ANTIBIOTIC SELECTION

By
Prof. ABDEL FATTAH ABDEL SATTAR
HEAD OF ANESTHESIA & PAIN RELIEF
DEPARTMENT

NATIONAL CANCER INSTITUTE

CAIRO UNIVERSTIY
2007

Topics:
Introduction.
Antibiotic Review.
Principles of Antibiotic choice.
Surgical Prophylaxis -- antimicrobial use

ANTIBIOTICS REVIEW
Since the development of Sulphonamides in
1930 and Penicillin in 1940, numerous effective
antibacterial, antifungal and recently antiviral
agents have become available.
The similarities of many of these antibiotics are
more striking than their differences.
The newest antibiotic is often not the best
choice.
Therefore obtaining culture in conjunction with
susceptibility testing is imperative.

The empiric use of antibiotics is the norm

rather than exception.
The physician should be familiar with the
suspected organisms for both community
and hospital acquired infection.
Choice will consider:
The nature of the infection (What organisms
are most likely involved) .
Understanding of different antibiotics
(spectrum and limitations)
The patient factors (renal or hepatic
dysfunction are common in ICU patient) .

The selection of specific antibiotics

depends on:
The presumed site of infection (see table 1
below).
Table 1: Frequency of Source of Infection
25%
Respiratory Tract
25%
Abdominal / Pelvic
15%
Bacteremia
10%
Urinary Tract
5%
Skin
5%
IV Catheter
15%
Other source
1.

2- Gram's stain results .

3- Suspected or known organisms
4- Resistance patterns of the common
hospital microbial flora.
5- Patients immune status (especially
neutropenia and immunosuppressive
drugs), allergies, renal dysfunction, and
hepatic dysfunction.
6- Antibiotic availability, hospital resistance
patterns, and clinical variables of patient
to be treated

CLASSIFICATION & PATHOGENICITY

OF MICROBES
1-BACTERIA:

* Gram-stained: positive, negative.

* Acid fast bacilli: Mycobacterium(TB,Leprae).
* Spirochetes: Treponema (Syphilis),
Leptospira, Borrelia(Relapsing Fever).
2-Viruses: DNA & RNA containing viruses.

3-Fungi:

* Filamentous: Tinea, Aspergillus.

* True Yeast: Cryptococcus neoformans.
* Yeast like: Candida albicans.
4- Protozoa :Toxoplasmosis,Leishmaniasis,
Trichomonas.

GRAM-STAINED BACTERIAL PATHOGENS

Gram- positive cocci (Aerobic):

* Staphylococcus:S.aureus, albus(epidermis).
* Streptococcus:S.pneumoniae, S.pyogenes
S.viridian's, S.faecalis(enterococci).

Gram-positive cocci(Anaerobic):
Gram-positive bacilli(Aerobic):

putridus

* Non-poring: Corynobacterium(c.dipht.),
Listeria (L.monocytogens)..B.Anthrax(Spor).

Gram- positive bacilli(Anaerobic):

* Sporing: Clostridium tetani,welchii.

* Non-sporing: propionibacter(p.acnes)
Actinomycetes(A.israelii).

Gram-negative cocci (Aerobic):

* Nersseria: N.meningitidis, N.gonorrhoae.

Gram-negative cocci (Anaerobic):

Gram negative bacilli (Aerobic):

(a) Enterobacteria: E.coli, K.aerogenes,

Proteus S.typhi, Sh.sonnei, Serrattia.
(b) Pseudomonas: P.aeruginosa.
( c)Parvobacteria: Haemophilus( H.influenza)
Brucella(B.abortus), Bordetella(B.pertussis).
(d) Vibrios(V.cholerae).
(e) Legionella: L.pneumoehila.

Gram-negative bacilli (Anaerobic)

* Bacteroides(B.fragelis).

In intensive care units approximately 25% of

infections are confirmed gram negative,
25% gram positive, 20% mixed gram
positive/gram negative, and 3% fungal.
Of the gram negative organisms, the
organisms in order of likelihood are e.coli
(25%), klebsiellla/citrobacter (20%),
pseudomonas (15%), enterobacter (10%)
and proteus (5%); the remaining 25% is
made up of dozens of different bacteriae.

Of the gram positive infections, by far

the most common is staphylococcus
aureus (35%), followed by enterococcus
(20%), coagulase negative staphylococcus
(15%) and streptococcus pneumoniae
(10%). The vast majority of fungal
infections are candidal.

ORGANISMS & SITE of INFECTION

* S.aureus skin,soft tissue,bone,IV lines.
* Strept(A). skin,soft tissue,fascial infection
* Enterococci Biliary,urinary, colonic infection
* Pseudomonas aerug. lung, skin infection
* Klebsiella
Infection around biliary Tract
* Proteus
Urosepsis.
* E.coli Intraabdominal pelvic or urinary
* Clostridium skin,soft t., biliary, colonic

PENICILLINS
Penicillins have predictable activity against
gram+ve cocci (Streptococci).
Ampicillin &Amoxycillin some gram-ve bacilli
Methicillin (Staphcillin) Staph albus.
Piperacillin, Ticracillin, Mezlocillin and Azlocillin
Anti-pseudomonas penicillins.
They should be used in combination with an
aminoglycoside or agent with anti- gram-Ve.
They have no anti gram-ve activity.

CEPHALOSPORINS
1st generation active against gram+ve.
e.g.:Cephalexin (Keflex), Cephardine (Velosef)
3 generation active against gram-ve.
e.g.: Cefotaxime (Claforan), Cefoperazine
(Cefobid), Cefotriaxone (Rociphen),
Ceftazidime (Fortum)
2 generation mixed activity.
e.g.: Cefuroxime (Zinnat).
4th generation: gram-ve(p.aureg.) +strept.+staph
+limited activity against anaerobes.
e.g.; Cefipime (Maxipime)

Penicillin Structural Features and

Requirements for Antibacterial Activity
Penicillins have similar structures: a
thiazolidine ring (A) atached to a lactam ring (B).
Substituents are attached to the amino
group (R). Moieties A and B together
constitute the 6-aminopennicillanic
acid nucleus required for
antibacterial activity.
Cleaving the -lactam ring by
penicillinases (-lactamases) results
in loss of antibacterial properties.
Penicillins may also be inactivated by
amidases.
Static figure (left top): Nitrogen atoms
are red, sulfur light blue-green and
oxygen atoms are green.
3D interactive figure (left, bottom) atoms
are identified

BETA-LACTAMASE INHIBITORS
Beta-Lactamases are bacterial enzymes that
inactivate beta-lactams antibiotics (Penicillins &
cephalosporins).
Beta- lactamase inhibitors bind to the enzymes
preventing them from inactivating antibiotics.
e.g. Sulbactam + ampicillin = Unasyn.
Clavulanate +amoxycillin = Augmentin.
Tazobactam +piperacillin = Tazocin.
They are active against beta-lactamases of
nisseria gonorrhea, K.pneumonia, H.influenza,
s.aureus m.cattaralis but less to Pseudomonas

CARBAPENEBS
Imipenem & Meropnem
They are active against most aerobic and
anaerobic gram +ve & gram ve organisms.
Imipenem (Tienem) Cilastatin sodium to
prevent renal metabolism & nephrotoxicity
but have CNS adverse effect (seizures).
Meropenem (Meronem) no cilastatin
epileptogenic &Renal degradation.
activity against aerobic gram ve bacilli.

MONOBACTAMS & AMINOGLYCOSIDES

Aztreonam (Azactam):
Extremely effective against aerobic gram-ve
bacilli including P.aeuroginosa.
Narrow spectrum emergence of resistant
bacteria.
Aminoglycosides: Gentamicin, Amikacin
Have great activity against gram-ve bacilli.
Post antibiotic effect dose interval.
Nephrotoxicity and Ototoxcicity.

MACROLIDES
Erythromycin
Azithromycin
Clarithromycin
All have activity against Clamydia pneumoniae,
Mycoplasma pneumoniae & Ligionella spices.
The latter two have greater activity against H.infleunza
& nontuberculus mycobacterium.
Used in critically ill patients suspected of having

Atypical pneumonias.

QUINOLONES
They bind to bacterial DNA, prevent replication
Excellent bioavailability (effective orally as IV).
Ciprofloxacin, Ofloxacin, Norfloxacin:
Active against gram-ve (anti-pseud.) &Staph.
Limited activity against anaerobes & Strept.
Levofloxacin, Moxifloxacin,Garifloxacin:
activity against Anaerobic&Strept.pneumon.
activity against atypical Pneumon(Ligionella).

VANCOMYCIN

Tricyclic glycopeptide active against:

B lactam resistant Gram +ve (MRSA &

enterocooci).

No activity for Gram -ve.

* Used in pts. with implanted heart prosthesis, dental
prophylaxis, Enterococcal endocarditis
(combination with aminoglycosides ).
* Oral :Antibiotic induced colitis(C.difficille).
*PO: 0.25g/12h. IV :0.5g/12h.(Renal excretion)
*Side effects: Serious(ototoxicity, neutropenia
Nephrotoxicity, rashs, hypotension if rapid IV)

LINEZOLIDS
Oxazolidinones group :
They have a novel mechanism block
bacterial protein synthesis at the ribosome
at a very early stage.
So, it does not share cross-resistance with
other antimicrobial agents
Spectrum Identical to Vancomycin.
Major indication Vancomycin
resistance.
Excellent oral bioavailability.

TRIAZOLES
They are fungistatic drugs.
Fluconazole (Diflucan):
High volume of distribution.
Active against Candida albicans,C tropicalis,
Cryptococcus neoformans.
80% excreted unchanged in urine no need
to adjust for renal insufficiency.
Itraconazole (Itrapex, Itranox):
Greater activity against aspergillus,
Blastoyces dermatidis & Histoplasa capsulat.

AMPHOTERICIN B
Empirical therapy in febrile patient with
neutropenia.
Standard fungicidal drug for treatment of severe
mycoses.
Adverse effect nephrotoxicity.

3 new formula nephrotoxicity:

-Amphotericin B Lipid complex.
-Amphotericin B colloidal dispersion.
-Liposomal Amphotericin B.

Pneumonia

Klebsiella pneumoniae

Proteus

Pneumonia

Treatment for Ambulatory Patients:

Oral macrolide ( erythromycin, azithromycin
(Zythromax), or clarithromycin
(Biaxin)), doxycycline (Vibramycin, Doryx), or
fluoroquinones with good anti-pneumococcal
activity (levofloxacin (Levaquin), grepafloxacin,
trovafloxacin)
Older patients or patients with underlying
disease: recommendation -- levofloxacin

(Levaquin)- grepafloxaci - trovafloxacin

Community-acquired bacterial
pneumonia
Most frequent cause: Streptococcus pneumoniae
(pneumococci)
Other pathogens:
Haemophilus influenzae
Staphylococcus aureus
Klebsiella pneumoniae
occasionally: other gram-negative bacilli and anaerobic
mouth organisms
"Atypical" pathogens:
Legionella
Mycoplasma pneumoniae
Chlamydia pneumoniae
respiratory viruses
tuberculosis

Pneumocystis carinii

Treatment: In Hospitalized Patients

Pending culture results and susceptibility testing:

Reasonable first-choice: cefotaxime or

ceftriaxone
Cefotaxime (Claforan), ceftriaxone
(Rocephin),

Vancomycin (Vancocin): high resistance

Vancomycin (Vancocin) and cephalosporin:
severe illness-- not responding to a betalactam.

Treatment: In Hospitalized PatientsA macrolide (erythromycin, azithromycin

(Zythromax), or clarithromycin (Biaxin)
added to
a fluoroquinone (good activity against S.
pneumoniae -- levofloxacin (Levaquin),
grepafloxacin and trovafloxacin) can be
used to cover Legionella, Mycoplasma,
chlamydia.
If aspiration pneumonia is a concern:
clindamycin (Cleocin) or metronidazole (Flagyl)
may be added

Treatment for hospital-acquired

bacterial pneumonia
Most often cause by gram-negative bacilli:
Klebsiella
Enterobacter
Serratia
Acinetobacter AND
Pseudomonas aeruginosa
Staphylococcus aureus (gram + positive)

Treatment for hospital-acquired

bacterial pneumonia
The initial treatment: third-generation
cephalosporin : cefotaxime (Claforan)
ceftizoxime (Cefizox) ceftriaxone (Rocephin)
ceftazidime (Fortax, Taxidime, Tazicef )
Or:
cefepime (Maxipime)
ticarcillin (Ticar)/ clavulanic acid
piperacillin (Pipracil)/tazobactam
meropenem (Merrem IV)
imipenem

Treatment for hospital-acquired

bacterial pneumonia
Considering third-generation cephalosporins:
Cefotaxime (Claforan), ceftizoxime (Cefizox),
and ceftriaxone (Rocephin)} limited activity
against Pseudomonas
Ceftazidime (Fortax, Taxidime, Tazicef)} more
activity against staphylococci and other grampositive cocci.
with or without the aminoglycoside
{tobramycin (Nebcin), gentamicin
(Garamycin), or amikacin (Amikin)}

Treatment for hospital-acquired

bacterial pneumonia
In the intensive care unit -- nosocomial
pneumonia due to highly resistant gramnegative bacteria and Pseudomonas
aeruginosa:
Good first choices-imipenem
meropenem (Merrem IV)
plus aminoglycoside
add vancomycin (Vancocin) in hospitals
where methicillin (Staphcillin)-resistant
staphylococci (MRSA) are common

Genitourinary

Urinary tract infection (UTI)

Acute, uncomplicated UTI
trimethoprim-sulfamethoxazole (Bactrim)
(3-day course of treatment)
Alternative: fluoroquinone (three-day course
of treatment)
Alternative (longer treatment):
oral cephalosporin
amoxicillin (Amoxil Polymox)(many
urinary pathogens -- resistance to
amoxicillin)
fosfomycin (Monurol)(single dose)

Urinary tract infection (UTI)

Repeated UTIs or UTI occurring in the
hospital
may be due to antibiotic-resistant gramnegative bacilli
Treatment:
fluoroquinone
oral amoxicillin (Amoxi)
Polymox)/clavulanic acid
oral third-generation cephalosporin
(cefixime (Suprax), cefpodoxime
(Vantin), ceftibuten) or idanyl ester of
carbenicillin

Urinary tract infection (UTI)

in patients hospitalized with UTI:
third-generation cephalosporin
ticarcillin (Ticar)/clavulanic acid
piperacillin (Pipracil)/tazobactam
imipenem (occasionally in
combination with aminoglycoside)

Sepsis

Sepsis
Initial treatment
Life-threatening sepsis and adults:
Third or fourth generation cephalosporin
cefotaxime (Claforan)
ceftizoxime (Cefizox)
ceftriaxone (Rocephin)
cefepime (Maxipime)
ticarcillin (Ticar)/clavulanic acid
piperacillin (Pipracil)/tazobactam
imipenem or meropenem (Merrem IV)
{each together with aminoglycoside
[gentamicin (Garamycin), tobramycin
(Nebcin), or amikacin (Amikin)]}

Sepsis
If methicillin-resistant staphylococci is
a consideration:
vancomycin (Vancocin) alone or
vancomycin (Vancocin) with gentamicin
(Garamycin) and/or rifampin (Rimactane)
If bacterial endocarditisis is a consideration
(prior to pathogen identification):
vancomycin (Vancocin) plus gentamicin
(Garamycin)

Sepsis
Treatment of intra-abdominal or pelvic infection (likely

to involve anaerobes):
ticarcillin (Ticar)/clavulanic acid)
ampicillin (Principen, Omnipen)/sulbactam)
piperacillin (Pipracil)/tazobactam)
imipenem
meropenem
cefoxitin (Mefoxin) or cefotetan (Cefotan)
{each with or without an aminoglycoside,
metronidazole (Flagyl) OR
clindamycin (Cleocin) with an aminoglycoside

Sepsis
gram-negative bacilli:
Third or fourth generation cephalosporins
cefotaxime (Claforan)
ceftizoxime (Cefizox)
cefoperazone (Cefobid)
ceftriaxone (Rocephin)
cefepime (Maxipime)
ceftazidime (plus activity against grampositive cocci)
imipenem, meropenem (Merrem IV),
aztreonam (Azactan )

Sepsis
Cephalosporins (other than cefoperazone
(Cefobid), cefepime (Maxipime), and
ceftazidime (Fortax, Taxidime, Tazicef)):
limited efficacy against Pseudomonas
aeruginosa

Pseudomonas aeruginosa:
effectively treated with imipenem, meropenem
(Merrem IV), and aztreonam (Azactan).
Aztreonam (Azactan): poor activity against
gram-positive organisms and anaerobes

Sepsis- Special Cases

Neutropenic patients with suspected bacteremia
ceftazidime (Fortax, Taxidime, Tazicef)
imipenem
meropenem (Merrem IV)
cefepime (Maxipime) (in more seriously ill
patients, add an aminoglycoside
amikacin (Amikin) and ceftriaxone (Rocephin)
(single daily doses)
piperacillin (Pipracil)/tazobactam plus amikacin
Addition of vancomycin (Vancocin): in neutropenic
cancer patients with bacteremia due to methicillin
(Staphcillin)-resistant staphylococci & some strains of
viridans

A 69 year old female, with no past medical

history, is admitted from home with pleuritic
chest pain, shortness of breath, pyrexia and
tachycardia

Presumed diagnosis :
community acquired pneumonia in
an immunocompetent host.

The most likely organisms are

pneumococci, Mycoplasma and
Legionella.
The patient requires coverage for both
gram positive and atypical organisms.
Cephalosporin iv + macrolide po or
fluroquinolone
Cefuroxime/Ceftriaxone iv +
azithromycin po or levofloxacin

An 85 year old female is admitted

unconscious and hypotensive from a
nursing home.
She has a fever and a leucocytosis and
her urine is foul smelling.
Presumed diagnosis urinary tract
infection.

The most common organisms causing urinary

tract infections are Enterobacteriacae and
enterococci, and the treatment is ciprofloxacin or
ampicillin and gentamycin.
In this case, however, the patient has been
admitted from a nursing home and pseudomonas
is a strong possibility.
Twin therapy is often required,
Anti-pseudomonal quinolone or aminoglycoside
plus anti-pseudomonal penicillin or
cephalosporin.
Ciprofloxacin /gentamycin/amikacin plus piperacillin
or ceftazidime

An 62 year old male presents with

abdominal pain, hypotension,
tachycardia, tachypnea, hypothermia
and neutropenia.
Presumed diagnosis perforated
diverticulum and fecal peritonitis

This patient requires surgical source control and

antibiotics. The most likely infecting organisms
are Enterobacteriaceae, enteococci, S.
pneumoniae and anaerobes.
Broad spectrum treatment is required, without
cover for pseudomonas.
Penicllin+ beta Lactam inhibitor or
ampicillin+aminoglycoside+anti-anaerobic agent
Ampicillin+Sulbactam or
Piperacillin+Tazobactam or ampicillin +
gentamycin/aztreonam +metronidazole or
imipenem

A 48 year old intellectually subnormal

lady is admitted with red hot indurated
skin over her left buttock.
Presumed diagnosis cellulitis
The most likely organisms are streptococci
and staphylococci, if community acquired
then cloxicillin is adequate,
again this patient was institutionalized, and
must be treated as hospital acquired:
Vancomycin + gentamycin.

The patient becomes progressively stuperose and

hypotensive as the day goes on. She is intubated
and CT of her pelvis reveals gas in the muscles and
along the fascial planes of her left buttock.
Confirmed diagnosis necrotizing fasciitis
This patient requires immediate surgical
intervention and debridement of necrotic tissue.
The infection has probably arisen from an ischiorectal abscess and is polymicrobial in nature:
Streptococci, Staphylococci, Bacteroides,
Clostridium (1).
Penicillin (high dose) or ciprofloxacin (if
penicllin allergic) + clindamycin

On the 8th day following admission, this patient is

extubated. Four hours later she becomes severely
dyspneic and hypoxemic. She is reintubated and
chest x-ray reveals a new infiltrate in her left base.
Presumed diagnosis aspiration pneumonitis

In most cases, aspiration events are sterile, and

antimicrobials are unnecessary . In the case of
patients already in intensive care, however,
nasopharyngeal colonization with gram negative
organisms has occurred, and aspiration of infected
material should be presumed, Although it has been
conventional to treat these patients with anti-anaerobe
coverage, it is unlikely that this is necessary.

Add ampicillin+sulbactam or piperacillin+tazobactam

.

A 75 year old male presents with

hypotension, pyrexia and leucocytosis.
Presumed diagnosis - sepsis, cause unknown

Broad spectrum coverage is required, to

cover gram positives, gram negatives
and pseudomonas
Suggested modalities are:

Combining either
antipseudomonal cephalosporin (ceftazidine)
or antipseudomonal penicillin (piperacillin +
azobactam) (particularly if anaerobes are
suspected) with either an aminoglycoside
(gentamycin or amikacin) or a
fluoroquinolone (ciprofloxacin).
If an antipseudomonal cephalosporin is used and

anaerobes are a possible cause, the

addition of metronidazole or clindamycin
should be considered.
Piperacillin+Tazobactam/Imipenem +
Gentamycin/Ciprofloxacin

PROPHYLACTIC ANTIBIOTICS
Surgical Prophylaxis
antimicrobial use

PROPHYLACTIC ANTIBIOTICS
The prophylactic antibiotics must be in
place already before the bacteria land in
the wound. For prevention of the
postoperative infection,
The antibiotics are usually injected some
30 minutes before the start of the
operation.
In this way the levels of the antibiotic in
the blood will attain concentrations that will
kill occasional bacteria that may land in the
operation wound.

Studies demonstrated that for prophylaxis against

postoperative wound infection, administering
antibiotics during only one day after the operation
has been equally effective as a two day or longer
antibiotic prophylactic regime.
For occasions later on, when you need antibiotic
protection during dental surgery and like, usually
one dose of antibiotics before the dental and other
surgery is sufficient.
use the antibiotics only when really necessary, and
then use them only during the shortest interval
possible.

Choice of agents (principles)

need not eradicate every potential pathogen
Effective agent example -- cefazolin (Ancef,
Defzol)
long serum half-life
vancomycin (Vancocin)
routine use of vancomycin (Vancocin) for
prophylaxis-- discouraged since it promotes
vancomycin (Vancocin)-resistant strains.

Colorectal surgery & appendectomy

cefoxitin (Mefoxin) or cefotetan (Cefotan)
preferred due to enhanced activity relative to
cefazolin (Ancef, Defzol) against anaerobes
(bowel), e.g. Bacteriodes fragilis
Agents not recommended
Third-generation cephalosporins
(cefotaxime (Claforan), ceftriaxone
(Rocephin), cefoperazone (Cefobid),
ceftazidime (Fortax, Taxidime, Tazicef), or
ceftizoxime (Cefizox)
Fourth-generation cephalosporins: e.g.
cefepime (Maxipime )

Choice of agents (principles)

Rationale:
expense, some are less active
cefazolin (Ancef, Defzol) (against
staphylococci)
non-optimal spectrum of action
(includes activity against organisms not
commonly encountered in elected
surgery
widespread for prophylaxis encourages
emergence of resistance

Gastrointestinal diseases

Gastrointestinal diseases
Antibiotic prophylaxis
recommended for esophageal surgery with
obstruction -- obstruction increases infection risk
factors that promote high infection risk after
gastroduodenal surgery:
reduced gastric acidity and gastrointestinal
motility
reduction may occur because of:
obstruction
hemorrhage
gastric ulcer
malignancy
treatment with H2 blocker {ranitidine (Zantac)}
or proton pump, inhibitors {e.g. omeprazole
(Prilosec)}
morbid obesity

Gastrointestinal diseases
Antibiotic prophylaxis not indicated for:
routine gastroesophageal endoscopy
(may be used for high-risk patients
undergoing esophageal dilatation or
sclerotherapy of varicies).

Genitourinary

Genitourinary
Probable pathogens:
enteric gram-negative bacilli,
enterococci
Prophylaxis
high-risk only (urinate culture
positive/unavailable; preoperative
catheter, transrectal prostatic biopsy) -ciprofloxacin (Cipro) {PO or IV}

Head & Neck Surgery

Incision through oral/pharyngeal mucosa.
Probable pathogens:
Anaerobes,
enteric gram-negative bacilli,
Staphylococcus aureus
Prophylaxis
clindamycin (Cleocin) + gentamicin
(Garamycin)
reduce the high incidence of wound infection
following head/neck operations which utilize
incisions through oral or pharyngeal mucosal

Neurosurgery

Craniotomy
Probable pathogens: Staphylococcus aureus,

Staphylococcus epidermidis
Prophylaxis: cefazolin (Ancef, Defzol) or vancomycin
(Vancocin) (IV)

Antibacterial prophylaxis
cerebrospinal fluid shunt: conflicting research results
Craniotomy: antistaphylococcal antibiotic -- reduced
infection incidence
Spinal surgery: antibiotics not effective in reducing the
already low postoperative infection rate following
conventional lumbar discectomy.
Questionable effectiveness (not yet demonstrated in
controlled clinical trials) for spinal fusion, prolonged spine
surgery, or insertion of foreign material

Ophthalmic

Ophthalmic
Probable pathogens: Staphylococcus epidermidis,
Staphylococcus aureus, streptococci, enteric gramnegative bacilli, Pseudomonas
Prophylaxis: gentamicin (Garamycin), tobramycin
(Nebcin), ciprofloxacin (Cipro), ofloxacin (Floxin), or
neomycin-gramicidin-polymixin B; cefazolin (Ancef,
Defzol)
Most ophthalmologist use antibiotic eyedrops for
prophylaxis in view of the potential for extremely serious
postoperative endophthalmitis.{limited data to support
effectiveness of prophylactic antimicrobials}
No evidence for the rational basis for use of
prophylactic antibiotics when procedures do not
invade the globe

Orthopedic

Orthopedic
Total joint replacement, internal fracture fixation
Probable pathogens: Staphylococcus aureus,
Staphylococcus epidermidis
Prophylaxis cefazolin (Ancef, Defzol) or vancomycin
(Vancocin) (IV)

Rationale for Prophylaxis:

antistaphylococcal agents decrease incidence of early &
late infection following joint replacement
decrease infection rate in compound/open fractures and
when hip & other fractures are managed with internal
fixation using nails, plates, screws, or wires
For diagnostic & operative arthroscopic surgery -antibody prophylaxis is not justified

Vascular

Vascular
Arterial surgery (involving: a prosthesis,
abdominal aorta, or groin incision)
Probable pathogen: Staphylococcus aureus,

Staphylococcus epidermidis, enteric gram-negative bacilli

Prophylaxis: cefazolin (Ancef, Defzol) or

vancomycin (Vancocin)
A lower extremity amputation for ischemia
Probable pathogen: Staphylococcus aureus,
Staphylococcus epidermidis, enteric gramnegative bacilli, clostridia
Prophylaxis: cefazolin (Ancef, Defzol)--or cefoxitin
(Mefoxin) for better anaerobic coverage--or vancomycin
(Vancocin)

Vascular
Rationale for prophylaxis:
Cephalosporin: reduced likelihood of postoperative
infection incidences following arterial reconstructive
surgery on the abdominal aorta, vascular limb
operations involving groin incisions, and lower
extremity amputation for ischemia
Recommended:
for any vascular prosthetic material implantation (e.g.
grafts supporting hemodialysis)
Not indicated for carotid endarterectomy or brachial
artery repair (assuming no prosthetic material
involved)

Cardiac Surgery

Cardiac Surgery
Prosthetic valve, coronary bypass, other open-heart
procedures, pacemaker/defibrillator implantation
Probable pathogen: -- Staphylococcus
epidermidis, Staphylococcus aureus,
Corynebacterium, enteric gram-negative bacilli

Antibacterial drug:
cefazolin (Ancef, Defzol), cefuroxime
(Zinacef, Ceftin)-- IV
Vancomycin, IV(Vancocin) (if above agents
are ineffective or contraindicated)

Antibacterial drug pre-treatment reduces

infection incidence after cardiac surgery;

Thoracic (noncardiac )
Probable pathogens: Staphylococcus aureus,

Staphylococcus epidermidis, streptococci, enteric

gram-negative bacilli
Treatment: cefazolin (Ancef, Defzol) or cefuroxime
(Zinacef, Ceftin) or vancomycin (Vancocin)
Rationale for Prophylaxis:
commonly used for routine pulmonary surgery; limited
research support
insertion of chest tubes following closed-tube
thoracostomy following chest trauma: cephalosporin
(multiple doses) can prevent infection
single preoperative cefazolin (Ancef, Defzol) dose
(pulmonary resection): decrease in the incidence of
wound infection -- no decrease in incidence of
pneumonia or empyema

Gynecologic & Obstetric

Gynecologic & Obstetric

Antibacterial prophylaxis:
reduces infection incidence following vaginal
hysterectomy & abdominal hysterectomy
(probably)
Perioperative/preoperative antibiotics:
prevention of infection when given:
following cord clamping in emergency
cesarean section
high-risk situations {active Labor, premature
membrane rupture,after mid-trimester
abortion}
Possibly substantial protective effect of
perioperative antibiotics in all women
undergoing therapeutic abortions

Gynecologic & Obstetric

Vaginal or abdominal hysterectomy
Probable pathogens: Enteric gram-negatives,

anaerobes, enterococci, Group B strep

Prophylaxis cefazolin (Ancef, Defzol) or cefotetan
(Cefotan) or cefoxitin (Mefoxin)(IV)

Cesarean section
Probable pathogens: Enteric

gram-negatives,
anaerobes, enterococci, Group B strep
Prophylaxis: high-risk {active labor or premature

membrane rupture};
cefazolin (Ancef, Defzol) -- IV after cord clamping

Gynecologic & Obstetric

Abortion
Probable pathogens: Enteric gram-negatives,
anaerobes, enterococci, Group B strep

Prophylaxis:
first trimester, high-risk {patients with
previous pelvic inflammatory disease,
previous gonorrhea or multiple sex partners)
-- aqueous penicillin V (Pen-Vee K,
Veetids) or
doxycycline (Vibramycin, Doryx )

PROPHYLACTIC ANTIBIOTICS
Medical Prophylaxis
antimicrobial use

PREVENTION of ENDOCARDITIS
Heart valve lesions or prosthetic valve.
(A)Dental procedure under No or L.Anasth.:
Pt. Havnt endocarditis
Amoxycillin(3g PO) 1h before operation
Clindamycin (600mg PO) Penicill.Allergy
Pt. With endocarcitis ( AS under GA ):
Amoxycillin(1g IV) + Gentamicin(120mg)
Vancomycin(1g IV) Allergy to Penicillin
Or Clindamycin(300mg IV) Over 10 min.

PROPHYLACTIC ANTIBIOTIC
(B)Dental procedure under GA :
Pt. Havnt endocarditis :
Amoxycillin (1g IV at induction) or
(3g PO 4h before induction)
Pt. With endocarditis( At risk) :
Amoxycillin(1g )+ Gentamicin(120mg)
at
induction or 15 min.before induction.
Or Vancomycin 1g + Gentamicin(120mg)
Or Clindamycin 300mg IV over 10 min (15
min before induction).

PROPHYLACTIC ANTIBIOTICS
MENINGITIS (meningococcal-N.menigitidis)
* For close contacts(children& adults).
Rifampicin(600mg)

/12h/2days.

or Ciprofloxacin (500mg)
or Ceftriaxone(250mg)

Single dose
Single dose.

Empiric treat. Of suspected bact.meningit.

*Penicillin G

IV:2-MU immediately.

ANTIBIOTIC PROPHYLAXIS
RHEUMATIC FEVER:
Benzathine penicillin (IM)
monthly or
Penicillin V( PO)
twice daily
* or Sulphadiazine (PO) 1g/day
* During childhood & early teenage .
GAS GANGERENE (L.L.Amputation) :
* Penicillin G
300-600mg(5000001000000U)/ 6h/5 days .
*Metronidazole(Allergy to Penicillin)
500 mg/8h.

Head & Neck Surgery

QUINUPRISTIN/DAFLOPRISTIN
A formulation of two bacteriostatic agents
when combined are bactericidal.
Mechanism inhibit protein synthesis at the
505 ribosome.
Spectrum: Similar to Vancomycin i.e. Active
against Streptococci, S.aureus and
coagulase negative Staph.
Used in treatment of Vancomycin
resistant cases.

Klebsiella pneumoniae

Proteus

Sepsis- Special Cases

Resistant gram-negative bacilli
Gram-negative bacilli resistant to:
aminoglycosides
third-generation cephalosporins
aztreonam (Azactan)
These bacilli susceptible to:
imipenem
meropenem (Merrem IV)

ciprofloxacin (Cipro)

Sepsis- Special Cases

Pseudomonas aeruginosa strains resistant
gentamicin (Garamycin)
Susceptible to:
amikacin (Amikin)
ceftazidime (Fortax, Taxidime, Tazicef)
cefepime (Maxipime)
imipenem
meropenem (Merrem IV)
ciprofloxacin (Cipro) trovafloxacin
aztreonam
possibly tobramycin (Nebcin) or netilmicin

(Netromycin

Gastrointestinal diseases

Gastrointestinal diseases
Esophageal/gastroduodenal
Probable pathogens:

enteric gram-negative bacilli,

gram-positive cocci
Treatment: (high-risk only, i.e. esophageal
obstruction, decreased gastric
acidity/gastrointestinal motility, morbid
obesity)

Cefazolin (Ancef, Defzol) (IV)

Gastrointestinal diseases
Biliary tract
Probable pathogens:

enteric gram-negative bacilli,

enterococci, clostridia
Treatment: (high-risk only,i.e. age > 70,
acute cholecystitis, non-functioning
gallbladder, obstructive jaundice or
common duct stones)

Cefazolin (Ancef, Defzol) IV

Gastrointestinal diseases
Appendectomy, non-perforated
Probable pathogens:
enteric gram-negative bacilli,
anaerobes, enterococci
Treatment:
Cefoxitin (Mefoxin)

Sepsis
Factors in selecting appropriate drugs to
manage sepsis syndrome:
source of infection
gram stain
immune status
bacterial resistance patterns in the community
and hospital

Sepsis
Factors in selecting appropriate drugs to
manage sepsis syndrome:
source of infection
gram stain
immune status
bacterial resistance patterns in the community
and hospital

ANTIBIOTIC SELECTION
By
Prof. ABDEL FATTAH ABDEL SATTAR
HEAD OF ANESTHESIA & PAIN RELIEF
DEPARTMENT
NATIONAL CANCER INSTITUTE
CAIRO UNIVERSTIY
2007

A 43 year old lady with short bowel syndrome

following surgery for Crohns disease, on
home TPN, is admitted with hypoxemia,
tachycardia, pyrexia and neutropenia.
Presumed diagnosis - infected intravenous
catheter (line sepsis).
A 54 year old male develops a fever,
leucocytosis and inflammation around his
midline sternotomy site 5 days after
undergoing coronary bypass surgery.
Presumed diagnosis wound infection,
possible mediastinitis.

There is a strong possibility of infection in both of

these cases with staphylococci, coagulasepositive or negative.
Vancomycin should be added to, for example,
piperacillin+azobactam.
Once the infecting organisms have been isolated,
the spectrum of antimicrobials should be
narrowed
(if methacillin resistant staph aureus MRSA- is
isolated, the piperacillin+ azobactam should be
discontinued).
Vancomycin + Piperacillin+Tazobactam or
Ciprofloxacin

The lady with Crohns disease and presumed line

sepsis does not respond to line removal and the
antibiotic regimen above, blood cultures come
back positive for unspeciated candida. Confirmed
diagnosis fungal sepsis.
The options are
1) start high dose fluconazole and if there is no
response move over to the more toxic agent,
amphoteracin,
2) start amphoteracin immediately. In this patients
case, she is severely ill, and has depleted
physiologic reserve and may well be
immunocompromised (steroids), I would start
amphoteracin B. If there is a question of renal
insufficiency, I would prescribe the less toxic
colloidal or liposomal form.

A 17 year old female presents with a 2 hour history of

confusion, pyrexia, headache
and a purpuric rash.
This patient has meningococcal septicemia until
otherwise proven.
The most likely alternative organisms are
pneumococci, H. Influenzae and, rarely,
Enterobacteriaceae and Listeria.
Third generation cephalosporin + vancomycin (if
penicillin resistant S. pneumoniae suspected) +
ampicillin (if Listeria suspected) .

Cefotaxime + Vancomycin

Gastrointestinal diseases
Esophageal/gastroduodenal
Probable pathogens:

enteric gram-negative bacilli,

gram-positive cocci
Treatment: (high-risk only, i.e. esophageal
obstruction, decreased gastric
acidity/gastrointestinal motility, morbid
obesity)

cefazolin (Ancef, Defzol) (IV)

Gastrointestinal diseases
Biliary tract
Probable pathogens:

enteric gram-negative bacilli,

enterococci, clostridia
Treatment: (high-risk only,i.e. age > 70,
acute cholecystitis, non-functioning
gallbladder, obstructive jaundice or
common duct stones)

cefazolin (Ancef, Defzol) IV

Gastrointestinal diseases
Appendectomy, non-perforated
Probable pathogens:
enteric gram-negative bacilli,
anaerobes, enterococci
Treatment:
cefoxitin (Mefoxin)
Lorcet (hydrocodone/acetaminophen) (IV)

Thoracic (noncardiac )
Probable pathogens: Staphylococcus aureus,

Staphylococcus epidermidis, streptococci, enteric

gram-negative bacilli
Treatment: cefazolin (Ancef, Defzol) or cefuroxime
(Zinacef, Ceftin) or vancomycin (Vancocin)
Rationale for Prophylaxis:
commonly used for routine pulmonary surgery; limited
research support
insertion of chest tubes following closed-tube
thoracostomy following chest trauma: cephalosporin
(multiple doses) can prevent infection
single preoperative cefazolin (Ancef, Defzol) dose
(pulmonary resection): decrease in the incidence of
wound infection -- no decrease in incidence of
pneumonia or empyema

PROPHYLACTIC ANTIBIOTICS
Pneumococcal meningitis :
* Cefotaxime (Vancomycin if resistant).
H.influenza meningitis :
*Cefotaxime or Chloramphenicol +
Riphampicin (4days before discharge)
Listeria meningitis :
*Amoxycillin +gentamicin

ORGANISMS & SITE of INFECTION

* S.aureus skin,soft tissue,bone,IV lines.
* Strept(A). skin,soft tissue,fascial infection.
* Enterococci Biliary,urinary , colonic
infection.
* Pseudomonas aerug. lung, skin infection
* Klebsiella
Infection around biliary T.
* Proteus
Urosepsis.
* E.coli Intraabdominal pelvic or urinary
* Clostridium skin,soft t., biliary, colonic