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Antibiotic Resistanace

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Antibiotic Resistanace

  1. 1. Antibiotic Review www.hi-dentfinishingschool.blogspot.com
  2. 2. Objectives <ul><li>Overview of organisms </li></ul><ul><li>Review of Antibiotics </li></ul><ul><li>Surgical Prophylaxis </li></ul>
  3. 3. Review of Organisms <ul><li>Dipiro, JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, editors. Pharmacotherapy. A Pathophysiologic Approach. 4th ed. Stamford, CT: Appleton & Lange, 1999: 1600. </li></ul>
  4. 4. “ Normal” Colonizing Flora <ul><li>Dipiro, JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, editors. Pharmacotherapy. A Pathophysiologic Approach. 4th ed. Stamford, CT: Appleton & Lange, 1999: 1599. </li></ul>
  5. 5. Antibiotic Classes <ul><li>Penicillins </li></ul><ul><li>Cephalosporins </li></ul><ul><li>Monobactam </li></ul><ul><li>Carbapenem </li></ul><ul><li>Glycopeptide </li></ul><ul><li>Oxazolidionone </li></ul><ul><li>Aminoglycosides </li></ul><ul><li>Macrolides </li></ul><ul><li>Tetracycline </li></ul><ul><li>Sulfonamide </li></ul><ul><li>Nitroimidazole </li></ul><ul><li>Quinolones </li></ul>
  6. 6. Antibiotic Spectrum <ul><li>Gilbet DN, Moellering RC, Eliopoulos GM, Sande MA. The Sanford Guide to Antimicrobial Therapy 2006. 36th ed. Sperryville, VA: Antimicrobial Therapy, INC., 2006: 53. </li></ul>
  7. 7. Antibiotic Spectrum <ul><li>Gilbet DN, Moellering RC, Eliopoulos GM, Sande MA. The Sanford Guide to Antimicrobial Therapy 2006. 36th ed. Sperryville, VA: Antimicrobial Therapy, INC., 2006: 54. </li></ul>
  8. 8. Antibiotic Spectrum <ul><li>Gilbet DN, Moellering RC, Eliopoulos GM, Sande MA. The Sanford Guide to Antimicrobial Therapy 2006. 36th ed. Sperryville, VA: Antimicrobial Therapy, INC., 2006: 55. </li></ul>
  9. 9. Antibiotic Spectrum
  10. 10. Vancomycin Dosing Nomogram
  11. 11. Vancomycin Dosing Nomogram
  12. 12. Aminoglycoside Dosing <ul><li>Pre-Op Dosing: 160mg or 240mg </li></ul><ul><li>Post-Op Dosing/ Treatment Dosing </li></ul><ul><ul><li>If CrCl > 30 ml/min give 5 or 7mg/kg dose </li></ul></ul><ul><ul><ul><li>Random Level 8 hours after infusion </li></ul></ul></ul><ul><ul><ul><li>Pharmacy to follow dosing per TDM Service </li></ul></ul></ul><ul><ul><li>If CrCl < 30 ml/min – contact pharmacy for dosing </li></ul></ul><ul><ul><ul><li>2-3 mg/kg dose </li></ul></ul></ul><ul><ul><ul><li>2 random levels to be ordered by pharmacy </li></ul></ul></ul><ul><li>All aminoglycosides monitored by TDM Service </li></ul>
  13. 13. Sinai Antibiogram
  14. 14. Therapeutics <ul><li>Determine Source/Site of infection </li></ul><ul><li>Identify suspected pathogens </li></ul><ul><li>Choose appropriate therapy based on the above </li></ul><ul><li>Determine duration of therapy </li></ul>
  15. 15. Surgical Prophylaxis <ul><li>Goals </li></ul><ul><li>Selection of antimicrobial agents </li></ul><ul><li>Timing of administration </li></ul><ul><li>Duration of administration </li></ul>
  16. 16. Goals of Surgical Prophylaxis <ul><li>Prevention of post-op infection at surgical site </li></ul><ul><li>Prevention of post-op infections morbidity & mortality </li></ul><ul><li>Reduction in duration and cost of health care </li></ul><ul><li>Produce no adverse effects </li></ul><ul><li>Have no adverse consequences for the microbial flora of the patient or the hospital </li></ul>
  17. 17. Goals of Surgical Prophylaxis <ul><li>Active against pathogen that is most likely to contaminate the wound </li></ul><ul><li>Give at an appropriate dosage and at a time to ensure adequate concentrations at the incision site during the period of potential contamination </li></ul><ul><li>Safe </li></ul><ul><li>Administered for the shortest effective period to minimize adverse effects, development of resistance, and cost. </li></ul>
  18. 18. Goals of Surgical Prophylaxis <ul><li>Antibiotic use for Dirty and contaminated procedures is not classified as prophylaxis, but treatment for presumed infection. </li></ul><ul><li>Prophylaxis typically not indicated for clean procedures </li></ul><ul><li>Justified for procedures involving prosthetic placement </li></ul><ul><li>Cardiothoracic, GI tract, head and neck, neurosurgical, obstetric or gynecologic, orthopedic, urologic and vascular </li></ul>
  19. 19. Selection of Antimicrobial Agents <ul><li>Based on cost, adverse-effect profile, ease of administration, pharmacokinetic profile, and antibacterial activity </li></ul><ul><li>Activity against most common surgical wound pathogens </li></ul><ul><ul><li>Clean-contaminated: effective against GI/GU organisms </li></ul></ul><ul><ul><li>Clean: effective against Staph and Strep </li></ul></ul>
  20. 20. Selection of Antimicrobial Agents
  21. 21. Selection of Antimicrobial Agents
  22. 22. Timing of Antibiotic Prophylaxis <ul><li>Delivery of drug to operative site before contamination occurs </li></ul><ul><li>Ideal timing is 30 minutes to one hour prior to incision (at time of induction of anesthesia) </li></ul><ul><ul><li>Flagyl given 1 hour prior </li></ul></ul><ul><ul><li>Vancomycin given 2 hours prior </li></ul></ul>
  23. 23. Duration of Antibiotic Prophylaxis <ul><li>24 hours or less </li></ul><ul><li>Cardiothoracic procedures- up to 72 hours </li></ul><ul><li>Coverage must be provided from time of incision to closure of incision </li></ul><ul><ul><li>Re-administer if short-acting agent used or surgery lasting longer than 6-8 hours </li></ul></ul><ul><ul><li>Re-administer if excessive bleeding or change in half-life of drug (i.e. extensive burns) </li></ul></ul><ul><ul><li>May avoid re-administration of half-life is extended ( i.e. renal insufficiency) </li></ul></ul>
  24. 24. Biliary Tract Surgery <ul><li>Cholecystetomy, exploration of common bile duct, choledochoenterostomy </li></ul><ul><li>Risk of infection 5-20% </li></ul><ul><li>Higher risk of infection: bacteria in bile, obesity, age > 70, acute episode of cholecystitis or cholelithiasis within previous 6 months, DM, h/o obstructive jaundice or bile duct obstruction </li></ul>
  25. 25. Biliary Tract Surgery <ul><li>Organisms: E.coli, Klebsiella, Enterococci </li></ul><ul><ul><li>Less frequent: other gram negative, strep, staph </li></ul></ul><ul><ul><li>Occasionally: anaerobes (Clostridium sp.) </li></ul></ul><ul><li>Recommendation: </li></ul><ul><ul><li>Single dose of cefazolin at induction of anesthesia for open procedures in biliary tract </li></ul></ul><ul><ul><li>No prophylaxis in laparoscopic cholecystectomies </li></ul></ul>
  26. 26. Appendectomy <ul><li>80% are Uncomplicated (acute inflammation) </li></ul><ul><li>Complicated (perforated or gangrenous; perotonitis, abcess formation) </li></ul><ul><ul><li>considered infection, not prophylaxis </li></ul></ul><ul><li>9-30% risk of infection </li></ul><ul><li>Oragnisms: anaerobic and aerobic gram-negative enteric organisms </li></ul><ul><ul><li>Bacteroides fragilis, E.coli </li></ul></ul><ul><ul><li>Aerobic and anaerobic strep, staph and enterococcus </li></ul></ul>
  27. 27. Appendectomy <ul><li>Recommendation: </li></ul><ul><ul><li>Cephalosporin with anaerobic and aerobic activity at induction of anesthesia </li></ul></ul><ul><ul><li>For PCN allergy: metronidazole, gentamicin at induction of anesthesia </li></ul></ul>
  28. 28. Colorectal Surgery <ul><li>30-60% risk of infection (<10% with prophylaxis) </li></ul><ul><ul><li>Rectal > intraperitoneal colon resection </li></ul></ul><ul><ul><li>Surgeries > 3.5 hours </li></ul></ul><ul><ul><li>Host defenses, age > 60, hypoalbuminemia, bacterial contamination of surgical wound, steroid therapy, malignancy </li></ul></ul>
  29. 29. Colorectal Surgery <ul><li>Organisms: B. fragilis, and other anaerobs (1,000-10,000 higher conc. than aerobes), E.coli </li></ul><ul><li>Mechanical bowel preparation: </li></ul><ul><ul><li>Neomycin and erythromycin: 1gm 19, 18, 9 hours before surgery </li></ul></ul><ul><li>aerobic and anaerobic activity (Ancef, Flagyl) at induction of anesthesia </li></ul>
  30. 30. References <ul><li>Dipiro, JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, editors. Pharmacotherapy. A Pathophysiologic Approach. 4 th ed. Stamford, CT: Appleton & Lange, 1999: 1599-1600. </li></ul><ul><li>Gilbet DN, Moellering RC, Eliopoulos GM, Sande MA. The Sanford Guide to Antimicrobial Therapy 2006. 36 th ed. Sperryville, VA: Antimicrobial Therapy, INC., 2006: 53-55. </li></ul><ul><li>ASHP Comission on Therapeutics. ASHP Therapeutic Guidelines on Antimicrobial Prophylaxis in Surgery. Am J Health Syst Pharm 1999; 56(18): 1839-1888. </li></ul>

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