Rationale of use of antibiotics in surgical practice

Professor Panna Lal SahaProfessor of Surgery & Head

Department of SurgeryBGC Trust Medical College

Chittagong

Surgical wound classificationaccording to contamination

Clean: Uninfected operative wound in which no inflammation is encountered and the respiratory, alimentary, genital, or infected urinary tract are not entered. Wounds are primarily closed and, if necessary, drained with closed drainage.

Infection rate 3.3%

Clean contaminated

• Operative wound in which the respiratory, alimentary, genital or urinary tracts are entered under controlled conditions and without unusual contamination

• Infection rate 10.8%

Contaminated

Open, fresh, accidental wounds. In addition, operations with major breaks in sterile technique or gross spillage from the gastrointestinal tract, and incisions in which acute, nonpurulent inflammation is encountered are included in this category

Dirty

Old traumatic wounds with retained devitalized tissue and those that involve existing clinical infection or perforated viscera. This definition suggests that the organisms causing postoperative infection were present in the operative field before the operation.

Antibiotic Prophylaxis Guidelines

• A single preoperative dose of antibiotic is as effective as full five days course of therapy assuming uncomplicated procedure.

• Prophylactic antibiotics should be administered within 1 hour prior to incision, preferably with induction of anesthesia.

• Prophylatic antibiotics should target anticipated organisms.

Contd;• Prophylaxis should not be extended beyond 24

hours following surgery.• One preoperative and two or three postoperative

doses are sufficient in clean surgery.• Contaminated and dirty procedures should

additionally receive additional postoperative coverage.

• During prolonged procedures antibiotic prophylaxis should be re administered every 3 hours.

• Use of antibiotic in procedures classified as contaminated or infected should be used as therapeutic and not prophylactic.

Contd;

• In traumatically injured patients antibiotics to be given before bacterial contamination occurs.

• Cephalosporins especially cephazolin is 1st line prophylactic agent for most surgical procedures because of their low toxicity, long serum half life, broad spectrum of activity, low cost. Third generation should not be used for routine prophylaxis because they promote the emergence of resistance.

Available antibiotics

(In Wards)

• Inj Augmentin

• Inj Ampiclox

• Inj Flagyl

• Inj Ceftriaxone

• Inj Cephradin

Available antibiotics

(In Emergency)Inj ceftriaxoneInj cefotaximeInj Benzyl penicillinInj novidatInj FlagylInj gentacinInj cephradine

Procedure Likely

Organisms

Recommended drug

Available Alternative

CARDIO-THORACIC

STAPH AUREUS,STAPH,EPSTREPT,

GRAM –VE BACCILI

CEFAZOLIN,

CEFAMANDOLE,CEFUROXIME

CEPHRADINE CLINDAMYCIN,

VANCOMYCIN

Vascular

Surgery

Staph,

Enterococcus,gram-ve baccili

Cefazolin,

Cefuroxime

Cephradine Clindmycin

Head and

Neck

Surgery

Organism

Are

Anerobes,

Staph Aureus,

Gram-ve

Clindamycin is recomended

Available

Include

metrnidazole + Cephradine

Altrnate

Cephazolin+Metronidazole

Urology surgery

(high risk

Only)

Diabetic,

Catheterized

Gram-ve bacilli

Enterococus

Cefazolin Ciprofloxacin Ciprofloxacin,

Gentamycin

Orthopedic surgery

Common

Organims

1st line Available 2nd line

1)Closed

fracture

Staph aureus,

Staph epi Cefazolin Cephradine Clindamycin

2) Open

fracture

Staph,

Strept,

Gram-ve

Baccili,

Anearobes

Cefazolin+Gentcin

Cephradin+

Gentacin

Clindamycin+

Gentacin

Amputations ClostridiaGram –ve

Bacili,

Gram+ve

Other anerobes

Metronidazole+

Gentacin+Flucoxacilin

Augmentin+

Gentacin+Metronidazole

General

Surgery

Gastoduodenal,Esophagial

(High risk only)

Organism

Enteric Gram-ve

Bacilli,

Gram +ve

cocci

1st line

Cephazolin

Available

Cephradin,

Augmentin+Gentacin

2nd line

Clindamycin+

Gentacin

Biliary

Tract

Surgery

Enteric

Gram-ve

Bacilli,

Cefotaxime single dose,

Cefazolin

Cefotaxime

Appendicectomy Enteric

Gram-ve

bacilli

Cefazolin+

Metronidazole

03doses in non perforated,5days in perforated

Cephradin+

Metronidazole

Cefoxitin

Colon

Surgery

(Elective)

Enteric

Gram-ve

Bacilli,

Enterococcus,

Anaerobes

Oral Prophylaxis

Oral neomycin+

erythromycin base 1g

Each at1300,1400,2100hrs preop

I/V Cefazolin+metronidazole

I/v

Cefotaxime+ metronidazole One dose or gentacin+metronidazole

Oral neomycin+metronidazole

I/v

Ampicilin+Gentacin+Metronidazole

Non elective Cefoxitin

1g preop+

3 postop doses 8 hrly

Laproscopic

Cholecystectomy

No antibiotic prophlaxis required

Herial repair without mesh

No prophylaxis required

Repair with mesh

Cefazolin

Single dose

Cephradin

Strangulated Hernia

Anerobic and Gram-ve Bacilli

Cefoxitin

1g 8hrly

Cefotaxime+metronidazole

Penetrating abdominal trauma

Enteric Gram-ve bacilli

Enterococcu,

Anaerobes

Cefazolin+metronidazole

Metronidazole+Cefotaxime

Metronidazole+gentacin

Breast

Surgery

Augmentin

Acute

Cholecystitus

Gram –ve

Bacilli+Anerobes

Ciprofloxacin 500mg BD+ Metronidazole

400mg TDS

Acute

Pancreatitis

(low risk)

High Risk

Cefuroxime

Imipenum

Cefotaxime

Antibiotics in pregnancy

• Penicillin , Cephalosporin's and Erythromycin are the drug of choice.

• Quinolones, Tetracycline ,Streptomycin are

contraindicated

Amino glycosides , Metronidazole (except 1st trimester) , Sulphonamides Can be taken when indicated.

•

• Thank You