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Antibiotic Prophylaxis inAntibiotic Prophylaxis in

SurgerySurgeryPrevention of Surgical SitePrevention of Surgical Site

InfectionInfection

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IntroductionIntroduction

Background: Infection of the surgical site is aBackground: Infection of the surgical site is a

common but avoidable complication of anycommon but avoidable complication of any

surgical procedure.surgical procedure.

Bacterial contamination of the surgical site isBacterial contamination of the surgical site isinevitable, from the patients own flora or theinevitable, from the patients own flora or the

environment.environment.

!.". study #$%%&' showed the prevalence of !.". study #$%%&' showed the prevalence ofwound infection to be (.)* among $(%+wound infection to be (.)* among $(%+

patients of different surgical specialties.patients of different surgical specialties.

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-oals of antibiotic prophylais-oals of antibiotic prophylais

/educe the incidence of surgical site/educe the incidence of surgical siteinfection #SSI'infection #SSI'

0inimi1e the effect on the patients normal0inimi1e the effect on the patients normalbacterial flora.bacterial flora.

0inimi1e adverse side effects of0inimi1e adverse side effects ofantibiotics.antibiotics.

0inimi1e the emergence of antibiotics0inimi1e the emergence of antibioticsresistant strains of bacteria.resistant strains of bacteria.

2ost effectiveness.2ost effectiveness.

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2riteria for defining a surgical site2riteria for defining a surgical site

infectioninfectionSuperficial incisional SSI: involving the skin and the subcutaneousSuperficial incisional SSI: involving the skin and the subcutaneoustissue. 3ccurs within &4 days after the operation and shows at leasttissue. 3ccurs within &4 days after the operation and shows at leastone of the followings: #$5 pain (5 swelling &5 redness +5heat 65one of the followings: #$5 pain (5 swelling &5 redness +5heat 65tenderness'tenderness'

B Purulent drainageB Purulent drainage

2 Isolation of organisms2 Isolation of organisms 7eep incisional SSI:$5 Purulent drainage from the deep incision but7eep incisional SSI:$5 Purulent drainage from the deep incision but

not from organ or space component of the surgical site.not from organ or space component of the surgical site.

(5 7eep incision dehiscence or deliberate opening(5 7eep incision dehiscence or deliberate opening

&5 8ever, locali1ed pain or tenderness&5 8ever, locali1ed pain or tenderness

+5 n abscess formation+5 n abscess formation 3rgan5space SSI: $5 n abscess or infection found by radiological,3rgan5space SSI: $5 n abscess or infection found by radiological,

histopathological means or at reoperationhistopathological means or at reoperation

(5 Purulent discharge from the drain or culture isolation.(5 Purulent discharge from the drain or culture isolation.

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Site specific classification of organSite specific classification of organ

space SSI infectionspace SSI infection$5 -astrointestinal tract (5 Intraabdominal$5 -astrointestinal tract (5 Intraabdominal

$5 0ale or female reproductive tract$5 0ale or female reproductive tract

$5 Breast$5 Breast

$5 !pper respiratory tract (5lower respiratory tract$5 !pper respiratory tract (5lower respiratory tract

$5Sinusitis (5 9ar,mastoiditis$5Sinusitis (5 9ar,mastoiditis

$53ral cavity$53ral cavity

$5 9ye other than conunctivitis$5 9ye other than conunctivitis

$5 0ediastinitis (5 Pericarditis &50yocarditis +5 9ndocarditis$5 0ediastinitis (5 Pericarditis &50yocarditis +5 9ndocarditis

$5 rterial or venous infection$5 rterial or venous infection

$5 3steomyelitis (5 ;oint or bursa &5 7isc space$5 3steomyelitis (5 ;oint or bursa &5 7isc space

$5 Brain abscess (5 0eningitis, ventriculitis &5 Spinal abscess$5 Brain abscess (5 0eningitis, ventriculitis &5 Spinal abscess

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-uidelines to antibiotic prophylais-uidelines to antibiotic prophylais

of SSIof SSI

/isk factors for SSI/isk factors for SSI

2ommon pathogens2ommon pathogens

Benefits and risks of antibiotic prophylaisBenefits and risks of antibiotic prophylais

dministration of intravenous prophylacticdministration of intravenous prophylactic

antibioticantibiotic

2ost effectiveness2ost effectiveness

8actors to be considered in auditing practice8actors to be considered in auditing practice

ntibiotic prophylais other than for SSI controlntibiotic prophylais other than for SSI control

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/isk factors for surgical site/isk factors for surgical site

infectioninfection

2lassification of operation2lassification of operation

Insertion of prosthetic implantsInsertion of prosthetic implants

7uration of surgery7uration of surgery2o morbidities2o morbidities

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2lassification of operations2lassification of operations

2lean: he presence of pus, previous perforatedhollow viscous or open inuries more than fourhollow viscous or open inuries more than fourhours.hours.

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Insertion of prosthetic implantInsertion of prosthetic implant

Implants has a detrimental effect on theImplants has a detrimental effect on the

host defences. s a result a lowerhost defences. s a result a lower

inoculum of bacteria is needed to causeinoculum of bacteria is needed to cause

SSI of a prosthetic implant than a viableSSI of a prosthetic implant than a viable

tissue, this increases the incidence of SSItissue, this increases the incidence of SSI

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7uration of surgery7uration of surgery

>he risk is additional to that of>he risk is additional to that of

classification of the operation.classification of the operation.

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2o morbidities2o morbidities

S score of ?( is associated with an increasedS score of ?( is associated with an increasedrisk of SSI, and this is additional to therisk of SSI, and this is additional to theclassification of the operation.classification of the operation.

S: $:

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Probability of SSIProbability of SSI

Operationclassification

Risk index 0 Risk index 1 Risk index 2

Clean 1.0% 2.3% 5.4%

Cleancontaminated

2.1% 4.0% 9.5%

Contaminated 3.4% 6.8% 13.2%

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2ommon pathogens antibiotic2ommon pathogens antibiotic

susceptibilitysusceptibilitySSI for a skin wound at any site: $5 Staph aureus . %4* remainsSSI for a skin wound at any site: $5 Staph aureus . %4* remainssensitive to flucloacillin, macrolides and clindamycin. (5 Betasensitive to flucloacillin, macrolides and clindamycin. (5 Betahaemolytic streptococci. %4* remains sensitive to penicillinhaemolytic streptococci. %4* remains sensitive to penicillinmacrolides and clindamycinmacrolides and clindamycin

dditional pathogens: @ead and neck surgery: $53ral anaerobes.dditional pathogens: @ead and neck surgery: $53ral anaerobes.

%6* remains sensitive to metronida1ole and coAamoyclav%6* remains sensitive to metronida1ole and coAamoyclavdditional pathogens: 3perations below the waist: $5 naerobes.dditional pathogens: 3perations below the waist: $5 naerobes.%6* remains sensitive to metronida1ole and coAamoyclav (5 9. coli%6* remains sensitive to metronida1ole and coAamoyclav (5 9. coliand other entrobacteriaceae. 2omple resistance, but %4* remainsand other entrobacteriaceae. 2omple resistance, but %4* remainssensitive to second generation cephalosporins, gentamicin or betasensitive to second generation cephalosporins, gentamicin or betalactam beta lactamase inhibitors.lactam beta lactamase inhibitors.

Insertion of prosthesis, graft or shunt: $5 2oagulase negativeInsertion of prosthesis, graft or shunt: $5 2oagulase negativeStaph.%4* remains sensitive to flucloacillin, clindamycin orStaph.%4* remains sensitive to flucloacillin, clindamycin ormicrolides. (5Staph aureus. (5& are 0/S but beta lactammicrolides. (5Staph aureus. (5& are 0/S but beta lactamantibiotics are still appropriate.antibiotics are still appropriate.

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0/S950/S antibiotic prophylais0/S950/S antibiotic prophylais

Beta lactam drugsBeta lactam drugs

-lycopeptides-lycopeptides

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Benefits and risks of antibioticBenefits and risks of antibiotic

prophylaisprophylaisBenefits of prophylais:$5 related to the severity of conse=uences ofBenefits of prophylais:$5 related to the severity of conse=uences ofSSI e.g. in colonic anastomosis prophylais reduces the mortality. InSSI e.g. in colonic anastomosis prophylais reduces the mortality. Intotal hip replacement reduces the long term morbidity, however intotal hip replacement reduces the long term morbidity, however inmost operation reduces the short term morbidity.most operation reduces the short term morbidity.

(5 surgical wound infection increases the length of hospital stay(5 surgical wound infection increases the length of hospital stay

depends on the type of the operation.depends on the type of the operation. /isks of prophylais:$5 Increased rates of antibiotic resistant/isks of prophylais:$5 Increased rates of antibiotic resistantbacteria. (5 increased incidence of 2. defficile carriage in patientsbacteria. (5 increased incidence of 2. defficile carriage in patientsreceived ? (+ hours prophylais.received ? (+ hours prophylais.

>he final decision depends on: $5 >he patients risk of SSI. (5>he>he final decision depends on: $5 >he patients risk of SSI. (5>hepotential severity of the conse=uences of SSI. &5 >he effectivenesspotential severity of the conse=uences of SSI. &5 >he effectiveness

of prophylais in that operation. +5 >he conse=uences of prophylaisof prophylais in that operation. +5 >he conse=uences of prophylaisin that patient #e.g. risk of colitis'in that patient #e.g. risk of colitis'

d i i t ti f i td i i t ti f i t

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dministration of intravenousdministration of intravenous

prophylactic antibioticsprophylactic antibiotics

>he choice of antibiotics>he choice of antibiotics!sually a small number of pathogens need to be!sually a small number of pathogens need to becovered. >he antibiotic used must reflect thecovered. >he antibiotic used must reflect thelocal information about common pathogens.local information about common pathogens.

>he choice should include economic>he choice should include economicconsiderations.considerations.0ust be aware that if infection occurs, usually it0ust be aware that if infection occurs, usually itremains sensitive to the antibiotic used forremains sensitive to the antibiotic used forprophylais.prophylais.

Penicillin allergy# anaphylais, articaria andPenicillin allergy# anaphylais, articaria andrash': 7o not use penicillin, challenge test forrash': 7o not use penicillin, challenge test forcephalosporins and admit another antibiotic incephalosporins and admit another antibiotic inthe regime.the regime.

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>iming of administration>iming of administration

>he risk begins at the time of incision so>he risk begins at the time of incision soeffective tissue concentration must beeffective tissue concentration must bereached at that time.reached at that time.

>his depends on pharmacokinetic of the>his depends on pharmacokinetic of thedrug and the route of administration.drug and the route of administration.

Ideally &4 minutes within induction ofIdeally &4 minutes within induction of

anaesthesia.anaesthesia.2onsiderations when use a tourni=uet and2onsiderations when use a tourni=uet andin caesarian sections.in caesarian sections.

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dditional dose during thedditional dose during the

operationoperation

!sing antibiotics of short half life#$( hours' it!sing antibiotics of short half life#$( hours' itseems logical to give an additional dose duringseems logical to give an additional dose duringoperations that last more than + hours.operations that last more than + hours.

2ontrolled trials did not show any evidence to2ontrolled trials did not show any evidence tosupport thissupport this

ll antibiotics should be administeredll antibiotics should be administeredintravenouslyintravenously

dditional doses may be needed if there is blooddditional doses may be needed if there is blood

loss and dilution by fluid replacementloss and dilution by fluid replacement2ontrolled trials did not show any benefit of2ontrolled trials did not show any benefit offurther postoperative dosesfurther postoperative doses

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2ost effectiveness2ost effectiveness

/ule $: >he number of patients needed to treat/ule $: >he number of patients needed to treatto prevent one wound infection increases into prevent one wound infection increases inoperations with low risk of wound infectionoperations with low risk of wound infection

/ule (: Prophylactic antibiotics are given if they/ule (: Prophylactic antibiotics are given if theyare likely to reduce the overall antibioticsare likely to reduce the overall antibioticsconsumption #use

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9stimated cost per wound infection9stimated cost per wound infection

by site of operationby site of operation

2olorectal surgery $,+4+2olorectal surgery $,+4+

Cascular surgery $,4D6Cascular surgery $,4D6

2holecystectomy $$2holecystectomy $$0astectomy ))0astectomy ))

3esophageal surgery )&63esophageal surgery )&6

-roin hernia repair &)-roin hernia repair &)

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8actors to be considered in auditing8actors to be considered in auditing

practicepractice

7ate and time of administration and surgical7ate and time of administration and surgicalincisionincision

3peration performed #elective or emergency'3peration performed #elective or emergency'

2lassification of operation2lassification of operation;ustification for prophylais;ustification for prophylais

ntibiotic name, dose and routentibiotic name, dose and route

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ntibiotics prophylais other thanntibiotics prophylais other than

for SSI controlfor SSI control

Prevention of urinary tract or respiratory tractPrevention of urinary tract or respiratory tractinfections after surgeryinfections after surgery

Prevention of endocarditisPrevention of endocarditis

>opical antibiotics>opical antibiotics>reatment of anticipated infection in dirty>reatment of anticipated infection in dirtyemergency operationsemergency operations

3ral antibiotics to achieve selective3ral antibiotics to achieve selectivedecontamination of the gutdecontamination of the gut

Patients with prosthetic implants undergoingPatients with prosthetic implants undergoingsurgery that may cause bacteraemiasurgery that may cause bacteraemia

>ransplant surgery>ransplant surgery

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!" "#$