Antimicrobial Prophylaxis in Digestive Surgery Toar JM. Lalisang, MD, PhD Digestive Surgery Division Cipto Mangunkusumo Hospital Medical Faculty Universitas Indonesia Antibiotic must be present before bacteria is introduced. Given shortly before surgery Prophylaxis Antibiotic Miles and Burke Laid the scientific basis for the use of prophylactic antibiotics in surgery PGMEDICALWORLD.COM Antimicrobial Prophylaxis The goal is to prevent SSI by reducing the burden of microorganisms at the surgical site during the operative procedure Antibiotic must be present before bacteria is introduced Patients who receive prophylactic antibiotics within one to two hours before the initial incision have lower rates of SSI than receive antibiotics sooner or later than this window Antimicrobial therapy administered in the setting of contaminated wounds is not considered prophylactic; in such cases a therapeutic course of antimicrobial therapy is warranted 1
Single dose sufficient Further dose waste of resources & more complication long surgeries- multiple doses Antibiotic must be active against common expected pathogens Prophylaxis Antibiotic Stop dosing when side effects outweigh benefits Prophylactic Antibiotic cover decisive period Body responds to a breach in defense after the decisive period Decisive period last up to 4hrs PGMEDICALWORLD.COM Surgical Side Wound Infections(SSI) The second most common healthcare-associated infection Among surgical patients, SSIs are the most common nosocomial infection, accounting for 38 percent of nosocomial infections It is estimated that SSIs develop in 2 to 5 percent of the more than 30 million patients undergoing surgical procedures each year The cost of SSIs is substantial Pathophysiology Whether a wound infection occurs after surgery depends on a complex interaction between the following: 1. Patient-related factors (e.g., host immunity, nutritional status, the presence or absence of diabetes) 2. Procedure-related factors (e.g., implantation of foreign bodies, degree of trauma to the host tissues) 3. Microbial factors (tissue adherence and invasion) 4. Perioperative antimicrobial prophylaxis 2
Infection, % General Principles in the prevention of SSIs A number of interventions have been used over the years to reduce the risk of SSIs, including : Preoperative showering with antimicrobial soaps Preoperative application of antiseptics to the skin of the patient Washing and gloving of the surgeon's hands Use of sterile drapes Use of gowns and masks by operating room personnel The most important factors are meticulous operative techniques and timely administration of effective preoperative antibiotics Preventing SSI Antibiotic prophylaxis Drugs- which when, how many doses? Non antibiotic measures- evidence based Hair removal Normothermia Oxygen supplementation Normoglycemia Hair-Removal Techniques and SSIs Discharge 30-Day Follow-up 1 2 8.8% 10% (26/260) (23/260) 7.5% 8 5.2% 6.4% (17/266) (18/241) 4 (14/271) 4% (10/250) 3.2% (7/216) 1.8% (4/226) 0 PM AM PM AM Razor Razor Clipper Clipper Alexander JW et al. Arch Surg. 1983;118:347 352. 3
Preoperative Strategies to Limit SSIs: Skin Surface Preparations Antiseptic showers Reduced bacterial counts by 3.5 log 10 from baseline 1 No evidence that they affect SSIs 2 Skin preparation in the operating room (OR) Usually iodophors, alcohol-containing products, or chlorhexidine gluconate 2 1. Seal LA et al. Am J Infect Control. 2004;32:57 62. 2. Mangram AJ et al. Am J Infect Control. 1999;27:97 134. Perioperative Normothermia 200 CRS patients Control: Routine intraoperative thermal care (mean temperature 34.7 C) Treatment: Active warming (mean temperature 36.6 C) 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. 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 P O2 higher 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. 4
Deep Infection Rate, % SSIs and Glucose Levels (cont) 1,000 cardiothoracic surgery patients with preoperative hemoglobin A1c (HbA1c) levels measured 300 known diabetic patients 42 with undiagnosed diabetes Incidence of SSI Diabetes (known and undiagnosed) 5.8% (20/342) Without diabetes 1.5% (10/658) Diabetes with HbA1c 8% 7.9% (10/126) Diabetes with HbA1c <8% 4.0% (7/174) Latham R et al. Infect Control Hosp Epidemiol. 2001;22:607 612. SSIs and Post-op Glucose Levels Glucose level (mg/dl) Infected patients (n=72) Noninfected patients (n=902) Odds ratio <200 (referrent) 35 (49%) 651 (72%) 1.00 200 249 21 (29%) 154 (17%) 2.54 250 299 11 (15%) 69 (8%) 2.97 300 5 (7%) 28 (3%) 3.32 Latham R et al. Infect Control Hosp Epidemiol. 2001;22:607 612. Adapted with permission from the University of Chicago Press 2001. SSIs and Glucose Levels 8 7 6 5 4 3 2 1 0 6.7% P=0.002 2.5% 1.3% 1.6% 100 150 150 200 200 250 250 300 Day 1 Blood Glucose (mg/dl) 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. Copyright 1997, with permission from the Society of Thoracic Surgeons. All rights reserved. 5
Antimicrobial Prophylaxis Antimicrobial agent to prevent or reduce infection Ideally Targeted antibiotic Narrow spectrum agent Targeting few pathogens Short term Preoperative antibiotics are warranted if there is a high risk of infection or if there is high risk of deleterious outcomes should infection develop at the surgical site (immune compromise, cardiac surgery, and/or implantation of a foreign device) Timing of prophylaxis Antimicrobial therapy should be administered within 60 minutes prior to the surgery to ensure adequate drug tissue levels at the time of initial incision This practice also reduces the likelihood of antibiotic-associated reactions at the time of induction of anesthesia If the 60 minute window for prophylaxis has past, administration of antimicrobial therapy 30 to 60 minutes prior to surgery appears to be more effective than administration immediately before surgery 6
Infections, % Perioperative Prophylactic Antibiotics: Timing of Administration 14/369 4 15/441 3 2 1/61 1/41 1/47 1 5/699 5/1,009 2/180 0 3 > 2 > 1 0 1 2 3 4 5 Hours From Incision Classen DC et al. N Engl J Med. 1992;326:281 286. Copyright 1992 Massachusetts Medical Society. All rights reserved. Repeat dosing Antibiotic concentration > MIC pathogen at the time of incision and throughout the procedure In general, repeat antimicrobial dosing following wound closure is not necessary and may increase antimicrobial resistance Repeat dosing is indicated every one to two half-lives of the drug in patients with normal renal function for procedures lasting more than four hours or in the setting of major blood loss 7
Prophylaxis Antibiotic Indication Clean wound with prostheses Clean Contaminated Class I Wound (Clean) Atraumatic wound without inflammation Do not enter GI, GU, biliary, or respiratory tract 1.5% infection rate Class II Wound (Clean-Contaminated) Respiratory, GI, GU, or biliary tract entered under controlled conditions 7.5% infection rate expected 8
Class III Wounds (Contaminated) Traumatic wounds Breaks in sterile technique Gross spillage from GI tract Acute, nonpurulent inflammation 15% anticipated infection rate Class IV Wounds (Dirty) Old traumatic wounds Devitalized tissue Clinical infection present Perforated viscus 40% expected infection rate SENIC Risk Index Abdominal operation Operation greater than 2 hours Class III or IV surgical wounds Three or more diagnosis at time of discharge Risk of Infection 0 1% 1 3.6% 2 9% 3 17% 4 27% 9
Classification SSI Superfici al Dee p Digestive Surgery Among the highest risk procedures for SSI due to the presence of intraluminal bacteria The regimen should include activity against enteric gramnegative bacilli, anaerobes, and enterococci Bowel preparation consists of two components: mechanical bowel preparation and administration of antibiotics (ciprofloxacin plus metronidazole) Oesophagogastric Surgery Organisms encountered Enterobacterium, Enterococci Prophylactic regimen Second generation cephalosporin & Metronidazole 10
Biliary Surgery Organisms encountered Enterobacterium, Enterococci Prophylactic regimen One dose second generation cephalosporin Small Bowel Surgery Organisms encountered Enterobacterium, Anaerobes Prophylactic regimen Second generation cephalosporin & Metronidazole Colorectal Surgery Organisms encountered Enterobacterium, Anaerobes Prophylactic regimen Second generation cephalosporin & Metronidazole 11
Infections, % Major Pathogens in SSI 20% 15% 10% 5% 0% NNIS Report. Am J Infect Control. 1996;24:380 388. Surgical Prophylaxis Wound Classification I II-Biliary,GU, Upper Digestive II-Distal Digestive Antibiotic 1 st generation Cephalosporin 1 st generation Cephalosporin 2 nd generation Cephalosporin PCN Allergy Vancomycin Clindamycin Vancomycin Clindamycin Aztreonam and Clindamycin/Flagyl III/IV Generally Therapeutic Pedoman Penggunaan Antibiotik Departemen Ilmu Bedah RSUPN-CM 2013 12
Digestive Division Cipto Mangunkusumo Hospital 2012 First Line Metronidazole Gentamycin Second Line Ampicillin-Sulbactam Cephalosporin third Generation Carbapenem Clean Contaminated RSUPN-CM MARCH 2013 67 Abdominal Operation 28 procedures used Prophylaxis Antibiotic LCC & Bilier operation = 15 Incisional biopsy n debulking tumor = 5 Elective Hernia repaired with mesh = 4 Colostomy = 4 Prophylaxis Ab. : Genta + Metronidazol = 23 Cases Cefazolin & Doripenem One case SSI debulking tumor cases 13
Antibiotic Prophylaxis-Caveats You can t kill everything Adverse drug effects Select resistant pathogens C diff colitis Select more virulent pathogens Avoid drugs/classes that are used for therapy Surgical Prophylaxis Summary Its not the tool it s the craftsman Is an adjunct to, not a substitute for, good surgical technique Decrease SSI Focus on likely pathogens-what are you cutting? Narrow spectrum, long half life drugs Single pre-op dose adequate for most Dose timing- pre-incision, Short Term better ( > 72 hours) Thank You For Your Attention 14