SURGICAL

PROPHYLAXIS
By Abanoub Nabil &
Ahmed Tarek AND
ANTIBIOTIC
SELECTION
Prophylaxis:
means protection against infection development in susceptible individuals &
prevent serious infection development.

Antibiotic prophylaxis is used for the following objectives or

indications:
To prevent secondary bacterial infections in risky patients, e.g., cancer
patients who are receiving cytotoxic drugs, AIDS patient, etc.
To prevent wound infections after surgery: e.g., in case of contaminated
wounds.
 To protect healthy persons from infection by certain microorganism to
which they are exposed, e.g., the use of rifampicin to prevent meningitis in
individuals who are in contact with patients with meningitis.
 To protect the heart in cardiac patient suffering from valvular or rheumatic
disease e.g., Benzathine penicillin G in patients with rheumatic fever.
 To protect high risk patients from infection as bone infections in case of
prosthetic orthopedics, e.g., total hip or knee replacement because the
complications of infections are serious.
GUIDELINES OF ANTIBIOTICS
PROPHYLAXIS:
 The risk of a surgical site infection (SSI) depends on: both type of surgery
and patient-specific risk factors.
 The timing of antimicrobial prophylaxis is very important. Antibiotics
should be administered within 1 hour before surgery to ensure adequate drug
levels at the surgical site prior to the initial incision
 Single-dose prophylaxis is appropriate for many types of surgery.
Antimicrobial agents with short half-lives (e.g., cefazolin) may require
intraoperative re-dosing during long procedures (> 3 hours).
GUIDELINES OF ANTIBIOTICS
PROPHYLAXIS:
 First-generation cephalosporins (e.g., cefazolin) are the mainstay for
prophylaxis in most surgical procedures because of their spectrum of activity,
safety, and cost.
 Vancomycin as a prophylactic agent should be used only in:
>> Patients with a documented history of life-threatening β-lactam
hypersensitivity.
>> Patients whom the incidence of infections with organisms resistant to
cefazolin (e.g., MRSA) is documented.
GUIDELINES OF ANTIBIOTICS
PROPHYLAXIS:

 Route of Administration:
➢ IV antimicrobial administration is the most common for surgical
prophylaxis
(complete bioavailability & minimizing patient-specific variables).
➢ Oral administration is also used in some bowel operations (used
adjunctively and do not replace IV agents).
 7- CHOOSING
AN
ANTIMICROBI a) The type of surgery
AL AGENT
b) Intrinsic patient risk factors
FOR
c) Commonly identified pathogenic organisms / site of
PROPHYLAXIS infection
DEPENDS ON
d) Antimicrobial resistance patterns,
THE
e) Cost
FOLLOWING
FACTORS:
The type of surgery
Operations can be separated into two basic categories:
A- Extra-abdominal operations: SSIs associated with extra-abdominal operations
are the result of skin flora organisms, including gram-positive aerobes as cocci,
with S. aureus and Staphylococcus epidermidis (the most
frequently pathogens). Streptococcus spp. may also be implicated.
➢Thus an antimicrobial with strong gram-positive coverage is useful. Cefazolin
provides a benign adverse-event profile, simple dosing, and low cost, making
cefazolin the mainstay for surgical prophylaxis of extra-abdominal procedures.
➢For patients with a β-lactam allergy, clindamycin or vancomycin can be used
as an alternative.
B- Intra-abdominal operations involve a diverse flora with the potential for
polymicrobial SSIs. E. coli make up a large portion of bowel flora and are
frequently isolated as pathogens. Other enteric gram-negative bacteria, as well
as anaerobes (especially Bacteroides spp.), may be encountered during
intraabdominal operations.
➢Intra-abdominal operations necessitate broad-spectrum coverage of gram-
negative organisms and anaerobes.
➢Anti-anaerobic cephalosporins (cefoxitin and cefotetan), are widely used.
➢Fluoroquinolones or aminoglycosides, paired with clindamycin or
metronidazole, should provide adequate coverage for intraabdominal
operations; these regimens are recommended as appropriate regimens for use
in patients with β-lactam allergies.
RISK FACTORS FOR SSI:
Bacterial contamination can occur from exogenous sources (e.g., the operative team, instruments, airborne
organisms) or from endogenous sources (e.g., the patient’s microflora of the skin, respiratory, genitourinary,
or GIT).

A. Operative factors:
- Classification of wounds (Type of surgical operation)
- Insertion of prosthetic implants
- Duration of surgery

B. Patient risk factors (Host factors):

- Extremes of age
- Obesity
- cigarette smoking
- Malnutrition
- Comorbidities
1- CLASSIFICATION OF WOUNDS:
1. Clean: No inflammation, no pus, e.g., Mastectomy, vascular surgery
(incidence of infections 2 %). Not involve GIT or GUT surgery.
2. Clean contaminated: GIT, GUT or respiratory tracts entered but without
significant spillage e.g., Gastrectomy or Hysterectomy (incidence of
infections 10 %).
3. Contaminated: Open traumatic wounds (acute inflammation without pus) -
open wounds operated within four hours. (incidence of infections 20 %)
1-CLASSIFICATION OF WOUNDS CONT. :

4. Dirty wounds: Open, traumatic, dirty wounds with presence of pus. e.g.,
Intestinal fistula, ruptured appendix (incidence of infections 30-70 %).
N.B. Antimicrobial prophylaxis is appropriate for clean surgeries involving
implantation of prosthetic material, clean-contaminated, and contaminated
operations. Dirty operations take place in situations of existing infection and
antimicrobials are used for treatment, not prophylaxis
2- INSERTION OF PROSTHETIC IMPLANT:
• Implants has a detrimental effect on the host defenses. As a result a lower
inoculum of bacteria is needed to cause SSI of a prosthetic implant than a
viable tissue, this increases the incidence of SSI.

3- Duration of surgery
• The longer the preoperative hospital stay (as a result of nosocomial bacterial
acquisition) and the surgical procedure (due to the greater amount of
bacterial contamination occurring over time), the greater the likelihood of
developing a postoperative wound infection.
ANTIMICROBIAL PROPHYLAXIS IN
SPECIFIC :
Surgical Procedures
»» Gynecologic and Obstetric
•• Possible pathogens: enteric gram-negative bacilli, anaerobes, group B
streptococci, enterococci .
•• E.g., Prophylaxis for hysterectomy: cefazolin, cefotetan, cefoxitin
•• Alternatives for β-lactam allergy:
- Clindamycin or vancomycin combined with aminoglycoside, aztreonam, or
fluoroquinolone;
- metronidazole combined with aminoglycoside or fluoroquinolone
ANTIMICROBIAL PROPHYLAXIS IN
SPECIFIC :

Orthopedic Surgery
•• Possible pathogens: gram-positive cocci, mostly staphylococci
•• Prophylaxis for total joint arthroplasty (hip or knee): cefazolin
•• Alternatives for β-lactam allergy: clindamycin, vancomycin
ANTIMICROBIAL PROPHYLAXIS IN
SPECIFIC :
Cardiothoracic and Vascular Surgery
•• Possible pathogens: gram-positive cocci, mostly staphylococci
•• Prophylaxis for cardiac surgeries: cefazolin
•• Prophylaxis for vascular surgeries: cefazolin
•• For all cardiothoracic and vascular surgeries alternatives for β-lactam
allergy: clindamycin, vancomycin
ANTIMICROBIAL PROPHYLAXIS IN
SPECIFIC :
Colorectal Surgery:
•• Possible pathogens: gram-positive, gram-negative, and anaerobic
organisms
•• Parenteral prophylaxis: cefazolin and metronidazole; cefoxitin; cefotetan;
ampicillin-sulbactam; ceftriaxone and metronidazole.
•• Alternatives for β-lactam allergy: clindamycin combined with
aminoglycoside, aztreonam, or fluoroquinolone; metronidazole
combined with aminoglycoside or fluoroquinolone
•• Oral routes for prophylaxis include the combination of neomycin with
either
erythromycin or metronidazole. For most patients, this oral regimen should
be combined with a parenteral regimen
 ANTIBIOTI
CS
SELECTION
Antibiotic: is a chemical
substance produced by
micro-organism having
property of inhibiting the
growth of or destroying
other m/o in high dilution .
 WHY IS THE PROCESS OF CHOOSING AN ANTIBIOTIC IS SO
IMPORTANT ?

• Bacteria exert antibiotic resistance by various pathways that are broadly classified in four ways:
1. Drug inactivation or modification.
2. Alteration of microbial membrane permeability.(p.aeruginosa)
3. Alteration of target site.(ex: transpeptidases with penicillins)
4. Alteration in the concentration of drug target receptor.(E.coli and Proteus Enterobacter have the
ability to alter the number of drug receptors that bind antibiotics.)
FACTORS AFFECTING HOICE OF AN
ANTIMICROBIAL AGENT:
PATIENT FACTORS:

• AGE :
Affect pharmacokinetics of many anti microbial agents. Conjugation and
excretion of chloramphenicol is 1inefficient in new born > Gray baby
syndrome. The t /.5 of amino glycosides prolonged in elderly, more prone
to 8th nerve develop toxicity. Tetracycline accumulate in developing teeth
and bone.
PATIENT FACTORS:

• RENAL AND HEPATIC FUNCTION:

Dose reductiones needed in renal failure. Even in mild failure; Aminoglycosides,
Cephalosporin, Vancomycin, Amphotericin B, Ethambutol.

In hepatic patients Drugs to be avoided;-erthromycin, pyrazinamide, tetracyclines,

talampicillin, nalidixic acid, pefloxacin. In case of chloramphenicol,
metronidazole, clindamycin, isoniazid, ripampiein dose may be reduced.
PATIENT FACTORS:

• Local factors:
Presence of pus and secretion decrease the efficacy of most anti microbial
agents specially sulfonamides & aminoglycosides. Presence of necrotic
material and foreign body makes eradication of infection practically
impossible.
Lowering pH at the site of infection reduces activity of macrolide &
aminoglycosides.
PATIENT FACTORS:

• Drug allergy :
If patients have history of the allergic drug reaction it has to be avoided in that
patient; e.g-drug of choice for syphilis in a patient sensitive to penicillin is
tetracycline.
B-lactams, sulfonamides, fluoroquinolones & nitrofurantoin frequently cause
allergy.
PATIENT FACTORS:

• Drug allergy cont.

*Penicillin:
Patients with delayed reactions to penicillin (skin rash) generally can receive
cephalosporins or other beta-lactam.
Patients with anaphylaxis hypersensitivity reactions to penicillins: should not
receive cephalosporins or carbapenems (but can receive the alternatives
including aztreonam, quinolones, sulfa drugs, or vancomycin based on type
of coverage indicated).
PATIENT FACTORS :

• HOST DEFENSE:
In patient with compromised immune response bactericidal drug is used such
as cephalosporin or penicillin should be used instead of bacteriostatic drugs
such as erythromycin or clindamycin.
PATIENT FACTORS:

• Pregnancy:
Most of the antibiotics are avoided in pregnancy because of risk to foetus.
Penicillin, many cephalosporin and erythromycin are safe. Tetracyclines
carry risk of the yellow atrophy of the liver, pancreatitis and kidney damage
in mother. Also cause teeth and bone deformities in the offspring
Aminoglycosides can cause fetal ear damage.
PATIENT FACTORS:

• Genetics:
fluoroquinolones, sulphonamide,
chloramphenicol are likely to produce
hemolysis in G-6PD deficient patient.
DRUG FACTORS:

• Spectrum of activity:
In definitive therapy – a narrow spectrum drug which selectively affects the
concerned organism is preferred. Empirical therapy- often a broad spectrum
antibiotic drug has to be used to cover all likely organisms.
• Relative toxicities:
A less toxic antibiotic is preferred. E.g B-lactam over an aminoglycoside
Erythromycin over clindamycin
DRUG FACTORS:

• Route of administration:
Many antimicrobial agents can be given orally as well as parentally but
amino glycoside, penicillin G, carbenicillin, many cephalosporins,
vancomycin have to be given by injection only . For less severe infection
an oral antibiotic is preferred.
• Cost:
Less expensive drugs are to be preferred.
LAB TESTS DETERMINING THE
ANTIBIOTIC OF CHOICE:
1. Direct examination of tissue and body fluids by
Gram stain.
2. Isolation of the offending organism by culture.
3. Using in vitro antimicrobial susceptibility testing.
4. Using molecular testing systems as PCR.
5. The laboratory evaluation of antimicrobial activity
as leucocytic count and CRP.
COMMON MISUSES OF ANTIBIOTICS:

 Prolonged Empiric Antimicrobial Treatment Without Clear Evidence of

Infection. One of the most common mistakes in antimicrobial use is
continuing to add or switch antibiotics when a patient does not appear to be
responding to therapy.
 Treatment of a Positive Clinical Culture in the Absence of Disease.
Colonization with potentially pathogenic organisms without any associated
manifestation of disease occurs frequently in certain populations (eg,
colonization of the urinary tract in women of advanced age )
COMMON MISUSES OF ANTIBIOTICS:

 Failure to Narrow Antimicrobial Therapy When a Causative Organism Is

Identified. Initial therapy is often empiric and relies on broad-spectrum
agents until culture or other tests help determine the microbiological etiology.
Once culture and susceptibility data are available, an antibiotic with the
narrowest possible spectrum should be selected for continuation of therapy.
COMMON MISUSES OF ANTIBIOTICS:

 Excessive Use of Certain Antimicrobial Agents. The frequent use of certain

agents (or classes of antimicrobial agents) in a hospital or other health care
setting can result in selection of organisms that are resistant to that particular
antibiotic. For example, the increased use of fluoroquinolones during the past
decade is thought to be, in part, responsible for the epidemic of a
fluoroquinolone-resistant strain of C.difficile ….
CONCLUSION :

Appropriate use of antimicrobial agents involves obtaining an

accurate diagnosis, determining the need for and timing of
antimicrobial therapy, understanding how dosing affects the
antimicrobial activities of different agents, tailoring treatment to host
characteristics, using the narrowest spectrum and shortest duration of
therapy, and switching to oral agents as soon as possible….