This document provides an overview of antibiotics used in surgical practice. It discusses the historical development of antibiotics and their classification. It covers principles of antibiotic prophylaxis for surgery, including timing, choice and administration of antibiotics. It also discusses therapeutic antibiotics for surgical infections, emphasizing rational choice and combination therapy. Commonly used antibiotics for various surgical procedures are outlined. The document raises some concerns about increasing antibiotic resistance and provides high-level descriptions of developing hospital antibiotic policies.

1. Antibiotics In
surgical
practice
Prepared by :
Dr. Angel Maharjan
Reviewed by :
Dr. Rubel

2. Table Of Contents
❖Historical Overview
❖Antibiotics And Its Classification In Brief
❖Surgical antibiotic prophylaxis ,its principles, choice & administration
❖Therapeutic antibiotics in surgery, its principles ,rationale & choice
❖Commonly used antibiotics in surgery
❖Antibiotic in pregnancy
❖Antibiotic resistance
❖Development of Antibiotic Policy

3. Historical Overview
❖Nineteenth century - Koch’s postulates Published by Robert Koch
❖Twentith century - Introduction of the principle of Aseptic
Surgery(carbolic acid) By Joseph Lister
❖Alexander fleming discovered Penicillin in 1928.
❖Antibiotic remain the mainstay of antimicrobial therapy that makes
many surgeries possible today.

4. Antibiotics &It’s
Classification (In
brief)
Cell Wall Synthesis Inhibitors
Protein Synthesis Inhibitors
• 50S Subunit Inhibitors
• 30S Subunit Inhibitors
Nucleic Acid Synthesis Inhibitors
• DNA Gyrase Inhibitors
• DNA Integrity Inhibitors (via free radical )
• mRNA Synthesis Inhibitors
Folic Acid Synthesis Inhibitors
Membrane Integrity Inhibitors

7. Principles Of Surgical Antibiotic Prophylaxis
❖Should be administered for Operative Procedures that are associated
with high risk of infection
▪ Not required in Clean Surgery unless associated with Prosthesis is implanted
❖Use antibiotic that are effective against expected pathogen within
the hospital guidelines
❖Shortest possible course (ideally single dose)

8. ❖Antibiotic Should be delivered to operative site before Contamination
occurs
▪ i.e Within Decisive period.
❖Repeat dose during long operation or excessive blood loss
❖Patient with heart valve disease or prosthesis should be protected
with prophylactic antibiotics from bacteremia caused by Dental
work,Urethral Instrumentation or Visceral surgery

9. Administration
of Prophylactic
Antibiotics
Timing :
• within decisive period
• 30-60 mins before surgical incision is
recommended
• single shot iv administration at Induction of
anesthesia
Route :
• IV usually
Dose :
• Depends on weight
• Single dose
• Duration –should be <24 hr

10. SSI Rates
relating to
wound
contamination
with & without
prophylaxis

11. Choice of
Antibiotics
For
Prophylaxis
❖Empirical Cover Against expected pathogens
within local Hospital Guidelines
➢Depends On
▪ Site & Type of surgery
✓ Orthopaedics (staph. Aureus /epidermidis) –
Flucloxacillin/Co-amoxiclav
✓ Abdominal , Colorectal and Bowel surgery –
cephalosporin +metronidazole
✓ Intraabdominal abscess-
Cephalosporin+metronidazole+Amikacin
✓ Urological (gram –ve) – Amikacin , nitrofurantoin
✓ Breast Surgery –CoAmoxiclav/ceftriaxone/ceftazidime
✓Antibiotic allergy

12. Antibiotic
Treatment Of
Surgical
Infection

13. Principles Of
Antibiotic
Use

14. Rational
Use Of
Antibiotics
• Patient receive medication
Appropriate to their Clinical needs
in doses that meet their own
individual requirements for an
adequate period of time at the
lowest cost to them and their
community (WHO)

15. Choice Of
Antibiotic
Make a dx defining:
• Site of infection
• Type Of Organism responsible
• Antibiotic Sensitivity
Select the best drug
Considering :
• Sensitivity , Pharmacokinetic Factor
,optimum dose , Frequency , Route ,
Duration & Patient Factors

16. Therapeutic
Antibiotics

17. Therapeutic Antibiotics
❖Empiric Therapy :
➢Antibiotics to treat a clinically suspected infection before microbiological
cause is known
➢Should cover range of pathogen
➢Most appropriate Broad spectrum Antibiotics
❖Targeted therapy / Directed Therapy :
➢Antibiotic to treat bacteriologically confirmed infection
➢“Start Smart – then Focus” is the principle of Converting from Empiric
Therapy to Narrow Spectrum Directed therapy

18. Combination Therapy
• Polymicrobial infection :
➢Several Bacteria Suspected,Acting in Synergy
▪ Opening of Perforated/Ischaemic Bowel
✓Meropenem (for aerobic) &
Metronidazole (for anaerobic)
✓Alternatively Triple Therapy(Amoxicillin, Gentamicin & Metronidazole)
• To increase Clinical Efectiveness
✓E.g Biofilm Infection , elderly patient
• To reduce Development of antimicrobial resistance

19. Antibiotics
use in
pregnancy

20. Common Antibiotics
used in Rx & prophylaxis
of Surgical Infection

21. ANTIBIOTICS ORGANISM
Penicillin/Cephalosporin ➢ Benzyl penicillin-Gram +ve Streptococci , Clostridia
➢ Flucloxacillin – Staphylococci
➢ Ampicillin & amoxicillin – enterococcus faecalis
➢ Cephalosporin – alternative for penicillin allergy
Co-Amoxiclav ➢ Beta lactamase producing bacteria – staph. Aureus ,E. coli ,H.
influenza ,Bacteroides , klebsiella
Aminoglycoside ➢ Gram –ve enterobactereciae
➢ Pseudomonas – Gentamicin
Vancomycin & teicoplanin ➢ Gram +ve bacteria
➢ MRSA
➢ C. deficille –pseudomembranous colitis

22. ANTIBIOTICS ORGANISMS
Carbapenems ➢ Broad spectrum Anaerobic & gram positive activity
➢Extended Spectrum Beta Lactamases (ESBL)
➢Mixed spectrum abdominal infection (peritonitis
Metronidazole ➢Anaerobic Bacteria
➢C. deficille Pseudomembranous Colitis
Ciprofloxacin ➢Broad spectrum activity against gram +ve & gram –ve
bacteria

23. Antibiotic
Resistance

24. Spread Of Antibiotic Resistance
❖From Person to Person
➢By Transfer of resistant bacteria between people
❖From Bacteria to Bacteria :
➢By transfer of resistance genes between bacteria
,usually on Plasmids
❖From Plasmid to plasmid
➢By transfer of resistance genes between genetic
elements within the bacteria , on Transposons

25. MultiDrug
Resistance
Many pathogenic bacteria
have developed resistance to
the commonly used
antibiotics
Common multidrug-resistant
nosocomial organism
grouped under acronym of
ESKAPE.

26. ESKAPE
Enteroccocus faecium (vancomycin resistant
enterococcus ,VRE)
Staphylococci (Methicillin resistant Staph. Aureus ,
MRSA)
Klebsiella & E. coli (Extended spectrum beta
lactamases , ESBL)
Acinetobacter baumannii
Pseudomonas Aeruginosa
Enterobacter spp.

27. Process of
development of
hospital
antibiotic policy

28. Antibiogram
Overall profile of antimicrobial susceptibility testing
results of a specific microorganism to a battery of
antimicrobial drugs
Aggregate data from Hospital
Only results for antimicrobial drugs that are
routinely tested & clinically useful should be
presented to clinicians
Helps Clinicians Selecting the best empiric
antimicrobial Rx in the event of pending
microbiology culture and susceptibility test.

29. Thank You
for your precious
time