Antibiotic Prophylaxis in Surgical Site Infection Prevention EDIT

8/13/2019 Antibiotic Prophylaxis in Surgical Site Infection Prevention EDIT

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ANTIBIOTIC PROPHYLAXIS

IN SURGICAL SITE INFECTION PREVENTION

Lailil Indah SeftianiBekasi City General Hospital

[email protected]

Abstract- Surgical sit i!"cti#! $SSI% is #! #" t&

'#st c#''#! c#'(licati#!s #" surgr) i! b#t&

a*ults a!* c&il*r!+ T& (ur(#s #" t& (rs!t

r,i is t# &ig&lig&t t& (r#grss i! t&

u!*rsta!*i!g #" SSIs a!* t& r#l #"

a!ti'icr#bial (r#(&)la.is $A/P%+

0)#r*s1 Surgical sit i!"cti#!2 a!tibi#tic

(r#(&)la.is

I. INTRODUCTION

Suri!al site infe!tions "SSIs# are defined as

infe!tions o!!urrin up to $% days after surery "or

up to one year after surery in patients re!ei&ini'plants# and affe!tin either the in!ision or deep

tissue at the operation site. Despite i'pro&e'ents in

pre&ention( SSIs re'ain a sinifi!ant !lini!al pro)le'

as they are asso!iated *ith su)stantial 'ortality and

'or)idity and i'pose se&ere de'ands on health!areresour!es. The in!iden!e of SSIs 'ay )e as hih as

+%,( dependin on the suri!al pro!edure( the

sur&eillan!e !riteria used( and the -uality of data!olle!tion. In 'any SSIs( the responsi)le pathoens

oriinate fro' the patients endoenous flora. The!ausati&e pathoens depend on the type of surery/

the 'ost !o''only isolated oranis's are

Staphylo!o!!us aureus( !oaulase0neati&e

staphylo!o!!i( 1ntero!o!!us spp. and 1s!heri!hia

!oli. Nu'erous patient0related and pro!edure0related

fa!tors influen!e the risk of SSI( and hen!e

pre&ention re-uires a )undle approa!h( *ith

syste'ati! attention to 'ultiple risk fa!tors( in orderto redu!e the risk of )a!terial !onta'ination and

i'pro&e the patients defen!es. The Centers for

Disease Control and 2re&ention uidelines for the

pre&ention of SSIs e'phasise the i'portan!e of ood

patient preparation( asepti! pra!ti!e( and attention to

suri!al te!hni-ue/ anti'i!ro)ial prophyla3is is also

indi!ated in spe!ifi! !ir!u'stan!es.3

II. SURGIC4L SIT1 IN51CTION

4"i!iti#!

4 *ound is defined )y the Center for Disease

Control "CDC# as an interruption or )reak in the

!ontinuity of the e3ternal surfa!e of the )ody or the

surfa!e of an internal oran( !aused )y suri!al orother for's of in6ury or trau'a. Suri!al site

infe!tion is a type of health!are0asso!iated infe!tion

in *hi!h a *ound infe!tion o!!urs after an in&asi&e

"suri!al# pro!edure. 4n SSI is dianosed )y a

!onstellation of !lini!al findins o!!urrin *ithin $%

days of surery. 4 suri!al site infe!tion "SSI# is

!lini!ally defined as presen!e of pain at a suri!ally

!reated *ound( *hi!h is a!!o'panied )y erythe'a(induration and lo!al tenderness or presen!e of

purulent dis!hare at *ound site.5

Sur,illa!c

In +%7%( an esti'ated 78 'illion operati&e pro!edures *ere perfor'ed in a!ute !are hospitals in

the United States. 4 re!ent pre&alen!e study found

that SSIs *ere the 'ost !o''on health!are0asso!iated infe!tion( a!!ountin for $7, of all H4Is

a'on hospitali9ed patients. NHSN data for +%%80+%%: "78(7;< SSIs follo*in :;=(8>= operati&e

pro!edures# sho*ed an o&erall SSI rate of 7.=,. SSI

is asso!iated *ith a 'ortality rate of $,(and <>, of

SSI0asso!iated deaths are dire!tly attri)uta)le to the

SSI.6

7#u!* status

?ound !hara!teristi!s *hi!h in!rease the risk of

SSI in!lude( presen!e of forein )odies( non&ia)le

tissue in *ound( tissue is!he'ia and hae'ato'a

for'ation. 4ll of these !hara!teristi!s pro&ide a

fruitful )a!terial ro*in en&iron'ent. Other fa!tors

kno*n to pro'ote SSIs are a proloned preoperati&e

hospital stay "sin!e there is a ro*in opportunity for

the skin to )e !oloni9ed )y pathoens#( a lon

1

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mailto:[email protected]



operation ti'e "as it pro)a)ly in!reases the e3tent of

)oth tissue trau'a and !onta'ination#( and poor

suri!al te!hni-ues "see )elo*#.

The risk of SSI &aries *ith the type of surery.

Certain types of surery !arry a hiher risk of!onta'ination than others and ha&e led to the

!lassifi!ation of suri!al *ounds as !lean( !lean0!onta'inated( !onta'inated( or dirty.8

Ta)le 7. ?ound !lass and Classifi!ation of the

risk of SSI

III. TH1 @1CH4NIS@S O5 B4CT1RI4L24THOG1NICITA

SSIs are !aused )y the deposition and'ultipli!ation of 'i!rooranis's in the suri!al site

of a sus!epti)le host. There are a nu')er of *ays

'i!rooranis's !oloni9e and !ause infe!tion(

in!ludin a# dire!t !onta!t either fro' another

patient( transfer fro' suri!al e-uip'ent or the hands

of the hospital staff/ )# air)orne dispersal

surroundin air !onta'inated *ith 'i!ro0oranis's

that deposit onto the *ound/ and !# self0!onta'ination "also kno*n as endoenous infe!tion#

physi!al 'iration of the patients o*n nor'al

flora *hi!h are present on the skin( 'u!ous

'e')ranes or astrointestinal tra!t to the suri!al

site. @ost suri!al infe!tion is due to )a!terial and(

'ore rarely( funal infe!tion.

T*o )road -ualities of pathoeni! )a!teria underlie

the 'eans )y *hi!h they !ause disease

7. In&asi&eness is the a)ility to in&ade tissues. It

en!o'passes 'e!hanis's for !oloni9ation

"adheren!e and initial 'ultipli!ation#( produ!tion of

e3tra!ellular su)stan!es *hi!h fa!ilitate in&asion

"in&asins# and a)ility to )ypass or o&er!o'e hostdefense 'e!hanis's.

+. To3ienesis is the a)ility to produ!e to3ins.Ba!teria 'ay produ!e t*o types of to3ins !alled

e3oto3ins and endoto3ins. 13oto3ins are released

fro' )a!terial !ells and 'ay a!t at tissue sites

re'o&ed fro' the site of )a!terial ro*th.

1ndoto3ins are !ell0asso!iated su)stan!e. "In a

!lassi! sense( the ter' endoto3in refers to thelipopolysa!!haride !o'ponent of the outer 'e')rane

of Gra'0neati&e )a!teria#. Ho*e&er( endoto3ins

'ay )e released fro' ro*in )a!terial !ells and

!ells that are lysed as a result of effe!ti&e host

defense "e.. lyso9y'e# or the a!ti&ities of !ertain

anti)ioti!s "e.. peni!illins and !ephalosporins#.

Hen!e( )a!terial to3ins( )oth solu)le and !ell0

asso!iated( 'ay )e transported )y )lood and ly'phand !ause !ytoto3i! effe!ts at tissue sites re'ote fro'

the oriinal point of in&asion or ro*th. So'e )a!terial to3ins 'ay also a!t at the site of

!oloni9ation and play a role in in&asion.

2i!ure 7. Ba!terial stru!ture

The !o''onest oranis' !ausin SSI is

Staphylococcus aureus. Other !o''on !ausati&e

oranis's in!lude other Gra'0neati&e aero)es(

Streptococcus spp. and anaero)es. O&erall( 7;; of the87: patients studied de&eloped SSIs( *ith the 'ost

!o''on isolates )ein S. aureus "$<,#( E. coli

"77,#( and Enterococcus spp. ">,#.9

2



2i!ture +. S!annin ele!tron 'i!roraph of

Staphylococcus aureus )a!teria.

Dependin on the parti!ular strain( there are

se&eral kinds of to3ins attri)uted to S. aureus

&irulen!e. 13oto3ins !an in!lude to3i! sho!k

syndro'e to3in07 "TSST07#( e3foliatins( and

enteroto3ins. Others 'ay in!lude alpha0to3in( )eta0

to3in( delta0to3in( and )i!o'ponent to3ins su!h as

2anton0Ealentine leuko!idin. 5a!tors in!ludin protein 4( Staphylo3anthin pi'ent( !lu'pin fa!tor(

!oaulase( hyaluronidase( leuko!idin( and )iofil'

produ!tion !an also affe!t the &irulen!e "5or)es etal .( +%%<#.

13oto3in TSST07 !auses to3i! sho!k syndro'e )y

sti'ulatin the release of lare a'ounts of

interleukin07 "IL07# )y hu'an 'ono!ytes(

interleukin0+ "IL0+#( and tu'our ne!rosis fa!tor.Si'ilarly( it indu!es the e3pression of IL0+ re!eptors

and the proliferation of hu'an T ly'pho!ytes. It

does this )y )indin to @HC !lass II 'ole!ules and

the e3otonin is produ!ed )y 'ost strains of S. aureus

"S!holl et al .( 7=:=#. In eneral( the to3in is not

produ!ed )y )a!teria ro*in in the )lood/ rather( it

is produ!ed at the lo!al site of an infe!tion( and then

enters the )loodstrea'.

IE.4NTIBIOTICS

A!tibi#tics 7#r:

2i!ture $. @a6or taret for anti)a!terial a!tion

2i!ture ;. Sites of anti)a!terial a!tion

A!tibi#tics "#r (r#(&)la.is #" SSIs

The oals of anti)ioti! prophyla3is are to a!hie&e

inhi)itory anti)ioti! le&els at in!ision and throuhoutthe pro!edure in an effort to de!rease the likelihood

of de&elopin a SSI. 4nti)ioti!s !an also play an

i'portant role in the treat'ent of SSIs.

Classen et al.( in a prospe!ti&e o)ser&ational

study( 'onitored the ti'in of anti)ioti! prophyla3is

in +:;< patients in F!lean or F!lean !onta'inated

surery. Usin a step0*ise loisti! reression 'odel(they found that preoperati&e anti)ioti!s *ithin t*ohours of in!ision had the lo*est rate of infe!tion as

!o'pared to anti)ioti!s i&en after in!ision or earlier

than t*o hours prior.;

In addition to )ein i&en preoperati&ely(

prophyla!ti! anti)ioti!s should not )e !ontinued

postoperati&ely. 4 fi&e0'onth prospe!ti&e sur&ey of

suri!al0site infe!tions "SSI# !ondu!ted in the

depart'ent of eneral surery at ili'an6aroChristian @edi!al Center( Tan9ania )y 1riksen et al.,

sho*ed that << "7=.;,# of the $=< patients studied

de&eloped SSI. T*enty0eiht "$8.;,# of these

infe!tions *ere apparent only after dis!hare fro'hospital. 4 surprisin eihty0se&en per!ent of the

patients *ho de&eloped SSI had re!ei&ed anti)ioti!s(

the 'a6ority ha&in re!ei&ed the anti)ioti!s for

se&eral days. Su!h a pra!ti!e is !ontrary to the

!urrent re!o''endation of a sinle preoperati&e

dose( and proloned inappropriate use of )road0spe!tru' anti)ioti!s 'ay !ontri)ute to in!reased

e'eren!e of resistan!e. <

The type of surery "!lean( !lean!onta'inated(

!onta'inated( or dirty# also i'pa!ts the role of

anti)ioti! prophyla3is. 4n understandin of this

!lassifi!ation( as *ell as kno*lede of

re!o''endations for spe!ifi! pro!edures( isin&alua)le in 'akin an appropriate !hoi!e reardinanti)ioti! prophyla3is. 4nti)ioti! ad'inistration in

dirty !ases is not !onsidered prophyla!ti! as these

!ases represent treat'ent of infe!tion rather than

prophyla3is.

3



Contro&ersy e3ists reardin the use of anti)ioti!

prophyla3is for !lean !ases. ?hen anti)ioti!

prophyla3is is i&en( the aent should taret S.

aureus( the 'ost !o''on oranis' !ausin SSIs in

!lean !ases/ !efa9olin is a ood !hoi!e. ?hen )one isin!ised( the use of prophyla!ti! anti)ioti!s is !learly

re!o''ended. 4 ood !hoi!e in this situation( or for!ardiothora!i! or &as!ular surery( is !efa9olin or

!efuro3i'e "or !linda'y!in or &an!o'y!in for

peni!illin alleri!#. 5or eneral suri!al !lean !ases(

the de!ision is less !lear. 4 Co!hrane Data)ase of

Syste'ati! Re&ie*s e3a'ined the use of

prophyla!ti! anti)ioti!s prior to hernia surery( andfound that infe!tion rates *ere lo*er *ith use of

anti)ioti!s "+.=, &ersus $.=,# )ut !on!luded that

Fanti)ioti! prophyla3is for ele!ti&e inuinal hernia

repair !annot )e uni&ersally re!o''ended )e!ause of

o&erall lo* infe!tion rates( a hih nu')er needed to

treat( and a la!k of a lare( rando'i9ed !ontrolled

trial to pro&e effi!a!y.

5or !lean0!onta'inated and !onta'inated !ases(anti)ioti! prophyla3is is re!o''ended. Colore!tal

surery is the 'ost thorouhly studied type of pro!edure in this !ateory( and as su!h 'ost

re!o''endations are )ased on studies in&ol&in

!olore!tal surery. The 'ost !o''only en!ountered

oranis' in !lean0!onta'inated and !onta'inated

SSIs is still S. aureus( thouh other aero)i! as *ell as

anaero)i! )a!teria are also !ulprits. 4s su!h(

prophyla3is should )e )roader than that used for

!lean !ases. Son et al. re&ie*ed all rando'i9ed!ontrolled trials of anti)ioti! prophyla3is in

!olore!tal surery. 5our of these studies !o'pared

anti)ioti! rei'ens to no anti)ioti!s and sho*ed a!on&in!in )enefit of prophyla!ti! anti)ioti!s "odds

ratio %.+;( =>, !onfiden!e inter&al %.7$ to %.;$#.

5urther analysis re&ealed that the 'ost effi!a!ious

rei'ens in!lude !o&erae aainst )oth aero)i! and

anaero)i! oranis's "su!h as a +nd or $rd eneration!ephalosporin( or enta'i!in in !o')ination *ith

'etronida9ole#( and !ited !ertain rei'ens

inade-uate "'etronida9ole alone( do3y!y!line alone(

pipera!illin alone#. Thouh data fro' 4fri!a is

li'ited( differen!es in effi!a!y )et*een &arious +nd

and $rd eneration !ephalosporins appear nelii)le(

and !hoi!e prophyla3is *ith a sinle0aent +nd or $rd

eneration !ephalosporin !an pro)a)ly )e di!tated )ya&aila)ility or !ost. 5or peni!illin0alleri! patients(

!linda'y!in !o')ined *ith enta'i!in( a9treona'(or !iproflo3a!in( or 'etronida9ole !o')ined *ith

enta'i!in or !iproflo3a!in are ade-uate !hoi!es.=2>

4 re!ent 'eta0analysis of 'eta0analysesJ

in&ol&in +>% !lini!al trials and ;:%= patients has

pro&ided an esti'ation of the relati&e )enefit of

syste'ati! prophyla!ti! anti)ioti!s to redu!e

infe!tion for +$ different types of surery. The type

of anti)ioti!( ti'in( dosin( and type of pro!edure

&aried *idely in this analysis( )ut the relati&e risk ofde&elopin infe!tion for all types of operations *ith

prophyla!ti! syste'i! anti)ioti!s &ersus no prophyla!ti! anti)ioti!s &aried fro' %.7= to %.:+(

suestin a enerali9ed )enefit reardless of the

deree of !onta'ination. Taken as a *hole( the use of

prophyla!ti! syste'i! anti)ioti!s de!reased the

in!iden!e of *ound infe!tions )y a)out one half. This

does not 'ean that prophyla!ti! anti)ioti!s should )eused for e&ery !ase( in as 'u!h as there are

sinifi!ant !osts in&ol&ed *ith their ad'inistration(

they !an ha&e serious ad&erse effe!ts and there is a

risk of the de&elop'ent of anti)ioti! resistant

pathoens or C. difficele !olitis. Be!ause of this( there

has )een relu!tan!e to use prophyla!ti! anti)ioti!s in

!lean !ases. Ho*e&er( prospe!ti&e rando'i9ed

studies ha&e sho*n a !lear )enefit in !lean ele!ti&eoperations su!h as hernia and )reast pro!edures

"SDC07$<07;7#. Re!ent reports ha&e also sho*nsinifi!ant prote!tion aainst infe!tions in patients

*ith a !esarean se!tion "SDC07;+07;$#. 4 re&ie* of

the use of anti'i!ro)ial prophyla3is in !olore!tal

surery( in!ludin 7:+ trials *ith $::% parti!ipants

and >% different anti)ioti!s( sho*ed a definite )enefit

of prophyla!ti! anti)ioti!s !o'pared to a pla!e)o or

no treat'ent "RR K %.$%#. In that sa'e study(

!o')ined therapy aainst )oth aero)i! and anero)i!oranis's and !o')ined oral and intra&enous

anti)ioti! prophyla3is !o'pared to intra&enous alone

had sinifi!ant )enefits "RR( %.;7 and %.<;(respe!ti&ely#. 3?

G!ral (ri!ci(ls i! surgical (r#(&)la.is

7.Duration of prophyla3isThe duration of

anti'i!ro)ial prophyla3is should not routinelye3!eed +; hours "7 dose at indu!tion and + 'ore

doses postoperati&ely( i.e. $ doses in total#. There is

*ide !onsensus that only a sinle dose of intra&enous

anti'i!ro)ial aent is needed for suri!al prophyla3is

in the reat 'a6ority of !ases. 2u)lished e&iden!e

sho*s that anti'i!ro)ial prophyla3is after *ound

!losure is unne!essary and !ould lead to e'eren!e

of resistant )a!teria. @ost studies !o'parin sinle0*ith 'ultiple0dose prophyla3is ha&e not sho*n

)enefit of additional doses.

+.Ti'in 5or 'any prophyla!ti! anti'i!ro)ial

aents( the ad'inistration of an initial dose should )e

i&en *ithin $% 'inutes )efore in!ision "!oin!idin

*ith the indu!tion of anesthesia# to a!hie&e an

4



ade-uate tissue !on!entration at the ti'e of initial

in!ision. This !an )e fa!ilitated )y ha&in the

anesthesioloist ad'inister the dru in the operatin

roo' at indu!tion.

$.4nti'i!ro)ial dosin The dose should )e ade-uate )ased on the patients )ody *eiht. 4n additional

dose of anti'i!ro)ial aent should )e i&en"intraoperati&ely# if the operation is still !ontinuin

after t*o half0li&es of the initial dose or 'assi&e

intraoperati&e )lood losses o!!ur. Suested initial

dose and ti'e to re0dose for sele!ted anti'i!ro)ial

aents used for suri!al prophyla3is.33

Ta)le +. 4nti'i!ro)ial aent

E. CONCLUSION

4 *ound is defined )y the Center for Disease

Control "CDC# as an interruption or )reak in the

!ontinuity of the e3ternal surfa!e of the )ody or the

surfa!e of an internal oran( !aused )y suri!al or

other for's of in6ury or trau'a. Suri!al site

infe!tion is a type of health!are0asso!iated infe!tionin *hi!h a *ound infe!tion o!!urs after an in&asi&e

"suri!al# pro!edure. Suri!al site infe!tions "SSIs#

are defined as infe!tions o!!urrin up to $% days after

surery "or up to one year after surery in patients

re!ei&in i'plants# and affe!tin either the in!ision

or deep tissue at the operation site. The !ausati&e

pathoens depend on the type of surery/ the 'ost

!o''only isolated oranis's are Staphylo!o!!usaureus( !oaulase0neati&e staphylo!o!!i(

1ntero!o!!us spp. and 1s!heri!hia !oli. The Centers

for Disease Control and 2re&ention uidelines for the

pre&ention of SSIs e'phasise the i'portan!e of ood

patient preparation( asepti! pra!ti!e( and attention tosuri!al te!hni-ue/ anti'i!ro)ial prophyla3is is also

indi!ated in spe!ifi! !ir!u'stan!es. The oals of

anti)ioti! prophyla3is are to a!hie&e inhi)itoryanti)ioti! le&els at in!ision and throuhout the

pro!edure in an effort to de!rease the likelihood of

de&elopin a SSI. 4nti)ioti!s !an also play an

i'portant role in the treat'ent of SSIs.

EI. R151R1NC1S

1. Horan TC ( Gaynes R2 ( @artone ?M (

Mar&is ?R ( 1'ori TG . C4C *"i!iti#!s #"

!#sc#'ial surgical sit i!"cti#!s2 3>>51 a

'#*i"icati#! #" C4C *"i!iti#!s #" surgical #u!*

i!"cti#!s + Infect Control Hosp Epidemiol .

7==+/7$8%88%:

+. Ussiri 1( @kony C( 49i9 @. Sutured and

open !lean0!onta'inated and !onta'inated

laparoto'y *ounds at @uhi')ili National Hospital

$. 4 !o'parison of !o'pli!ations. 1ast and

Central 4fri!an Mournal of Surery+%%;/="+#:=0=>.

4. CDC. Data from the National Hospital

Discharge Survey. +%7% !ited +%7$ De! 7%/

4&aila)le fro'

http***.!d!.o&n!hsdatanhds;pro!edures+%7

%proPnu')erper!entae.pdf .

>. Gardner D( T*eedle D. 2atholoy forsureons in trainin00an 40Q re&ision te3t. $rd ed.

London 4rnold 2u)lishers/ +%%+.6. 4r!iola CR( Ca'po!!ia D( Ga')erini S(

Donati @1( Baldassarri L( @ontanaro L. O!!uren!e

of i!a enes for sli'e synthesis in a !olle!tion of

Staphylo!o!!us epider'idis strains fro' orthopedi!

prosthesis infe!tions. 4!ta Orthop S!and. +%%$

O!t/<;">#87<0+7. 2@ID7;8+%=:8<. Classen D( 1&ans R( 2estotnik S( Horn S(

@enlo&e R( Burke M. The ti'in of prophyla!ti!

ad'inistration of anti)ioti!s and the risk of suri!al0

*ound infe!tion. Ne* 1nland Mournal of

@edi!ine7==+/$+8+:708. 4&aila)le fro'

httpsi'plelink.li)rary.utoronto.!a.'ya!!ess.li)rary.

utoronto.!aurl.!f'><:+7.:. 1riksen H( Chuulu S( ondo S( Linaas 1.Suri!al0site infe!tions at ili'an6aro Christian

@edi!al Center. Mournal of Hospital

Infe!tion+%%$/>>7;0+%.

4&aila)le fro'

httpsi'plelink.li)rary.utoronto.!a.'ya!!ess.li)rary.

utoronto.!aurl.!f'><:%$

=. Brat9ler D( Hou!k 2. 4nti'i!ro)ial

prophyla3is for surery 4n ad&isory state'ent fro'

the National Suri!al Infe!tion 2re&ention 2ro6e!t.

Clini!al Infe!tious Diseases+%%;/$:7<%807>.4&aila)le fro'

httpsi'plelink.li)rary.utoronto.!a.'ya!!ess.li)rary.utoronto.!aurl.!f'><:+$.

7%. Son 5( Glenny 4. 4nti'i!ro)ial

prophyla3is in !olore!tal surery a syste'ati!

re&ie* of rando'ised !ontrolled trials. Health

Te!hnoloy 4ssess'ent7==:/+"<#7077%.

4&aila)le fro'httpsi'plelink.li)rary.utoronto.!a.'ya!!ess.li)rary.

utoronto.!aurl.!f'><:+<.

5

http://www.cdc.gov/nchs/data/nhds/4procedures/2010pro_numberpercentage.pdf


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Antibiotic Prophylaxis in Surgical Site Infection Prevention EDIT