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Antimicrobial Prophylaxis in

Digestive Surgery

Toar JM. Lalisang, MD, PhD

Digestive Surgery Division

Cipto Mangunkusumo Hospital

Medical Faculty Universitas Indonesia

Antibiotic must be present before bacteria is

introduced.

Given shortly before surgery

Miles and Burke

Laid the scientific basis for the use of prophylactic antibiotics in surgery

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Prophylaxis Antibiotic

Antimicrobial Prophylaxis

• The goal is to prevent SSI by reducing the burden of microorganisms at the surgical site during the operative procedure

• Antibiotic must be present before bacteria is introduced

• Patients who receive prophylactic antibiotics within one to two hours before the initial incision have lower rates of SSI than receive antibiotics sooner or later than this window

• Antimicrobial therapy administered in the setting of contaminated wounds is not considered prophylactic; in such cases a therapeutic course of antimicrobial therapy is warranted

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Single dose sufficient

•Further dose waste of resources & more complication

•long surgeries- multiple doses

Antibiotic must be active against common expected

pathogens

Stop dosing when side effects outweigh benefits

Prophylactic Antibiotic cover – decisive period

•Body responds to a breach in defense after the decisive

period

•Decisive period last up to 4hrs

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Prophylaxis Antibiotic

Surgical Side Wound Infections(SSI)

• The second most common healthcare-associated infection

• Among surgical patients, SSIs are the most common nosocomial

infection, accounting for 38 percent of nosocomial infections

• It is estimated that SSIs develop in 2 to 5 percent of the more than 30

million patients undergoing surgical procedures each year

• The cost of SSIs is substantial

Pathophysiology

Whether a wound infection occurs after surgery depends on a complex interaction between the following:

1. Patient-related factors (e.g., host immunity, nutritional

status, the presence or absence of diabetes)

2. Procedure-related factors (e.g., implantation of foreign bodies, degree of trauma to the host tissues)

3. Microbial factors (tissue adherence and invasion)

4. Perioperative antimicrobial prophylaxis

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General Principles

in the prevention of SSIs

• A number of interventions have been used over the years to reduce the risk

of SSIs, including :

Preoperative showering with antimicrobial soaps

Preoperative application of antiseptics to the skin of the patient

Washing and gloving of the surgeon's hands

Use of sterile drapes

Use of gowns and masks by operating room personnel

• The most important factors are meticulous operative techniques and

timely administration of effective preoperative antibiotics

Preventing SSI

Antibiotic prophylaxis

• Drugs- which when, how many doses?

Non antibiotic measures- evidence based

• Hair removal

• Normothermia

• Oxygen supplementation

• Normoglycemia

0

4

8

1 2

Alexander JW et al. Arch Surg. 1983;118:347–352.

Hair-Removal Techniques and SSIs

Infe

ction

, %

Discharge

30-Day Follow-up

5.2%

(14/271)

8.8%

(23/260)

6.4%

(17/266)

10%

(26/260)

4%

(10/250)

7.5%

(18/241)

1.8%

(4/226)

3.2%

(7/216)

PM AM PM AM

Razor Razor Clipper Clipper

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Preoperative Strategies to Limit SSIs: Skin Surface Preparations

Antiseptic showers

– Reduced bacterial counts by 3.5 log10 from

baseline1

– No evidence that they affect SSIs2

• Skin preparation in the operating room (OR)

– Usually iodophors, alcohol-containing

products,

or chlorhexidine gluconate2

1. Seal LA et al. Am J Infect Control. 2004;32:57–62.

2. Mangram AJ et al. Am J Infect Control. 1999;27:97–134.

Perioperative Normothermia

• 200 CRS patients

– Control: Routine intraoperative thermal care

(mean temperature 34.7°C)

– Treatment: Active warming

(mean temperature 36.6°C)

• Incidence of SSI

– Control 19% (18/96)

– Treatment 6% (6/104); P=0.009

Kurz A et al. N Engl J Med. 1996;334:1209–1215.

Supplemental Oxygen

• 500 CRS patients

– 80% or 30% inspired oxygen during operation and for 2 hours post surgery

– All patients received prophylactic antibiotics

• Results

– Arterial and subcutaneous PO2 higher in

80% oxygen group

– Lower incidence of SSIs with higher supplemental oxygen (5.2% vs 11.2%; P=0.01)

Greif et al. N Engl J Med. 2000;342:161–167.

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• 1,000 cardiothoracic surgery patients with preoperative hemoglobin A1c (HbA1c) levels measured

– 300 known diabetic patients

– 42 with undiagnosed diabetes

• Incidence of SSI

– Diabetes (known and undiagnosed) 5.8% (20/342)

– Without diabetes 1.5% (10/658)

– Diabetes with HbA1c ≥8% 7.9% (10/126)

– Diabetes with HbA1c <8% 4.0% (7/174)

Latham R et al. Infect Control Hosp Epidemiol. 2001;22:607–612.

SSIs and Glucose Levels (cont)

Latham R et al. Infect Control Hosp Epidemiol. 2001;22:607–612. Adapted with

permission from the University of Chicago Press © 2001.

SSIs and Post-op Glucose Levels

Glucose level

(mg/dL)

Infected patients

(n=72)

Noninfected

patients (n=902)

Odds

ratio

<200

(referrent) 35 (49%) 651 (72%) 1.00

200–249 21 (29%) 154 (17%) 2.54

250–299 11 (15%) 69 (8%) 2.97

≥300 5 (7%) 28 (3%) 3.32

SSIs and Glucose Levels

0

1

2

3

4

5

6

7

8

100–150 150–200 200–250 250–300

Day 1 Blood Glucose (mg/dL)

Deep

In

fecti

on

Rate

, %

Zerr KJ et al. Glucose control lowers the risk of wound infection in diabetics after open heart

operations, page 360. Reprinted from The Annals of Thoracic Surgeons, Vol. 63. Copyright

1997, with permission from the Society of Thoracic Surgeons. All rights reserved.

1.3% 1.6%

2.5%

6.7%

P=0.002

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Antimicrobial Prophylaxis

Antimicrobial agent to prevent or reduce infection

Ideally

Targeted antibiotic

Narrow spectrum agent

Targeting few pathogens

Short term

Preoperative antibiotics are

warranted

if there is a high risk of infection or

if there is high risk of deleterious outcomes

should infection develop at the surgical site

(immune compromise, cardiac surgery,

and/or implantation of a foreign device)

Timing of prophylaxis

• Antimicrobial therapy should be administered within 60 minutes prior to the surgery to ensure adequate drug tissue levels at the time of initial incision

• This practice also reduces the likelihood of antibiotic-associated reactions at the time of induction of anesthesia

• If the 60 minute window for prophylaxis has past, administration of antimicrobial therapy 30 to 60 minutes prior to surgery appears to be more effective than administration immediately before surgery

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Perioperative Prophylactic Antibiotics: Timing of Administration

Infe

ctio

ns, %

Hours From Incision

14/369

5/699

5/1,009

2/180

1/61

1/41

1/47

15/441

0

1

2

3

4

≤–3 >–2 >–1 0 1 2 3 4 ≥5

Classen DC et al. N Engl J Med. 1992;326:281–286. Copyright © 1992 Massachusetts Medical

Society. All rights reserved.

Repeat dosing

• Antibiotic concentration > MIC pathogen at the time of incision and throughout the procedure

• In general, repeat antimicrobial dosing following wound closure is not necessary and may increase antimicrobial resistance

• Repeat dosing is indicated every one to two half-lives of the drug in patients with normal renal function

for procedures lasting more than four hours

or in the setting of major blood loss

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Prophylaxis Antibiotic Indication

• Clean wound with prostheses

• Clean Contaminated

Class I Wound (Clean)

• Atraumatic wound

without inflammation

• Do not enter GI, GU,

biliary, or respiratory

tract

• 1.5% infection rate

Class II Wound

(Clean-Contaminated)

• Respiratory, GI, GU,

or biliary tract entered

under controlled

conditions

• 7.5% infection rate

expected

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Class III Wounds

(Contaminated) • Traumatic wounds

• Breaks in sterile technique

• Gross spillage from GI tract

• Acute, nonpurulent inflammation

• 15% anticipated infection rate

Class IV Wounds (Dirty)

• Old traumatic wounds

• Devitalized tissue

• Clinical infection

present

• Perforated viscus

• 40% expected

infection rate

SENIC Risk Index

• Abdominal operation

• Operation greater than

2 hours

• Class III or IV surgical

wounds

• Three or more

diagnosis at time of

discharge

Risk of Infection

0 1%

1 3.6%

2 9%

3 17%

4 27%

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Classification SSI

Superfici

al

Dee

p

Digestive Surgery

• Among the highest risk procedures for SSI due to the presence of intraluminal bacteria

• The regimen should include activity against enteric gram-negative bacilli, anaerobes, and enterococci

• Bowel preparation consists of two components: mechanical bowel preparation and administration of antibiotics (ciprofloxacin plus metronidazole)

Oesophagogastric Surgery

Organisms encountered – Enterobacterium, Enterococci

Prophylactic regimen – Second generation cephalosporin & Metronidazole

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Biliary Surgery

Organisms encountered

– Enterobacterium,

Enterococci

Prophylactic regimen –

One dose second

generation

cephalosporin

Small Bowel Surgery

Organisms encountered

– Enterobacterium,

Anaerobes

Prophylactic regimen –

Second generation

cephalosporin &

Metronidazole

Colorectal Surgery

Organisms encountered

– Enterobacterium,

Anaerobes

Prophylactic regimen –

Second generation

cephalosporin &

Metronidazole

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0%

5%

10%

15%

20%

Infe

cti

on

s, %

Major Pathogens in SSI

NNIS Report. Am J Infect Control. 1996;24:380–388.

Surgical Prophylaxis

Wound

Classification

Antibiotic PCN Allergy

I 1st generation

Cephalosporin

Vancomycin Clindamycin

II-Biliary,GU, Upper

Digestive

1st generation

Cephalosporin

Vancomycin Clindamycin

II-Distal Digestive 2nd generation

Cephalosporin

Aztreonam and

Clindamycin/Flagyl

III/IV Generally Therapeutic

Pedoman Penggunaan Antibiotik

Departemen Ilmu Bedah

RSUPN-CM 2013

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Digestive Division

Cipto Mangunkusumo Hospital 2012

• First Line

– Metronidazole

– Gentamycin

• Second Line

– Ampicillin-Sulbactam

– Cephalosporin third

Generation

– Carbapenem

Clean Contaminated

RSUPN-CM

MARCH 2013

• 67 Abdominal Operation

• 28 procedures used Prophylaxis Antibiotic

– LCC & Bilier operation = 15

– Incisional biopsy n debulking tumor = 5

– Elective Hernia repaired with mesh = 4

– Colostomy = 4

Prophylaxis Ab. : Genta + Metronidazol = 23 Cases

Cefazolin & Doripenem One case

SSI debulking tumor cases

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Antibiotic Prophylaxis-Caveats

• You can’t kill everything

• Adverse drug effects

• Select resistant pathogens

• C diff colitis

• Select more virulent pathogens

• Avoid drugs/classes that are used for therapy

Surgical Prophylaxis Summary

• Its not the tool it’s the craftsman

• Is an adjunct to, not a substitute for, good surgical technique

• Decrease SSI

• Focus on likely pathogens-what are you cutting?

• Narrow spectrum, long half life drugs

• Single pre-op dose adequate for most

• Dose timing- pre-incision,

• Short Term better ( > 72 hours)

Thank You For Your Attention