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Antibioprophylaxis in surgery and MDROs
Atelier antibioprophylaxie en chirurgieWorkshop Antibiotica profylaxe in de chirurgie
Baudouin Byl
Hygiène Hospitalière
et Gestion de l’antibiothérapie
Hôpital Erasme – ULB
Plan
• MDR definition• Prophylaxis – spectrum - principles• Literature – prophylaxis et SSI MDROs• Discussion
Definition MDR
• Clinical microb infec 2011: 18(3), 268-281
Definition MDR
2013 9
Antibioprophylaxiscommon principles
• Limited to well proven indications• Targeted to organisms involved in SSI• Timing of administration• Perop administration if needed• Duration < 24 hrs
2013 10
Antibioprophylaxis
• new recommendations Bratzler DW et al
Am J Health-Sys Pharm
Vol 70, feb1, 2013
previous:
Clin Infect Dis, 1994; 18: 422-427
ASHPIDSASHEASIS
Spectrum
• The narrowest
• Resistance patterns from organisms causing SSI should take precedence over hospitalwide antibiograms
• In some cases, procedure-specific resistance patterns!
Consensus 2013
2013 12
Spectrum
• Skin incision: SSI:
~ 80% Gram positive~ 20% Gram négative
First choice: anti-staph (oxa-S) + anti bgn cef 1 (cef2)
2013 14
From 1994 to 2013 …
• Dramatic decrease in sensitivity to cef1 (cef2)
• MDR ….
2013 15
• R rate cef1 cef2, enterobacterial species Erasme• 1993-2011
1993 1996 2000 2004 2007 20110
5
10
15
20
25
30
35
40
45
50
czol ambucfur ambuczol hospicfur hospi
2013 16
Rec 2013 - Quid des MDR?
• MRSA• MDR Enterobacteriacae• Pseudomonas aeruginosa
• VRE• …
2013 17
Rec 2013 - Quid des MDR?
Consensus 2013
2013 18
2013/ MRSA
• Glycopeptides en prophylaxie– Consensus 2013
• Cluster of MRSA or MRSE• known MRSA colonisation (or at high risk)
AND who will have a skin incision• !!! vanco less effective on MSSA !!!
– czol+vanco!
• (Specific setting: community MRSA)
2013 19
2013/ MR(S)SA
• From controverse to growing evidence…• S aureus carriage eradication recommended
– Cardiac surgery– Orthopedic surgery– Spinal procedures
• ! Surveillance of R to mupi !• ? Timing? Duration?• ! operational considerations ! (BB)
Consensus 2013
2013 20
MRSA
• Screening vs high risk conditions – Pts/units
• Eradication• + Vancomycine
2013 21
VRE
• Enteroccoccus uncovered by conventional prophylaxis (rare exceptions)
• VRE to be considered in special settings (Li TX, …)
2013 22
Enterobacteriaceae
2013 23
Gram neg / PUBMED
• MDR / prophylaxis / surgery : 0• Carbapenemase / SSI / prophylaxis: 0• Carbapenemase / prophylaxis: 0• ESBL / prophylaxis: 47
– Surgery 12- 7 urology- 4 transplantation- 1 obesity (pharmaco ertapenem)
2013 24
MDR carriage / exposition to antibiotics
• Abundant literature – overlaps between:
– ESBL– UTI– Neutropenic patients– Quinolone use
2013 25
Urology / ciproR
• Urology• Transrectal prostate biopsy• E coli : first causative (75-
90%)• Haute prévalence esbl et
ciproR
• E coli ciproR 17%!!!• Quid proph quinolones?
Qi et al J Urol 2013: 2026
Williamson et al, CID, 2013:267
2013 26
Urology / customized prophylaxis
• FQ vs [ctri or genta or sxt or cefpodox]• Reduction infection / ctrl histor
• by screening and adapted prophylaxis• Reduction infection
Taylor J Urol 2012: 1275
Duplessis et al Urology 2012: 556-563
2013 27
Urology / cipro + amikacin
Kehinde J Urol 2013; 189: 911
Historic contrl : ciproIntervention: cipro+amika
2013 28
ESBL / epidemiology / liver Tx
• Independant risk factors – fecal carriage ESBL– Previous infection with ESBL– Previous Blactam– Previous SBP (quinolones!)
• Need for targeted prophylaxis
Bert , Transplant infect disease, 2013:0: 1-6
2013 29
ESBL / epidemiology / liver Tx
Bert , Transplant infect disease, 2013: 1-6
2002 20100
5
10
15
20
25
30
35
40
ESBL+ carriageESBL+ infection
%pts
2013 30
Colonisation / Clinical impact
• ICU~7 % infections caused by ESBL+– Among carriers
• 10% first infection and 27% second infection caused by ESBL+
Razazi Int Care Med 2012; 38:1769-1778
2013 31
ESBL / prophylaxis
2013 32
Antibioprophylaxis
• new recommendations Bratzler DW et al
Am J Health-Sys Pharm
Vol 70, feb1, 2013
previous:
Clin Infect Dis, 1994; 18: 422-427
2013 33
Rec 2013
• Transplanted pts (liver, lungs):– Include coverage for any potential pathogen
(isolated < donor / receiver)
• Colo-rectal– czol+ metro– Or ctri+metro (if high R cef1/2)
• [or ertapenem!!]
Consensus 2013
Quid Gram neg MDRO?
2013 35
Quid Gram neg/MDR?
• Consider customising– Urology (trans rectal biopsy)– Local SSI epidemiology
• Screening!(rectal)• Screening high risk• Customize to screening results• Customize to high risk (ex
uro!)
2013 36
Operational considerations
• Preoperative clinical path• Customize vs systematic
screening (lab costs!)
2013 37
Operational considerations
0
20
40
60
80
100
120
Evolution nombre de frottis BMR par mois et unité
mois
No
mb
re
Your opinion?