr >72hr
Berry A, Barratt A. J urol 2002

31. TRANSURETHRAL RESECTION OF PROSTATE
• The most studied entity w.r.t antibiotics – over 32 RCT’s
• Antibiotics – yes or no? DEFINITELY YES
• How long? VARIABLE
• Single dose
• Upto 72 hours
• Extended
• Which antibiotic?
Berry A, Barratt A. J urol 2002

32. PERCUTANEOUS NEPHROSTOLITHOTOMY
• STONE score
• Low risk - <2cm, single stone, sterile culture – antibiotic ≡ no antibiotic
• Others with sterile culture – single dose antibiotic > no antibiotic
• Infected case – preop 3-7 days  continue for 7 days Treatment,
not prophylaxis
Lai WS, Assimos D. Rev Urol 2016

33. URETEROSCOPY
• Similar to PCNL
• Systematic review and Meta-analysis
• Low risk, lower ureteric calculi - antibiotic ≡ no antibiotic
• Anything more - single dose antibiotic > no antibiotic
Pyuria
Bacteruria
Bacteremia
Lo et al. Surg Inf 2015

34. Kidney transplantation
• N = 212
• SD = cefazolin just preop (after 2015)
• MD = pip-taz x 7 days sulbacin x 3d
0
5
10
15
20
25
30
35
40
45
50
SD MD
COST SAVING
97.5%
8 € vs 387 €
Bachmann et al. World J urol 2018

35. Antibiotic Prophylaxis and the Risk of SSI
following Total Hip Arthroplasty: Timely
Administration Is the Most Important Factor
• 1900+ patients undergoing hip arthroplasty

36. CONCLUSION
• SO IT TURNS OUT THAT MOST OF THE TIME WE ARE TREATING
OUR OWN FEARS

37. CONCLUSION
• SO IT TURNS OUT THAT MOST OF THE TIME WE ARE TREATING
OUR OWN FEARS
• DON’T WAIT FOR SOMEBODY ELSE TO TAKE ACTION
• ACT BEFORE IT’s TOO LATE
• THINK BEFORE WRITING / TAKING NEXT ANTIBIOTIC

39. THANK YOU