Clinic-Pharmacologic Approaches To Antimicrobial Therapy in Surgical Infections

CLINIC-PHARMACOLOGIC
APPROACHES TO ANTIMICROBIAL
THERAPY IN SURGICAL INFECTIONS

Djakubekova A.U.
SURGICAL PROPHYLAXIS
800 000
2 400 000
MAIN QUESTIONS FOR DRUG
SELECTION IN SURGICAL INFECTIONS
What kind of causative agents or
microorganisms ?
Is this infection hospital or non-
hospital?
Mono-therapy or combined therapy?
TWO TYPES OF SURGICAL INFECTIONS
NON-HOSPITAL
HOSPITAL (NOSOCOMIAL)
HOSPITAL OR NOSOCOMIAL
INFECTIONS
clinically and laboratorial estimated
infection that is not situated in
incubation period at patients
admission and developed 48 hours
after patients hospitalization.
COMMON CAUSATIVE AGENTS OF
SURGICAL INFECTIONS
AEROBS RATE (%)
E.coli 65
Proteus spp. 25
Klebsiella spp. 20
Pseudomonas spp. 15
Enterococci 15
Streptococcus spp. 10
COMMON CAUSATIVE AGENTS OF
SURGICAL INFECTIONS
ANAEROBS RATE (%)
B.fragilis 80
Clostridium spp. 65
Bacteroides spp. (others) 30
Peptostreptococcus spp. 25
Fusobacterium spp. 20
Peptococcus spp. 15
Antimicrobial prophylaxis
The aim and main tasks:
to minimize the influence of AMD on
normal microflora of intestine;
to minimize the risk of adverse effects;
to decrease the cost of treatment.
Antimicrobial agents are effective in
preventing infections in many settings.
Antimicrobial prophylaxis should be used in
circumstances in which efficacy has been
demonstrated and benefits outweigh the risks
of prophylaxis.
Antimicrobial prophylaxis may be divided into
surgical prophylaxis and nonsurgical
prophylaxis.
prophylactic administration of
antimicrobial drugs for patients without
infectious signs (clinical, laboratorial) to
prevent the risk of exogenic or endogenic
infections and exacerbation, recurrence,
generalizing of latent infections.
The antibiotic should be present in
adequate concentrations at the operative
site prior to incision and throughout the
procedure;
initial dosing is dependent on the volume
of distribution, peak levels, clearance,
protein binding, and bioavailability.
IV administration of antimicrobial drugs
is preferred.
Parenteral agents should be administered
during the interval beginning 60 minutes
before incision; administration up to the
time of incision is preferred.
RISK FACTORS FOR
Surgical wound infections
Elderly patients
Neonates
Decreased weight
Smokers
Diabetic patients
Obesity
Concurrent infection in other locations
Immunosuppressive therapy
Decreased immune activity
Coloniazation S.aureus in nasal cavity
RISK FACTORS FOR
Preoperational preparing
Surgical techniques
Bleeding
Duration of operation
Drainage of wound
Oxygen supplying and temperature in the site
of wound
Infections in surgeons and other persons
Virulence and resistance of bacteria to AMD
CLASSIFICATION OF
SUPERFICIAL (skin, subcutaneous tissue)
DEEP (fascia, muscles)
ASSOCIATED WITH ORGANS AND CAVITIES
WOUND CLASSIFICATION
(National Research Council (NRC) Wound
Classification Criteria)

Clean: Elective, primarily closed procedure;
respiratory, gastrointestinal, biliary,
genitourinary, or oropharyngeal tract not
entered; no acute inflammation and no break in
technique; expected infection rate 2%.
Clean contaminated: Urgent or emergency case
that is otherwise clean; elective, controlled
opening of respiratory, gastrointestinal, biliary, or
oropharyngeal tract; minimal spillage or minor
break in technique; expected infection rate 10%.
continuance
Contaminated: Acute nonpurulent inflammation
present; major technique break or major spill
from hollow organ; penetrating trauma less than
4 hours old; chronic open wounds to be grafted
orcovered; expected infection rate about 20%.
Dirty: Purulence or abscess present; preoperative
perforation of respiratory, gastrointestinal, biliary,
or oropharyngeal tract; penetrating trauma more
than 4 hours old; expected infection rateabout
40%.

The Study of Efficacy of Nosocomial
Infection Control (SENIC)
SENIC identified four independent risk
factors for postoperative wound infections:
operations on the abdomen,
operations lasting more than 2 hours,
contaminated or dirty wound classification,
the presence of at least three medical
diagnoses.
The Study of Efficacy of Nosocomial
Infection Control (SENIC)
Patients with at least two SENIC risk
factors who undergo clean surgical
procedures are at increased risk of
developing surgical wound infections and
should receive antimicrobial prophylaxis.
GENERAL PRINCIPLES OF SURGICAL
ANTIMICROBIAL PROPHYLAXIS
(1) The antibiotic should be active against
common surgical wound pathogens;
unnecessarily broad coverage should be
avoided.
(2) The antibiotic should have proved
efficacy in clinical trials.
(3) The antibiotic must achieve concentrations
greater than the MIC of suspected pathogens,
and these concentrations must be present at
the time of incision.
(4) The shortest possible courseideally a single
doseof the most effective and least toxic
antibiotic should be used.

(5) The newer broad-spectrum antibiotics
should be reserved for therapy of
resistant infections.
(6) If all other factors are equal, the least
expensive agent should be used.
Criteria of drug selection for
Antimicrobial Prophylaxis
Adequate spectrum of action of AMD
(staphylococci produce about 80% of post-
operational complications)
Adequate drug selection
Adequate dose
Adequate time of injection
Adequate interval between doses
Adequate route of drug administration
RECOMMENDATIONS FOR SURGICAL
Ceftriaxon
Ceftriaxon
Ceftriaxon
Ceftriaxon
Ceftriaxon
Ceftriaxon
RECOMMENDATIONS FOR SURGICAL
Ceftriaxon
Ceftriaxon
Ceftriaxon
Ceftriaxon
NON-HOSPITAL SURGICAL
INFECTIONS
Any antimicrobials active against E.coli and
B.fragilis are effective
They are following:
Amoxicillin + clavulanic acid
Cefalosporines III-IV+ Metronidazol
Fluoroquinolones + Metronidazol

EMPIRIC ANTIMICROBIAL THERAPY
OF NOSOCOMIAL INFECTIONS
Cefoperazone + sulbactam (sulperazone)
Imipenem
Meropenem
Cefepim + metronidazol
Ceftazidim + metronidazol
Levofloxacin + metronidazol
Ciprofloxacin + metronidazol

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