Prophylactic antibiotic – timing and dosage · for surgical site infection in cardiac surgery....

Prophylacticantibiotic–timinganddosage

Dr.SanjeevSinghAIMS,Kochi

Meaning-Webster

MedicalDefinitionofprophylaxispluralpro·phy·lax·es\-ˈlak-ˌsēz\play:measuresdesignedtopreservehealthandpreventthespreadofdisease:protectiveorpreventivetreatment<prophylaxisagainstviraldiseases><apastecontainingfluorinefordentalprophylaxis>

Definition

•  Antibioticprophylaxisreferstothepreventionofinfectioncomplicationsusingantimicrobialtherapy

•  Surgicalantibioticprophylaxisisdefinedastheuseofantibioticstopreventinfectionsatthesurgicalsite.

Indications

•  Immunecompromised•  Cardiacvalves,prostheticsinbody•  Visittoanothercountry•  Surgery

SIGN104•Antibioticprophylaxisinsurgery.Anationalclinicalguideline.July2008

•  Asingleantibioticdose,givenimmediatelybeforethestartofsurgery,maybejustaseffectiveinpreventinginfection,whilereducingtheriskofdrugsideeffects

http://www.surgeryencyclopedia.com/Pa-St/Prophylaxis-Antibiotic.html#ixzz407iM1Dr3

Classification Criteria Risk (%) Clean Elective, not emergency, nontraumatic, primarily closed;

no acute inflammation; no break in technique; respiratory, gastrointestinal, biliary and genitourinary tracts not entered

< 2

Clean-contaminated Urgent or emergency case that is otherwise clean; elective opening of respiratory, gastrointestinal, biliary or genitourinary tract with minimal spillage (e.g., appendectomy) not encountering infected urine or bile; minor technique break

<10

Contaminated Nonpurulent inflammation; gross spillage from gastrointestinal tract; entry into biliary or genitourinary tract in the presence of infected bile or urine; major break in technique; penetrating trauma < 4 hours old; chronic open wounds to be grafted or covered

Approx. 20

Dirty Purulent inflammation(e.g., abscess); preoperative perforation of respiratory, gastrointestinal, biliary or genitourinary tract; penetratinbg trauma > 4 hours old

Approx. 40

Classification of operative wounds and risk of infection

CruzePJ,Ford.Theepidemiologyofwoundinfection.A10-yearprospectivestudyof62,939wounds.SurgClinNorthAm.1980Feb;60(1):27-40.

Commonsurgicalpathogens

•  cleanprocedures-skinflora,includingS.aureusandcoagulase-negativestaphylococci

•  clean-contaminatedprocedures(abdominalproceduresandheart,kidney,andlivertransplantations)-gram-negativerodsandenterococciinadditiontoskinflora

ASHPReport.AmJHealth-SystPharm—Vol70Feb1,2013,204-5

•  Theuseofantimicrobialagentsfordirtyproceduresorestablishedinfectionsisclassifiedastreatmentofpresumedinfection,notprophylaxis

•  Choiceofantibioticsshouldbemadeaccordingtodataonpharmacology,microbiology,clinicalexperienceandeconomy

•  Antibioticsshouldbechosenwithkineticsthatwillensureadequateserumandtissuelevelsthroughouttheriskperiod.

Idealantibiotic

•  goodtolerability•  Lowtoxicity•  Highconcentrationatallsites

–  systemicvslocal

•  Longacting•  Cephalosporin

MIC

MinimumInhibitoryConcentration(MIC)isthelowestconcentrationofanantimicrobialthatwillinhibitthevisiblegrowthofamicroorganismafterovernightincubation.

Vancomycin•  Routineuseofvancomycinprophylaxisisnotrecommendedforanyprocedure

•  IncludedintheregimenofchoicewhenaclusterofMRSAcases(e.g.,mediastinitisaftercardiacprocedures)ormethicillinresistantcoagulase-negativestaphylococciSSIshavebeendetectedataninstitution.ScottishIntercollegiateGuidelinesNetwork.Antibioticprophylaxisinsurgery.www.sign.ac.uk/pdf/sign104.pdf(accessed2009Jul30).

Advantageoflongactingantibiotic

•  Asingledosecoversthewholeperioperativeriskperiod-eveniftheoperationisdelayedorlong-lasting

•  Repeatadministrationsforprophylaxisarenotnecessary,sothatadditionaldosesarelesslikelytobeforgotten

•  Lessriskofdevelopmentofresistanceandlesssideeffects

•  Increasedcomplianceandreducederrorsofadministration

•  Possiblybetter-effectiveness(lessmaterialandlaborcost,lesssepticperioperativecomplications)

Factorsthataffectphysicians’compliance

•  Culturalfactors•  Educationalbackground•  Training•  Nurseandpharmacistinfluences,•  Medicationsupply•  Logistics

AliA.Al-Dabbagh,andMazinA.Hajy.HowGoodisCompliancewithSurgicalAntibioticProphylaxisGuidelinesinErbil/Iraq?.2ndInternationalConferenceonMedical,BiologicalandPharmaceuticalSciences(ICMBPS'2013)June17-18,2013London(UK)

ClevelandClinicGuidelinesforAntimicrobialUsage2012-2013

AmericanSocietyofHealth-SystemPharmacists.2013

Timing

•  Theantibioticshouldbeadministeredideally30minutesbeforeincisioninordertoachieverelevanttissueconcentration.

•  Inoperationslastinglongerthanthreehoursaseconddosageisrecommended.

•  Thereisnoevidencetosupportaprolongationofantibioticadministrationto24or48hoursinmostinstances.

•  Singledoseischeaperanddoesnotincreasetheriskofthedevelopementofbacterialresistance

ClassenDC,EvansRS,PestotnikSL,HornSD,MenloveRL,BurkeJP.Thetimingofprophylacticadministrationofantibioticsandtheriskofsurgical-woundinfection.NEnglJMed.1992;326:281–286.

ScottishIntercollegiateguidancenetwork(SIGN).AntibioticprophylaxisinSurgery.Edinburg.2008,updated2014

•  Forsurgicalprocedures,intravenousprophylacticantibioticsshouldbegivenwithin60minutesbeforetheskinisincisedandasclosetotimeofincisionaspracticallypossible.

•  vancomycinshouldbegivenbyintravenousinfusionstarting90minutespriortoskinincision.

•  FluoroquinolonesandVancomycin,requireadministrationoveronetotwohours

•  therefore,theadministrationoftheseagentsshouldbeginwithin120minutesbeforesurgicalincision.

ASHPTherapeuticguidelines

•  NICEandtheInfectiousDiseasesSocietyofAmerica(IDSA)recommendsthat-forCaesareansection,antibioticprophylaxistoreducematernalinfectiouscomplicationscanbegivenpre-incisionoraftercordclamping

• 

BratzlerDW,DellingerEP,olsenKM,PerlTM,AuwaerterPG,BolonMK,etal.Clinicalpracticeguidelinesforantimicrobialprophylaxisinsurgery.AmJHealthSystPharm2013;70(3):195-283.

NationalCollaboratingCentreforWomen’sandChildren’sHealth.Caesareansection.London:NICE;2011.[cited01/05/2013].

Dosage

•  Asinglestandardtherapeuticdoseofantibioticissufficientforprophylaxisundermostcircumstances

Duration

•  Asingledoseofantibioticwithalongenoughhalf-lifetoachieveactivitythroughouttheoperationisrecommended.

•  upto24hoursofantibioticprophylaxisshouldbeconsideredforarthroplasty.

Additionaldosage

•  Anadditionalintraoperativedosageofantibioticisrecommendedforcardiacsurgerylongerthanfourhourswhenusinganantibioticwithpharmacokineticsequivalenttocefazolin.

ZanettiG,GiardinaR,PlattR.Intraoperativeredosingofcefazolinandriskforsurgicalsiteinfectionincardiacsurgery.EmergingInfectiousDiseases2001;7(5):828-31

•  Intheeventofmajorintraoperativebloodlossinadults(>1,500ml)or(children25ml/kg)additionaldosageofprophylacticantibioticshouldbeconsideredafterfluidreplacement.

Howmanydays

•  Ifprophylacticantibioticgivenmorethan24hoursitisnolongeraprophylaxisbuttherapeuticschedule