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