UNIVERSITI KEBANGSAAN MALAYSIA

SEM II

2011/ 2 0 1 2

NF40 4 5 FARMASI KLINIKAL & TERAPEUTIK II

SURGICAL ANTIBIOTIC PROPHYLAXIS

ASSOC. PROF. DR AHMAD FUAD

SHAMSUDDI N

23 FEB 2012

LECTURE OBJECTIVES
After the lecture, studen ts are expected
to understan d the follow ing;

The import ance of antibio tic

prophylaxis in surgery

The pathogen esis of complications

due to surgical infection

Risk factors for surgical infection

Types of surgical site bacteria

Classification of surgical procedures

Approach to the use of antibio tics in

surgery

Pharmacy- manag ed Antibiotics

Program m e

ACT III Scene I

Pharmacy- manag ed Antibiotics

Program m e
Questions to ask;
1.

How do we start the

progra m m e?
-

Study current practice

Retrospective
Prospective
Identify the wards or the
group of patien ts
- Be aw are of your streng th and
weaknesses
a.Know ledg e
b.Skills
c. Staff
2. Can we make a difference to
the current practice?
- Incidence of post- surgical
infections
- Cost- benefit
- Overall cost
3. Is it beneficial to the patien t?
- Overall clinical outcome

Introduction to Surgical Site Infection

-

Surgical site infection, SSI (surgical

wound infection) is the most
common surgical complication

Rate of infection due to surgical site

complication is 6% while postdischarge data shows infection rate
due to surgical site complication
50% (Weig el t et al 1992 )

SSI is the third most common

nosocomial infection after UTI, and
pneumoni a (Bergogn e- Berezin 1999 )

SSI increases 2x doctors time, and

5x nursing time in treat m e n t of
patien t (Noel et al 1997 )

SSI hospital stay

Study in Canada revealed increase in
length of hospital stay by 19.5 days

compared to uninfected
(Taylor et al 1995)

patien ts

SSI cost

Antibiotic
use
involving
surgery
amounts to 30% of antibio tic use in
hospitals

In the US the cost of treatin g an

infection amount e d to RM15 2 0
2850 0
(Sands et al 1999)

In Canada trea t m e n t of each SSI

amoun t e d to RM149 6 0 (Zout m a n et
al 1998)

Generally hospital trea t m e n t cost

by 50% (McGow an 1991 )

SSI causes discomfor t and morbidity

0.62 1.9% of SSI patien ts die (Roy

& Perl 1997 )

What
about
practice?

the

general

Malaysian

The Pathogen esis Of Complications Due

To Surgical Infection

Epithelial surface of the body

separa t es the bodys sterile conten ts
from the outside environ m en t which is
inundat e d with bacteria

Outside environ m e n t includes the

luminal conten ts and so forth.

Epithelial layer includes the skin,

conjunctiva, tymph anic memb ran e ,
mucosal layers of the respira to r y,
gastroin t es tin al, and genitourinar y
tract

Penetr a t io n of bacteria across the

border due to trau m a or surgery may
cause infection.

The occurrence of infection depends

on the ability of the bodys defence
system to annihilat e the elemen ts that
manag ed to bypass this border.

The defence mechanisms include the

antibodies, phagocytic (neutrop hils,
monocytes, and macrophag es) , and
complem e n t a r y cells

Both the antibiotics and the bodys

immune system can sterilise the
contamin a t io n of the internal system
by the extern al elemen ts

Bacteria need to exist at the wound

site before any infection could occur
The state m e n t should read;
- the type of microorganism, and the
magnitu d e of inoculum have a
bearing on the occurrence of
infection
- magni tu d e of inoculum for
infection to occur is 10 5 organisme
at the surgical site

The condition surrounding the wound

will influence the minimal infecting
dose
- presence of foreign bodies,
trau m a , haema to m a inoculum

Risk Factors for SSI

1. Age > 60 years
2. Prema t u ri t y
3. Obesity
4. Malnutri tion
5. Underlying diseases
6.

Shock

7. Diabe t es mellitus
8.

Leukae mi a

9.
10.

Immunocomp ro mised
patien ts
Hepatic failure

11. Renal failure

12.

13.
14.

Use of steroids,
antim e t a b oli t es and other
anticancer drugs
Blood transfusion
Personal net skills

15.

Long surgery

16.

Prolonged hospital stay

Types of Pathogens Found in Various

Parts of the Body
Skin
Nose

S. aureus, S. epider mi dis

:

S. aureus, Pneumococcus
sp.,
Meningococcus sp.

Mouth /
pharynx : Strep tococci ( , ),
Pneumococcus sp. E.coli,
(oral) Bacteroides sp.,
Fusobacteriu m sp. ,
Peptostr e p t ococci sp.
Upper
Respirato ry : Pneumococcus sp.
tract
H. influenzae
Biliary tract : E. coli, Klesiella sp.,
Proteus sp., Clostridia sp.

Urinary
tract

: E. coli, Klesiella sp., Proteus

sp., Enterobact e r sp.

Colon

E.coli, Klebsiella sp.,

Enterob act er sp., Clostridia
sp., Bacteroides spp.,
Peptostr e p t ococci sp .

Vagina

: Strep tococci sp.,

Staphylococci sp., E. coli,
Bacteroides spp., Gonococcus
sp., Peptostr e p t ococci sp.

Classification of Surgical Wound and its Risk of

Infection

Wound
Types
Clean

Rate
of SSI

Criteria

< 2% Non- trau m a t ic; Respirato r y,

alimen t a r y, biliary, and
genitourin ar y tracts not
operat e d; No inflam m a t i o n; No
break in techniqu e *; elective
case*

Clean<1 0 %
Surgery on the respira to r y,
Contamin a t e d
alimen t a r y, biliary, and
genitourin ar y
tracts
withou t significan t spillage &
withou t infected bile or
urine ;
Minor break in techniqu e
Contamin a t e d
20%
alimen t a r y tract,

Major spillage* from

entry into biliary or

genitourin ar y
Tracts with in the presence of
bile or
conta min a t e d urine, presence
of
Non- purulen t inflam m a t i o n
Dirty
40%
presence of pus

Faecal conta min a t io n;

and necrotic tissue ;

presence of
know n infection

[ NATIONAL RESEARCH COUNCIL Classification (Page et

al 199 3 );
[Jenkins & Pedlar 199 9 in Clinical Pharmacy &
Therap eu tics]

* Definitions
Spillage
- Spread or spillage of organ conten ts (e.g.
intenstin e) , cysts, abcess in surgical sites
Break in Technique
-

Technical disturbances or breakdow n during

surgical procedure

Personnel fault e.g. touching part of

colleagues body (e.g. hand); or parts of
surgical table cloth;

Surgical procedure continued withou t

disinfection
Elective Surgery
-

Non- emerg ency surgery

OT date given e.g. surgery to thyroid gland

Approach to Antibiotic Use in Surgery

Prophylaxis
Administra tio n of antibio tic(s) in the absence of
infection but the chances of infection occurring is
high e.g. in certain surgical procedures
Therapeu tic Use
Antibiotic(s)
infection

administer e d

in

the

presence

In surgery;
Administra tio n of antibio tic(s) when
contamin a t io n during surgical procedure
happens e.g. spillage of organ conten ts
Import ance of Surgical Antibiotic Prophylaxis

of

 SSI
SSI complications
chances of nosocomial infections
Hospital stay
Cost
When is Surgical Antibiotic Prophylaxis
necessary?
i.

surgical procedures
infection occurring;

with

high

risk

of

ii.

presence of infection will worsen patien t s

condition;

iii. immunocomp ro mised patien ts

Principles in the Prophylactic Use of Antibiotics in

Surgery

Administra tion of antibiotics at the right time

during the surgical procedure can preven t or
reduce the magni tu d e of an infection which
can lead to other surgical complications

The factors listed are considered in surgical

antibiotic prophylaxis
i.
Risk of infection
ii. Choice of antibiotic regimen
iii. Deter mi n a t io n of time of administra t io n
(w rt surgical procedure)
iv. Route of administra t io n

i.

Risk of Infection in Surgery

Risk of infection depend abl e on;

a. Host Factor
(Refer above notes)
b. Pathog en
- Types of microorg anisms at surgical site
- Presence of underlying infection
c. Technique and skills of personnel
- depend abl e on surgical skills of personnel
and
surgical procedure

- it is found that high incidence of infection in

hospital with less surgery perfor m e d
- long surgery increases risk of infection

ii.Choice of antibio tic regimen

- Based on type of pathogens presen t
- Based on antibio tics spectru m of reaction
Broad vs narrow spectru m
- Antibiotics toxicity
- Antibiotics ability to penetr a t e tissue
- Half- life of antibiotics
- Cost- effectiven ess
The choice of antibio tics or antibio tic regimen
should
be
based
on
proven
clinical
effectiven ess

iii.Det e r m i n a t i on of time of administra ti on

- Too early administra ti on of antibiotics can

lead to
tissue [ ] during surgical procedure
- Prophylaxis should not be given > 24 hours
before
procedure
- The best time would be immedi a t el y before
- One dose sufficient
iv.Route of Administra tio n
a. IV Administra tion
Antibiotic
given
anaesth esia

during

induction

of

b. IM administra t io n
Antibiotic
given
togeth e r
premedica tion
~ 1- 2 hours before procedure
c. Rectal administra t io n
Suppository inserte d 2- 4 hours before
procedure

with

d.

Topical administra t io n
Not recomm en d e d except in ophthal mic
operation & burn wounds

Route & time of antibiotic administra t io n should

be planned so that tissue antibio tic [ ] is at
maximu m during and after surgery

Antibiotic prophylaxis is useful in the follow ing

procedures:
1. Gynaecology
a.

Emergency Caesarean section

b.

Hysterecto m y

2. Orthopae dic surgery

a.

Major Art0hroplasty of joints

b.

Open reduction of fracture

c. Lower limb ampu t a ti on

3. General surgery
a. Gastro- oesophag e al
e.g. bleeding gastric/duod en al, gastric
resection/byp ass, benign/ m align an t
stricture
b. Biliary
Cholecystecto m y
-

age > 60 years

hx cholecysti tis

Exploration of bile duct

occlusion/stricture

Pancrea ticoduod en ecto m y

-

c.

carsinoma

Colorectal Surgery
- resection/an as to m osis of colon for benign
or
malignan t
- Abdominop erin e al resection for rectal
carsinoma

d. Appendicecto m y

4. Urology
- Prostat ec to m y with presence contamin a t e d
urine
Urin (presurg er y)

- PCNL
Percutan eous nephrolitho to m y
The removal or trea t m e n t of a kidney stones by
inserting a
tube through the skin and into the kidney, under a
general
anaesth e t ic.

5. ENT surgery
- surgery involving the head, neck, & oral
(throa t )
region
Antibiotic prophylaxis not indicated in the
follow ing:
Thyroid & parath yroid surgery
Mastecto m y
Lapara to m y for adhesiolysis
Herniorrap h y/h er niopl asty/h er ni a repair
- procedure for correcting hernias
Minor wounds & lacerations
Lumpecto m y

Risk in Antibiotic Prohylaxis in Surgery

ii.

Direct effect to patien ts

For patien ts who do not require prophylaxis;

- exposure to dose- relate d toxicity
- drug interaction
- idiosyncratic reaction
ii.

Effects to Hospital Bacterial Ecology

Extensive use of antibiotics will result in the

ecological pressure production of resistant
strains
Will worsen therap eu tic use of antibio tics

Benefits
i.
ii.

The right patien ts will be safe from infection

For others, transfer of bacteria will be
preven t e d