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ANTIBIOTIC PROPHYLAXIS IN SURGICAL SITE INFECTION PREVENTION

Lailil Indah Seftiani


Bekasi City General Hospital

lailil_chaofrogy@yahoo.co.id

Abstract- Surgical sit i!" cti#! $SSI% is #! #" t& '#st c#''#! c#'(licati#!s #" surg r) i! b#t& a*ults a!* c&il*r !+ T& (ur(#s #" t& (r s !t r ,i - is t# &ig&lig&t t& (r#gr ss 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 (r#(&)la.is i!" cti#!2 a!tibi#tic

I. INTRODUCTION Sur i!al site infe!tions "SSIs# are defined as infe!tions o!!urrin up to $% days after sur ery "or up to one year after sur ery in patients re!ei&in i'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 si nifi!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!are resour!es. The in!iden!e of SSIs 'ay )e as hi h as +%,( dependin on the sur i!al pro!edure( the sur&eillan!e !riteria used( and the -uality of data !olle!tion. In 'any SSIs( the responsi)le patho ens ori inate fro' the patient.s endo enous flora. The !ausati&e patho ens depend on the type of sur ery/ the 'ost !o''only isolated or anis's are Staphylo!o!!us aureus( !oa ulase0ne ati&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 order to redu!e the risk of )a!terial !onta'ination and i'pro&e the patient.s 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 sur i!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 or an( !aused )y sur i!al or other for's of in6ury or trau'a. Sur i!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 "sur i!al# pro!edure. 4n SSI is dia nosed )y a !onstellation of !lini!al findin s o!!urrin *ithin $% days of sur ery. 4 sur i!al site infe!tion "SSI# is !lini!ally defined as presen!e of pain at a sur i!ally !reated *ound( *hi!h is a!!o'panied )y erythe'a( induration and lo!al tenderness or presen!e of purulent dis!har e 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!are0 asso!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 forei n )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 prolon ed preoperati&e hospital stay "sin!e there is a ro*in opportunity for the skin to )e !oloni9ed )y patho ens#( a lon

operation ti'e "as it pro)a)ly in!reases the e3tent of )oth tissue trau'a and !onta'ination#( and poor sur i!al te!hni-ues "see )elo*#. The risk of SSI &aries *ith the type of sur ery. Certain types of sur ery !arry a hi her risk of !onta'ination than others and ha&e led to the !lassifi!ation of sur i!al *ounds as !lean( !lean0 !onta'inated( !onta'inated( or dirty. 8

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 host defense 'e!hanis's. +. To3i enesis 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 the lipopolysa!!haride !o'ponent of the outer 'e')rane of Gra'0ne ati&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'ph and !ause !ytoto3i! effe!ts at tissue sites re'ote fro' the ori inal 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.

Ta)le 7. ?ound !lass and Classifi!ation of the risk of SSI TH1 @1CH4NIS@S O5 B4CT1RI4L 24THOG1NICITA SSIs are !aused )y the deposition and 'ultipli!ation of 'i!roor anis's in the sur i!al site of a sus!epti)le host. There are a nu')er of *ays 'i!roor anis's !oloni9e and !ause infe!tion( in!ludin B a# dire!t !onta!t C either fro' another patient( transfer fro' sur i!al e-uip'ent or the hands of the hospital staff/ )# air)orne dispersal C surroundin air !onta'inated *ith 'i!ro0or anis's that deposit onto the *ound/ and !# self0 !onta'ination "also kno*n as endo enous infe!tion# C physi!al 'i ration of the patientDs o*n nor'al flora *hi!h are present on the skin( 'u!ous 'e')ranes or astrointestinal tra!t to the sur i!al site. @ost sur i!al infe!tion is due to )a!terial and( 'ore rarely( fun al infe!tion. T*o )road -ualities of patho eni! )a!teria underlie the 'eans )y *hi!h they !ause diseaseB III.

2i!ure 7. Ba!terial stru!ture The !o''onest or anis' !ausin SSI is Staphylococcus aureus. Other !o''on !ausati&e or anis's in!lude other Gra'0ne ati&e aero)es( Streptococcus spp. and anaero)es. O&erall( 7;; of the 87: patients studied de&eloped SSIs( *ith the 'ost !o''on isolates )ein S. aureus "$<,#( E. coli "77,#( and Enterococcus spp. ">,#.9

2i!ture +. S!annin ele!tron 'i!ro raph 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( !oa ulase( hyaluronidase( leuko!idin( and )iofil' produ!tion !an also affe!t the &irulen!e "5or)es et al.( +%%<#. 13oto3in TSST07 !auses to3i! sho!k syndro'e )y sti'ulatin the release of lar e 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 ;. 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 throu hout 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. 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 sur ery. Usin a step0*ise lo isti! re ression 'odel( they found that preoperati&e anti)ioti!s *ithin t*o hours 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 sur i!al0site infe!tions "SSI# !ondu!ted in the depart'ent of eneral sur ery at Gili'an6aro Christian @edi!al Center( Tan9ania )y 1riksen et al., sho*ed that << "7=.;,# of the $=< patients studied de&eloped SSI. T*enty0ei ht "$8.;,# of these infe!tions *ere apparent only after dis!har e fro' hospital. 4 surprisin ei hty0se&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 sin le preoperati&e dose( and prolon ed inappropriate use of )road0 spe!tru' anti)ioti!s 'ay !ontri)ute to in!reased e'er en!e of resistan!e. < The type of sur ery "!lean( !leanH!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*led e of re!o''endations for spe!ifi! pro!edures( is in&alua)le in 'akin an appropriate !hoi!e re ardin anti)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.

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

Contro&ersy e3ists re ardin the use of anti)ioti! prophyla3is for !lean !ases. ?hen anti)ioti! prophyla3is is i&en( the a ent should tar et S. aureus( the 'ost !o''on or anis' !ausin SSIs in !lean !ases/ !efa9olin is a ood !hoi!e. ?hen )one is in!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 sur ery( is !efa9olin or !efuro3i'e "or !linda'y!in or &an!o'y!in for peni!illin aller i!#. 5or eneral sur i!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 sur ery( and found that infe!tion rates *ere lo*er *ith use of anti)ioti!s "+.=, &ersus $.=,# )ut !on!luded that Fanti)ioti! prophyla3is for ele!ti&e in uinal hernia repair !annot )e uni&ersally re!o''ended )e!ause of o&erall lo* infe!tion rates( a hi h nu')er needed to treat( and a la!k of a lar e( rando'i9ed !ontrolled trial to pro&e effi!a!y. 5or !lean0!onta'inated and !onta'inated !ases( anti)ioti! prophyla3is is re!o''ended. Colore!tal sur ery is the 'ost thorou hly studied type of pro!edure in this !ate ory( and as su!h 'ost re!o''endations are )ased on studies in&ol&in !olore!tal sur ery. The 'ost !o''only en!ountered or anis' in !lean0!onta'inated and !onta'inated SSIs is still S. aureus( thou h other aero)i! as *ell as anaero)i! )a!teria are also !ulprits. 4s su!h( prophyla3is should )e )roader than that used for !lean !ases. Son et al. re&ie*ed all rando'i9ed !ontrolled trials of anti)ioti! prophyla3is in !olore!tal sur ery. 5our of these studies !o'pared anti)ioti! re i'ens to no anti)ioti!s and sho*ed a !on&in!in )enefit of prophyla!ti! anti)ioti!s "odds ratio %.+;( =>, !onfiden!e inter&al %.7$ to %.;$#. 5urther analysis re&ealed that the 'ost effi!a!ious re i'ens in!lude !o&era e a ainst )oth aero)i! and anaero)i! or anis's "su!h as a +nd or $rd eneration !ephalosporin( or enta'i!in in !o')ination *ith 'etronida9ole#( and !ited !ertain re i'ens inade-uate "'etronida9ole alone( do3y!y!line alone( pipera!illin alone#. Thou h data fro' 4fri!a is li'ited( differen!es in effi!a!y )et*een &arious +nd and $rd eneration !ephalosporins appear ne li i)le( and !hoi!e prophyla3is *ith a sin le0a ent +nd or $rd eneration !ephalosporin !an pro)a)ly )e di!tated )y a&aila)ility or !ost. 5or peni!illin0aller i! 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>

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 sur ery. The type of anti)ioti!( ti'in ( dosin ( and type of pro!edure &aried *idely in this analysis( )ut the relati&e risk of de&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 %.:+( su estin a enerali9ed )enefit re ardless of the de ree 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 )e used for e&ery !ase( in as 'u!h as there are si nifi!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 patho ens 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&e operations su!h as hernia and )reast pro!edures "SDC07$<07;7#. Re!ent reports ha&e also sho*n si nifi!ant prote!tion a ainst infe!tions in patients *ith a !esarean se!tion "SDC07;+07;$#. 4 re&ie* of the use of anti'i!ro)ial prophyla3is in !olore!tal sur ery( 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 a ainst )oth aero)i! and anero)i! or anis's and !o')ined oral and intra&enous anti)ioti! prophyla3is !o'pared to intra&enous alone had si nifi!ant )enefits "RR( %.;7 and %.<;( respe!ti&ely#. 3? G ! ral (ri!ci(l s i! surgical (r#(&)la.is 7.Duration of prophyla3isBThe duration of anti'i!ro)ial prophyla3is should not routinely e3!eed +; hours "7 dose at indu!tion and + 'ore doses postoperati&ely( i.e. $ doses in total#. There is *ide !onsensus that only a sin le dose of intra&enous anti'i!ro)ial a ent is needed for sur i!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'er en!e of resistant )a!teria. @ost studies !o'parin sin le0 *ith 'ultiple0dose prophyla3is ha&e not sho*n )enefit of additional doses.

4 re!ent I'eta0analysis of 'eta0analysesJ in&ol&in +>% !lini!al trials and ;:%= patients has

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

ade-uate tissue !on!entration at the ti'e of initial in!ision. This !an )e fa!ilitated )y ha&in the anesthesiolo ist ad'inister the dru in the operatin roo' at indu!tion. $.4nti'i!ro)ial dosin B The dose should )e ade-uate )ased on the patientLs )ody *ei ht. 4n additional dose of anti'i!ro)ial a ent 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. Su ested initial dose and ti'e to re0dose for sele!ted anti'i!ro)ial a ents used for sur i!al prophyla3is.33 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 or an( !aused )y sur i!al or other for's of in6ury or trau'a. Sur i!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 "sur i!al# pro!edure. Sur i!al site infe!tions "SSIs# are defined as infe!tions o!!urrin up to $% days after sur ery "or up to one year after sur ery in patients re!ei&in i'plants# and affe!tin either the in!ision or deep tissue at the operation site. The !ausati&e patho ens depend on the type of sur ery/ the 'ost !o''only isolated or anis's are Staphylo!o!!us aureus( !oa ulase0ne ati&e staphylo!o!!i( 1ntero!o!!us spp. and 1s!heri!hia !oli. The Centers for Disease Control and 2re&ention uidelines for the pre&ention of SSIs e'phasise the i'portan!e of ood patient preparation( asepti! pra!ti!e( and attention to sur i!al te!hni-ue/ anti'i!ro)ial prophyla3is is also indi!ated in spe!ifi! !ir!u'stan!es. The oals of anti)ioti! prophyla3is are to a!hie&e inhi)itory anti)ioti! le&els at in!ision and throu hout the pro!edure in an effort to de!rease the likelihood of de&elopin a SSI. 4nti)ioti!s !an also play an i'portant role in the treat'ent of SSIs. EI. R151R1NC1S Horan TC ( Gaynes R2 ( @artone ?M ( Mar&is ?R ( 1'ori TG . C4C * "i!iti#!s #" !#sc#'ial surgical sit i!" cti#!s2 3>>51 a '#*i"icati#! #" C4C * "i!iti#!s #" surgical -#u!* i!" cti#!s + Infect Control Hosp Epidemiol . 7==+/7$B8%8C8%: +. Ussiri 1( @kony C( 49i9 @. Sutured and open !lean0!onta'inated and !onta'inated laparoto'y *ounds at @uhi')ili National HospitalB

1.

$. 4 !o'parison of !o'pli!ations. 1ast and Central 4fri!an Mournal of Sur ery+%%;/="+#B:=0=>.

Ta)le +. 4nti'i!ro)ial a ent CDC. Data from the National Hospital Discharge Survey. +%7% N!ited +%7$ De! 7%O/ 4&aila)le fro'B httpBHH***.!d!. o&Hn!hsHdataHnhdsH;pro!eduresH+%7 %proPnu')erper!enta e.pdf. >. Gardner D( T*eedle D. 2atholo y for sur eons in trainin 00an 40Q re&ision te3t. $rd ed. LondonB 4rnold 2u)lishers/ +%%+. 6. 4r!iola CR( Ca'po!!ia D( Ga')erini S( Donati @1( Baldassarri L( @ontanaro L. O!!uren!e of i!a enes for sli'e synthesis in a !olle!tion of Staphylo!o!!us epider'idis strains fro' orthopedi! prosthesis infe!tions. 4!ta Orthop S!and. +%%$ O!t/<;">#B87<0+7. 2@IDB7;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 sur i!al0 *ound infe!tion. Ne* 1n land Mournal of @edi!ine7==+/$+8B+:708. 4&aila)le fro'B httpBHHsi'plelink.li)rary.utoronto.!a.'ya!!ess.li)rary. utoronto.!aHurl.!f'H><:+7. :. 1riksen H( Chu ulu S( Gondo S( Lin aas 1. Sur i!al0site infe!tions at Gili'an6aro Christian @edi!al Center. Mournal of Hospital Infe!tion+%%$/>>B7;0+%. 4&aila)le fro'B httpBHHsi'plelink.li)rary.utoronto.!a.'ya!!ess.li)rary. utoronto.!aHurl.!f'H><:%$ =. Brat9ler D( Hou!k 2. 4nti'i!ro)ial prophyla3is for sur eryB 4n ad&isory state'ent fro' the National Sur i!al Infe!tion 2re&ention 2ro6e!t. Clini!al Infe!tious Diseases+%%;/$:B7<%807>. 4&aila)le fro'B httpBHHsi'plelink.li)rary.utoronto.!a.'ya!!ess.li)rary. utoronto.!aHurl.!f'H><:+$. 7%. Son 5( Glenny 4. 4nti'i!ro)ial prophyla3is in !olore!tal sur eryB a syste'ati! re&ie* of rando'ised !ontrolled trials. Health Te!hnolo y 4ssess'ent7==:/+"<#B7077%. 4&aila)le fro'B httpBHHsi'plelink.li)rary.utoronto.!a.'ya!!ess.li)rary. utoronto.!aHurl.!f'H><:+<.

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77. Bo*ater RM( Stirlin S4( Lilford RM. Is anti)ioti! prophyla3is in sur ery a enerally effe!ti&e inter&entionR Testin a eneri! hypothesis o&er a set of 'eta0analyses. nn Surg. +%%=/;=B>>7C>>8.

7+. Holto' D. 4nti)ioti! 2rophyla3isB Current Re!o''endations. M 4' 4!ad Orthop Sur . +%%8/ 7;BS=:0S7%%.

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