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Seno Budi SantosoDiv. Of Digestive Surgery
Dept.Of SurgeryTeam of Antimicrobial Resistance Control
Persahabatan Hospital Jakarta
Prophylaxis Antibiotic in Surgery
What do you think about
Prophylaxis antibiotics
Wound infection surgery
Common issues
over-use and misuse of antibiotics exacerbates the development of
drug-resistant bacteria
Still confused about the role of antibiotics and the right way to take them
Cost burden increased
RESULT
Case
Anti septic
Human resources Linen
Facility in the OR
ComorbidAge
Patient’s condition
Postoperative
care
Sanitation
Bacterial resistance
Antibiotics
Equipment
Standard operation
procedures
Hand washOperator capability
Surgical site infection
Scottish Intercollegiate Guidelines NetworkSIGN
Antibiotic Prophylaxis in Surgery
A National Clinical Guideline
Definition :Antibiotic which is given before-during-after operation for case which unproven
infection clinically
Aim : 1. to prevent wound surgical infection/surgical site infection/surgical area infection
2. to prevent bacterial colonization
Delayed healing
HerniaPossible evisceration
AbscessFistula
Other procedures needed
Infection here may cause:
Decreased risk of surgical site
infection and morbidity
Shorten length of hospital stay
Reduce cost
Benefits of prophylaxis antibiotics
Increased risk of colitisdue to Clostridium difficile when using 3rd
cephalosporin generation
Increased frequency of bacterimiain patients taking prophylactic antibiotics more than 4 days compared with 1 day therapy
Limitations
of
prophylaxis
antibiotics
Single Dose vs Multiple dose
Single-dose versus multiple-dose antibiotic
prophylaxis for the surgical treatment of closed
fractures .
Slobogean.et.al. Acta Orthopaedica 2010; 81 (2): 256–262
Reports
Impact of Prolonged Antibiotic
Prophylaxis
• 2,641 pts post coronary artery bypass
– Group 1 <48 hours of antibiotics
– Group 2 >48 hours of antibiotics
• SSI rates
– Group 1 9% (131/1,502)
– Group 2 9% (100/1,139)
– Odds ratio 1.0 (95% CI: 0.8–1.3)
• Increased of resistency in group 2:
– Odds ratio 1.6 (95% CI: 1.1–2.6)
CABG = coronary artery bypass grafting; CI = confidence interval.
Harbarth S et al. Circulation. 2000;101:2916–2921.
Treating > 48hrs:• More resistant bugs• Higher cost
Prophylaxis antibiotics
Bacterial colonization
Classification of Operation
(Mayhall)
• Clean– No inflammation is
encontoured– Respiratory, genitourinary,
alimentary are not entered
• Clean-contaminated– Respiratory, genitourinary,
and alimentary are entered
– Without significant spillage
• Contaminated
– Acute inflammation (without pus) is encontoured or there is visible contamination of the wound
– Gross spilage from hollow viscus
• Dirty
– Presence of pus
– Previously perforated of hollow viscus, open injuries more than fours
Indication
of
prophylax
is
antibiotics
• In clean and clean-contaminated operation
• For clean operation :
is given if there is risk of
complication greater
infertility, cardiac surgery
• Using implant/foreign bodies
Probability of Surgical Area Infection
Risk Definition
0 No risk factor
1 1 risk factor
2 2 risk factor
Classification of operation
Risk Index
0 1 2
Clean 1,0 % 2,3 %
5,4 %
Clean-contaminated
2,1 % 4,0 %
9,5 %
Contaminated 3,4 % 6,8 %
13,2 %
Most effectively inhibitthe growth of microbial colonization
Low toxicity
The lowest group which is still effective to supress the growth of the colony
1st and 2nd generation of Cephalosporin
How to choose prophylaxis antibiotics
Dose and
duration
The prophylaxis dose is same as the therapeutic
Single-shot Many studies : giving once shoot as effective as 3 times
The duration is not more than 24 hours
Choice of
Prophylaxis
antibiotics
• Type of prophylaxis antibiotics• 1st and 2nd cephalosporin
– Cephazolin (1 gr)
– Cefuroxime (1-1.5 gr)
• If cephalosporin allergic +• Ampicillin sulbactam (1 gr)
• Amoxicilin clavulanat (1 gr)
• Gentamycin (5-8 mg/bw)
• Digestive surgery cases :• Combined with Metronidazole ( 500 mg)
• Neurosurgery cases (penetrating of blood brain barrier)
• Ceftriaxon (1-2 gr)
24
Harbarth et al, Circulation 2000
0
1
2
3
4
5
6
2 0 2 4 6 8 10
hours
SS
I (%
)Start of incision
Classen et al. N Engl J Med 1992
• 30-60 minutes before first incision
• Intravenous (dissolved in 100 ml NS)
• Duration : in 15-30 minutes
• Single dosemaximum 24 hours
• No need to do“skin test” ?
27
Duration of operation > 3 hours
Amount of bleeding >1500 ml
Reduced drug level in tissue
When prophylaxis antibiotic need to be repeated
( max 24 hours )
Results: A total of 540 patients were recruited; (females73.7% of total ). The
performed surgical procedures were 547. The rate of wound infection was
10.9%. Multivariable logistic analysis showed that; ASA score > 3; (p= <0.001),
wound class (p= 0.001), and laparoscopic surgical technique; (p= 0.002) were
significantly associated with prevalence of wound infection. Surgical prophylaxis
was unnecessarily given to 311 (97.5%) of 319 patients for whom it was not
recommended. Prophylaxis was recommended for 221 patients; of them 218
(98.6 %) were given preoperative dose in the operating rooms. Evaluation of
prescriptions for those patients showed that; spectrum of antibiotic was
adequate for 160 (73.4%) patients, 143 (65.6%) were given accurate doses,
only 4 (1.8%) had the first preoperative dose/s in proper time window, and for
186 (85.3%) of them prophylaxis was extended post-operatively. Only 36 (6.7%)
prescriptions were found to be complying with the stated criteria.
Conclusion: The rate of wound infection was high and prophylactic antibiotics
were irrationally used. Multiple interventions are needed to correct the situation.
Results: Perioperative antibiotic prophylaxis was appropriate in 18.1% of
cases. The multivariate logistic regression analysis showed that patients with
hypoalbuminemia, with a clinical infection, with a wound clean were more likely to
receive an appropriate antibiotic prophylaxis. Compared with patients with an
American Society of Anesthesiologists (ASA) score 4, those with a score of 2 were
correlated with a 64% reduction in the odds of having an appropriate prophylaxis. The
appropriateness of the timing of prophylactic antibiotic administration was observed in
53.4% of the procedures. Multivariate logistic regression model showed that such
appropriateness was more frequent in older patients, in those admitted in general
surgery wards, in those not having been underwent an endoscopic surgery, in those
with a higher length of surgery, and in patients with ASA score 1 when a score 4 was
chosen as the reference category. The most common antibiotics used
inappropriately were ceftazidime, sultamicillin, levofloxacin, and
teicoplanin.
Conclusions: Educational interventions are needed to improve
perioperative appropriate antibiotic prophylaxis.
Results:
the study involved 21 wards of 4 Public hospital
Of the 320 cases collected, 63 were excluded; of the
remaining 257 cases, 56.4 % of the procedures
were appropriate (score 4), 15.2 % were
acceptable and 28.4 % were not acceptable.
The study found an unjustified continuation of
antimicrobial prophylaxis in 17.1 % of the 257 cases, an
unjustified re-start of antimicrobial therapy in 9.7 % and a
re-dosing omission in 7.8 %.
Preparation for operation
Elective Surgical
Procedures Prevention of Hyperglycemia
Volume 345:1359-1367 November 8, 2001 Number 19
Intensive Insulin Therapy in Critically Ill PatientsGreet Van den Berghe, M.D., Ph.D., Pieter Wouters, M.Sc., Frank Weekers, M.D.,
Charles Verwaest, M.D., Frans Bruyninckx, M.D., Miet Schetz, M.D., Ph.D.,
Dirk Vlasselaers, M.D., Patrick Ferdinande, M.D., Ph.D., Peter Lauwers, M.D.,
and Roger Bouillon, M.D., Ph.D.
80 mg/dl> blood glucose <110mg/dl will reduce :
Mortality rate in intensive care (8%-4.6%)
Sepsis (46%)
ARF requiring HD (41%)
RBC transfusion (50%)
Polyneuropathy (44%) Independent variable with conventional
care
SSIs and Glucose Levels CTS pts
0
1
2
3
4
5
6
7
8
100–150 150–200 200–250 250–300
Day 1 Blood Glucose (mg/dL)
De
ep
Infe
ctio
n R
ate
, %
Zerr KJ et al. Glucose control lowers the risk of wound infection in diabetics after open heart operations, page 360. Reprinted from The Annals of Thoracic Surgeons, Vol. 63.
1.3% 1.6%
2.5%
6.7%
P=0.002
Glucose control (200 mg/dl)decreases infection rate
Elective Surgical
ProceduresPerioperative
Normothermia
• 200 CRS patients
• Incidence of SSI
– Control 19% (18/96)
– Treatment 6% (6/104); P=0.009
Kurz A et al. N Engl J Med. 1996;334:1209–1215.
Warm Patient Strategies:•Start with warm room•Use Bair Hugger•Cool room for procedure•Use 40o irrigation•Warm room on closingGOAL : >36oC (98.6oF)
cold patientsIncreasing 3 x risk
of infection
Control• Routine intraoperative thermal
care
• mean temperature 34,7C
Treatment• Active warming
• mean temperature 36,6 C
Elective Surgical
Procedures Supplemental
Oxygen
• 500 CRS patients
– 80% or 30% inspired oxygen during operation and for 2 hours post surgery
– All patients received prophylactic antibiotics
• Results
– Arterial and subcutaneous PO2higher in
80% oxygen group
– Lower incidence of SSIs with higher supplemental oxygen (5.2% vs 11.2%; P=0.01)
Greif et al. N Engl J Med. 2000;342:161–167.
Oxygen Strategy:•Supplemental O2
for 2hrs in RRlow O2 2x infection
rate !!!
Controlled infection
prevention
Before Operation
• Calm
• Sleep enough
– R/ Sleep inducer
• Take a bath with soap
Elective Surgical
ProceduresHair Removal
Clipping hair just before case is best
Hair Removal
Method
Infection Rate
afternoon/
kerok/shaving
5.2 - 8.8%
morning/ kerok 6.4 - 10%
afternoon/ shaving 4 - 7.5%
morning / shavin 1.8 - 3.2%
Alexander JW, et al. Arch Surg 1983; 118:347-352
Controlled infection
prevention
Cap
Mask
apron
Hand scrubbing
Gown
Gloves
Antiseptic with iodophore/chlorhexidine
Anaphylactic
reaction
Anaphylactic reaction
Incidence : 0,0025% in penicillin
administration
36 % : allergy of penicillin
64 % no history of allergy
Anaphylactic
Anaphylactic cross-reaction between Penicillin groups against cephalosporin
Pts with allergic of penicillin increasing of risk in beta lactam administration ©
- anaphylactic
- Laryngeal edema
- Bronchospasm
- Hypotension
- Local swelling
- Urticaria, pruritus
SIGN. antibiotic
prophylaxis in
Surgery . 2008.)
Cases &Prophylaxis antibiotics
ProcedureAntibiotics
Level of evidence
OR
Caesaria HR 1 0.41
Hysterectomy TAH / TVH R 1 0.17
Tonsilectomy NR 1
Vulnuc laceratum at face
NR 1
Normal labour + episiotomy
NR 1
Strumecomy NR 1 -
Breast cancer R 1
Appendectomy HR 1 0.58
Colorectal surgery HR 1
Hernia NR 1
TUR prostate HR 1
Arthroplasty HR 1
Urinary catheter insertion
NR 1
Don’t forget to wash your hand
Thank you
Curiculum VitaeFull name : Seno Budi Santoso, MD, consultant of digestive surgery
Born : Karanganyar, 28 Januari 1976
Religion : Moeslem
Status : married
Wife : Diani Kartini ,MD, oncologist surgery
Formal education
1. Graduated as general practioner in UNS Surakarta 1994-2000
2. Graduated as General surgeon in Faculty of Medicine UGM Jogjakarta 2001-2006
3. Graduated as consultant of digestive surgeon in Faculty of Medicine UI Jakarta 2010-2012
Non-formal education
1. Obs + WS advanced laparascopy colorectal and anal surgery, IRCAD, Taiwan 2015
2. Obs + WS advanced Endoluminal surgery, NUH Hospital, Singapore 2017
3. WS Neo and Adjuvant Chemoterapy for Surgical Malignancy, Jakarta, 2012
Employment history
1. RSUD Bengkalis Riau 2006-2010
2. RSUP Persahabatan 2012- now
3. RS Bethsaida Tangerang 2012- 2014
4. RS Antam Medika Jakarta 2012-now
5. RS Siloam Simatupang Jakarta 2014- now
Job Position
1. Staff of digestive surgery at RSUP Persahabatan 2012-now
2. Head of Central Surgical Installation 2015-now
3. Head of Antimicrobial Resistance Control RSUP Persahabatan2015-now