Pemakaian antibiotika pra bedah pada fraktur terbuka

PEMAKAIAN ANTIBIOTIKA PEMAKAIAN ANTIBIOTIKA PRA BEDAH PADA PRA BEDAH PADA

FRAKTUR TERBUKAFRAKTUR TERBUKAOlehOleh

Dr.Azharuddin,SpBO-K.Spine FICSDr.Azharuddin,SpBO-K.Spine FICS

Divisi Bedah Orthopaedi FK UNSYIAH/BPK-Divisi Bedah Orthopaedi FK UNSYIAH/BPK-RSUZA Banda AcehRSUZA Banda Aceh

20042004

Fr terbuka+plating 6 minggu post opFr terbuka+plating 6 minggu post op

PendahuluanPendahuluan ““AB” Profilaksis pada fraktur terbuka; infeksi.AB” Profilaksis pada fraktur terbuka; infeksi.

Dasar Pemilihan Jenis“AB” ?Dasar Pemilihan Jenis“AB” ? -Kemungkinan kuman patogen yang spesifik.-Kemungkinan kuman patogen yang spesifik. Fraktur terbuka, kuman>> staphylococcusFraktur terbuka, kuman>> staphylococcus ““AB”Ideal pada fr terbuka? AB”Ideal pada fr terbuka? CEFAZOLINCEFAZOLIN

ALTERNATIF “AB”PROFILAKSISALTERNATIF “AB”PROFILAKSIS ERYTROMYCIN & VANCOMYCIN HCLERYTROMYCIN & VANCOMYCIN HCL

KOMBINASI BENZYL PENICILLIN-KOMBINASI BENZYL PENICILLIN-FLUCOXACILLINFLUCOXACILLIN

LUKA SANGAT KOTOR: KOMBINASIKAN DGNLUKA SANGAT KOTOR: KOMBINASIKAN DGN *GENTAMYCIN &*GENTAMYCIN & *METRONIDAZOLE*METRONIDAZOLE (UTK KUMAN GRAM(-)&ANAEROB)(UTK KUMAN GRAM(-)&ANAEROB)

CARA PEMBERIAN “AB” CARA PEMBERIAN “AB” PROFILAKSISPROFILAKSIS

SATU KALI PRE OPERASISATU KALI PRE OPERASIDOSIS TINGGIDOSIS TINGGISETENGAH JAM PRE OPERASISETENGAH JAM PRE OPERASI INTRAVENOUSINTRAVENOUS

PRINSIP PENANGANAN PRINSIP PENANGANAN FRAKTUR TERBUKAFRAKTUR TERBUKA

ASUMSIKAN SEMUA “GRADING” FR ASUMSIKAN SEMUA “GRADING” FR TERBUKA------TERKONTAMINASITERBUKA------TERKONTAMINASI

CEGAH PASIEN MENJADI “INFECTED”CEGAH PASIEN MENJADI “INFECTED” CARA:CARA: 1.WOUND DEBRIDEMENT1.WOUND DEBRIDEMENT 2.”AB” PROFILAXIS2.”AB” PROFILAXIS 3.STABILIZATION OF THE FRACTURE3.STABILIZATION OF THE FRACTURE 4.EARLY WOUND COVER4.EARLY WOUND COVER

MIP0MIP0

INSIDEN INFEKSI FR TERBUKA INSIDEN INFEKSI FR TERBUKA ??

KORELASI DENGAN KORELASI DENGAN EXTENT OF SOFT EXTENT OF SOFT TISSUE DAMAGETISSUE DAMAGE

GRADE GRADE II : < : < 1 %1 %GRADE GRADE III : > 10 % III : > 10 %

KONSEP UMUM INFEKSI KONSEP UMUM INFEKSI MUSKULOSKELETALMUSKULOSKELETAL

GAMBARAN KLINIS?? ------BERVARIASI, GAMBARAN KLINIS?? ------BERVARIASI, TERGANTUNG:TERGANTUNG:

TYPE INFEKSI(ST,BONE,JOINT)TYPE INFEKSI(ST,BONE,JOINT) LOKASI INFEKSILOKASI INFEKSI KUMAN PENYEBAB INFEKSIKUMAN PENYEBAB INFEKSI DELAYED IN DIAGNOSISDELAYED IN DIAGNOSIS DELAYED DELAYED DLM MEMBERIKAN “AB”DLM MEMBERIKAN “AB” HOST FACTORHOST FACTOR

HAL-HAL YANG PERLU HAL-HAL YANG PERLU DIKETAHUIDIKETAHUI

RIWAYAT TRAUMARIWAYAT TRAUMAKONTAMINASIKONTAMINASIRIWAYAT PENYAKIT LAIN RIWAYAT PENYAKIT LAIN FOTO POLOSFOTO POLOSKULTUR DAN SENSITIVITY TESKULTUR DAN SENSITIVITY TESKULTUR DARAHKULTUR DARAH

PENGGUNAAN “AB” RASIONAL PENGGUNAAN “AB” RASIONAL PD OPERASIPD OPERASI

INFEKSI PASKA OPERASI → NOSOKOMIAL??INFEKSI PASKA OPERASI → NOSOKOMIAL?? DAMPAK TERHADAP PX:DAMPAK TERHADAP PX: * LAMA OPNAME?* LAMA OPNAME? * * COSTLYCOSTLY * * MENYUSAHKAN PX & KEL.MENYUSAHKAN PX & KEL.

KAMAR OPERASI IDEAL ??KAMAR OPERASI IDEAL ??

TABEL “AB” PROFILAKSIS KASUS TABEL “AB” PROFILAKSIS KASUS KASUS BEDAHKASUS BEDAH

Surgical procedure Surgical procedure predominant inf microorganismpredominant inf microorganism recommened agent recommened agent dose dose routeroute

___________________________________________________________________________________ ___________________________________________________________________________________ CARDIO THORACIC CARDIO THORACIC Staphylococci CEFAZOLIN 1-2 g Staphylococci CEFAZOLIN 1-2 g iviv

or CEFUROXIME 1,5 g ivor CEFUROXIME 1,5 g iv or VANCOMYCIN or VANCOMYCIN ____________________________________________________________________________________________________________________________________________________________________Non-cardiac Non-cardiac Staphylococci CEFAZOLIN or 1-2 g iv Staphylococci CEFAZOLIN or 1-2 g ivVascular Surgery Vascular Surgery CEFUROXIME 1,5 g iv CEFUROXIME 1,5 g iv______________________________________________________________________________________________________________________________________________________________________ARTHTROPLASTY OF Staphylococci CEFAZOLIN ARTHTROPLASTY OF Staphylococci CEFAZOLIN

1-2 g IV 1-2 g IV JOINT REPLACEMENTJOINT REPLACEMENT

OPEN REDUCTIONOPEN REDUCTIONOF FRACTURESOF FRACTURES

LOWER LIMB AMPUTATIONLOWER LIMB AMPUTATION______________________________________________________________________________________________________________________________________________________________________

Gastro duodenal Streptococci,Coliforms, CEFAZOLIN 1-2 g Gastro duodenal Streptococci,Coliforms, CEFAZOLIN 1-2 g iv iv

anaerobic bacteria incl.anaerobic bacteria incl. Bacteroides spp Bacteroides spp ________________________________________________________________________________________________________________________________BILIARY TRACT BILIARY TRACT Coli form, enterococci, CEFAZOLIN 2 g Coli form, enterococci, CEFAZOLIN 2 g

ivivFor high risk only anaerobic bact incl. CEFOXITIN 2 g For high risk only anaerobic bact incl. CEFOXITIN 2 g

iviv: > 70 years Bacteroides,clostridia: > 70 years Bacteroides,clostridiaObstr joundiceObstr joundiceAcute cholecystit isAcute cholecystit isAcute cholangitisAcute cholangitisCommon duct stoneCommon duct stoneLow risk…… NO PROPHYLAXISLow risk…… NO PROPHYLAXIS________________________________________________________________________________________________________________________________

Colon/small bowel Colon/small bowel coliforms,anaerobic CEFOXITIN 2 g iv coliforms,anaerobic CEFOXITIN 2 g iv bacteria incl.bacteroibacteria incl.bacteroi des fragilis des fragilis ____________________________________________________________________________________________________________________APPENDECTOMYAPPENDECTOMY Coliforms,anaerobic CEFOXITIN 2 g iv Coliforms,anaerobic CEFOXITIN 2 g iv bacteria incl.bacteroibacteria incl.bacteroi des fragilisdes fragilis____________________________________________________________________________________________________________________PENETRATING PENETRATING idem CEFOXITIN 2 g iv idem CEFOXITIN 2 g ivABD TRAUMAABD TRAUMA____________________________________________________________________________________________________________________

VAGINALor abdominalVAGINALor abdominal Coliformes,enterococciCEFAZOLIN 1-2 g Coliformes,enterococciCEFAZOLIN 1-2 g iviv

Hysterectomy Hysterectomy group B streptococci group B streptococci____________________________________________________________________________________________________________________Caesarian secti ionCaesarian secti ion with as for hysterectomy CEFAZOLIN 1 g with as for hysterectomy CEFAZOLIN 1 g

ivivHigh risk e.g prematureHigh risk e.g prematureRupture of membranes CEFOXITIN 2 g ivRupture of membranes CEFOXITIN 2 g iv

Low risk_elective NO PROPHYLAXISLow risk_elective NO PROPHYLAXIS____________________________________________________________________________________________________________________ABORTION ABORTION as for hysterectomy CEFAZOLIN 1 g iv as for hysterectomy CEFAZOLIN 1 g iv____________________________________________________________________________________________________________________PROSTATECTOMY PROSTATECTOMY Coliforms CIPROFLOXACIN 500mg Coliforms CIPROFLOXACIN 500mg

oraloral____________________________________________________________________________________________________________________CNS Shunt CNS Shunt Staphylococci CEFAZOLIN 1 g Staphylococci CEFAZOLIN 1 g

iviv__________________________________________________________ __________________________________________________________

““AB” DI BIDANG AB” DI BIDANG MUSKULOSKELETALMUSKULOSKELETAL

IDEAL: SETELAH ADA HASIL KULTURIDEAL: SETELAH ADA HASIL KULTUR

LIFE OR LIMB THREATENING AB: LIFE OR LIMB THREATENING AB: SEGERA, SEGERA, BROAD SPECTRUMBROAD SPECTRUM

PROFILAK >< TERAPEUTIK ??PROFILAK >< TERAPEUTIK ??

““AB” LOKAL , TOPIKAL ??AB” LOKAL , TOPIKAL ??

GUIDE LINE AB PROFILAXIS GUIDE LINE AB PROFILAXIS ORTHO DI INDONESIA?ORTHO DI INDONESIA?

DATA (-)DATA (-)

ORTHO FK UNAIR/RS SUTOMO:ORTHO FK UNAIR/RS SUTOMO:

* GRADE I: CEFALOSPORIN I, 2 Gr* GRADE I: CEFALOSPORIN I, 2 Gr pre op, lanjut 3 x 1-2 gr selama 1 hari.pre op, lanjut 3 x 1-2 gr selama 1 hari.* GRADE II: CEFALOSPORIN I, 2gr* GRADE II: CEFALOSPORIN I, 2gr Pre op, lanjut 3 x 1-2 gr selama 2 hari.Pre op, lanjut 3 x 1-2 gr selama 2 hari.* GRADE III: CEFALOSPORIN I, 2 gr pre op, lanjut 3 x 1-2 * GRADE III: CEFALOSPORIN I, 2 gr pre op, lanjut 3 x 1-2

gr selama 3 hari &gentamycin 2 x 80 mg, 3 hari.gr selama 3 hari &gentamycin 2 x 80 mg, 3 hari.

KESIMPULANKESIMPULAN DIAGNOSIS PRE OP—PENTINGDIAGNOSIS PRE OP—PENTING PILIH PILIH ABAB ~ PETA KUMAN SECARA EMPIRIS ~ PETA KUMAN SECARA EMPIRIS WAKTU OP:WAKTU OP:GOLDEN PERIODE ?GOLDEN PERIODE ? IDEAL, CEFALOSPORIN I, BILA INFEKSI IDEAL, CEFALOSPORIN I, BILA INFEKSI

MANIFEST; CEF II, III dan GentamycinMANIFEST; CEF II, III dan Gentamycin IDEAL: ~ HASIL KULTUR & S TESIDEAL: ~ HASIL KULTUR & S TES

CEGAH INFEKSI NOSOKOMIAL !!CEGAH INFEKSI NOSOKOMIAL !!AB AB BUKAN SATU-SATUNYA FAKTOR BUKAN SATU-SATUNYA FAKTOR

YG BISA CEGAH INFEKSI.YG BISA CEGAH INFEKSI.PERHATIKAN HAL-HAL LAIN YG ERAT PERHATIKAN HAL-HAL LAIN YG ERAT

KAITAN TERHADAP KEJADIAN KAITAN TERHADAP KEJADIAN INFEKSI.INFEKSI.

Thank u doctor , i`m oke !!Thank u doctor , i`m oke !!

TERIMA KASIHTERIMA KASIH….….