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Prophylactic Use of Antibiotics in Otolaryngology & Head-Neck Surgery
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Prophylactic Use of Antibiotics in Otolaryngology & Head-Neck Surgery
Dr. Muhammad Lipu SarwerMedical Officer
Medical Department
Beximco Pharma
Introduction
Surgical site infection (SSI) is one of the most common healthcare
associated infections resulting in an average additional hospital stay of
6.5 days per case.
In operations with a higher risk of infection (e.g. clean-contaminated
surgery), perioperative antibiotic prophylaxis has been shown to lower
the incidence of infection.
High antibiotic levels at the site of incision for the duration of the
operation, are essential for effective prophylaxis.
Risk of infection
• Age
• Nutritional status
• Diabetes
• Smoking
• Obesity
• Coexistent infections at a remote body site
• Colonization with microorganisms (e.g. Staph. aureus)
• Immunosuppression (inc. taking glucocorticoid steroids)
• Length of preoperative stay
• Coexistent severe disease
Patient
The risk of SSI depends on a number of factors; these can be related to the patient or the operation and some of them are modifiable
Risk of infection
Operation
• Duration of surgical scrub
• Preoperative shaving/ preoperative skin prep.
• Length of operation
• Appropriate antimicrobial prophylaxis
• Operating room ventilation
• Inadequate sterilization of instruments
• Foreign material in the surgical site
• Surgical drains
• Surgical technique inc. haemostasis,
• poor closure, tissue trauma
• Post-operative hypothermia
The risk is also related to the amount of contamination with microorganisms which is called “class” of the operation
Class Definition
Clean Operations in which no inflammation is encountered and the respiratory, alimentary or genitourinary tracts are not entered. There is no break in aseptic operating theatre technique.
Clean-contaminated Operations in which the respiratory, alimentary or genitourinary tracts are entered but without significant spillage.
Contaminated Operations where acute inflammation (without pus) is encountered, or where there is visible contamination of the wound. Examples include gross spillage from a hollow viscusduring the operation or compound/open injuries operated on within four hours
Dirty Operations in the presence of pus, where there is a previously perforated hollow viscus, or compound/open injuries more than four hours old.
Prophylactic antibiotics
• Prophylaxis with antibiotics has decreased the high incidence of
wound infection after head and neck operations that involve
incisions through oral or pharyngeal mucosa.
• Prophylactic administration of antibiotics can decrease
postoperative morbidity, shorten hospitalization, and reduce overall
costs attributable to infections.
• Additional doses during the procedure are advisable if surgery is
prolonged (i. e, >4 h), major blood loss occurs, or an antimicrobial
with a short half-life is used
The aim of prophylaxis
• The aim of prophylaxis is to augment host defense
mechanisms at the time of bacterial invasion.
• Prophylaxis is an attempt to attack organisms before
they have a chance to induce infection.
Antibiotic Prophylaxis
Timing for Administration
Additional Intra-operative doses
Post-operative antibiotic prophylaxis
Timing for Administration
Antibiotic prophylaxis administered too early or too late
increases the risk of SSI. Studies suggest that
antibiotics are most effective when given 30 minutes
before skin is incised.
Additional Intra-operative doses
High antibiotic levels, at the site of incision, for the duration of the operation, are essential for effective prophylaxis.
For operations lasting more than 4 hours re-dosing may be necessary.
Antibiotic Recommended re-dosinginterval/dose to give
Cefuroxime 4 hours, give 750mg IV
Clindamycin 4 hours give 300mg IV
Co-amoxiclav 4 hours, give 1.2g IV
Metronidazole 8 hours, give 500mg IV
Post-operative antibiotic prophylaxis
Studies have shown that giving additional antibiotic
prophylaxis after wound closure does not reduce infection
rates further. Post-operative antibiotics should only be
given to treat active/on-going infection unless specifically
recommended against the surgical procedure.
Surgical antibiotic prophylaxis guidelines within Maxillofacial and ent for adult patients by NHS published in 2013
Procedure Standard AntibioticDose / Route
Mild Penicillin Allergy
Severe Penicillins /Cephalosporin Allergy
Alveolar bonegrafting(Intra-oral)
No prosthesis
Co-amoxiclav 1.2g IV at Induction
Cefuroxime 1500mg IV and Metronidazole 500mg IV atinduction
Clindamycin 600mg IV oninduction
Prosthesis forinternal fixation
Co-amoxiclav 1.2g IV atinduction + 2 furtherpost-op doses at 8 and16 hrs
Cefuroxime 1500mg IV andMetronidazole 500mg IV+ 2 further post-op doses at8 and 16 hrs
Clindamycin 600mg IV oninduction + 3 further post-opdoses at 6, 12 and 18 hrs
Head and Neck Surgery
Summary Table for Maxillofacial / ENT Antibiotic Prophylaxis Regimens in Patients
Procedure Standard AntibioticDose / Route
Mild Penicillin Allergy
Severe Penicillins /Cephalosporin Allergy
Openreduction andinternalfixation offractures(ORIF):
No prosthesis
Co-amoxiclav 1.2g IV atinduction
Cefuroxime 1500mg IV andMetronidazole 500mg IV atinduction
Clindamycin 600mg IV oninduction
Prosthesis forinternal fixation
Co-amoxiclav 1.2g IV atinduction + 2 furtherpost-op doses at 8 and16 hrs
Cefuroxime 1500mg IV andMetronidazole 500mg IV+ 2 further post-op doses at8 and 16 hrs
Clindamycin 600mg IV oninduction + 3 further post-opdoses at 6, 12 and 18 hrs
Head and Neck Surgery
Procedure Standard AntibioticDose / Route
Mild Penicillin Allergy
Severe Penicillins /Cephalosporin Allergy
Open fractures forconservative treatment
Co-amoxiclav 625mgPO TDS for 3 days
Cefradine 500mg QDS PO and Metronidazole 400mg TDS PO for 3 days
Clindamycin 450mg QDS PO for 3 days
Head and Neck Surgery
Procedure Standard AntibioticDose / Route
Mild Penicillin Allergy
Severe Penicillins /Cephalosporin Allergy
Major head and neck surgery (withmucosal breach)
Co-amoxiclav 1.2g IV atinduction
Cefuroxime 1500mg IV andMetronidazole 500mg IV atinduction
Clindamycin 600mg IV oninduction
Salivary glandsurgery
Co-amoxiclav 1.2g IV atinduction
Cefuroxime 1500mg IV andMetronidazole 500mg IV atinduction
Clindamycin 600mg IV oninduction
Head and Neck Surgery
Procedure Standard AntibioticDose / Route
Mild Penicillin Allergy
Severe Penicillins /Cephalosporin Allergy
Complex procedurese.g. ‘free’ cartilagereplacement
Co-amoxiclav 1.2g IV atinduction
Cefuroxime 1500mg IV andMetronidazole 500mg IV atinduction
Clindamycin 600mg IV oninduction
Closure of CSF leak with intranasalpathology / pack in position
Co-amoxiclav 1.2g IV atinduction.
Cefuroxime 1500mg IV andMetronidazole 500mg IV atinduction
Clindamycin 600mg IV oninduction
Nasal Surgery
Procedure Standard AntibioticDose / Route
Mild Penicillin Allergy
Severe Penicillins /Cephalosporin Allergy
Cochlear Implants Cefuroxime 1500mg IV+ 2 post-op doses at 8and 16 hrs.
Cefuroxime 1500mg IV+ 2 post-op doses at 8 and16 hrs.
Clindamycin 600mg IV oninduction + 3 further post-opdoses of oral clindamycin600mg at 6, 12 and 18 hrs
Ear Surgery
Antibiotics
Tab. Cefuroxime 250/500 mgInj. Cefuroxime 750 mg
Sus. Cefuroxime 125 mg/5 ml
Amoxicillin & Clavulanic acid (Co-amoxiclav)
Antibiotics
Clindamycin 150 mg and 300 mg capsules
Antibiotics
Metronidazole Tablet, Suspension, IV Infusion
Inj. Ceftriaxone 250/500 mg/1g/2g IM/IV
Beximco Pharma also offers---
Tab. Cefixime 200 mg
Thank Youwww.beximcopharma.com