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Antibiotics in Surgical Practice

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Presentation on theme: "Antibiotics in Surgical Practice"— Presentation transcript:

1 Antibiotics in Surgical Practice
Sepsis in Surgical Practice Dr A. Badrek-Amoudi FRCS

2 ABA-UMQU- Antibiotics in Surgical Practice
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3 ABA-UMQU- Antibiotics in Surgical Practice
Historical Overview Contagious disease- The concept1830 Bacteria as a cause of disease, leeuwenhoek 1850. Hand washing, Semmelweis 1850. Introduction of the principle of aseptic surgery (Carbolic acid), Lister 1880. Steam sterilization, Schimmelbusch & Octave 1990 Early 20th century Halsted introduced the use of gloves. 1928 Alexander Fleming discovered Penicillin 4/28 ABA-UMQU- Antibiotics in Surgical Practice

4 ABA-UMQU- Antibiotics in Surgical Practice
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5 ABA-UMQU- Antibiotics in Surgical Practice
Antisepsis OR environment. Drapes and instruments Hand washing Gloves and other barrier methods Short preoperative stay Treat remote infections Skin and bowel preparation Improved host defences Improved surgical technique Minimization of cross infection Infection control ? Hair removal 4/28 ABA-UMQU- Antibiotics in Surgical Practice

6 Nasocomial)) Hospital Acquired Infections
Infections that become clinically evident with in 48 hours of admission Found: Common postoperative infections In critically ill patients (ICU) Significance: Increased postoperative mortality Increased Hopspital stay Increased cost of surgical care Afflicated by multiresistanct organisms 4/28 ABA-UMQU- Antibiotics in Surgical Practice

7 Hospital Acquired Infections
Risk factors: Age > 70 Shock Steroids Chemotherapy ICU > 3 days Mechanical ventilation Invasive monitoring Indwelling catheter > 10 days Surgical Acute renal failure 4/28 ABA-UMQU- Antibiotics in Surgical Practice

8 Hospital Acquired Infections The most common infections
Blood stream infections 28% Lower respiratory tract infections 21% Wound Infections:7% Urinary tract infections 15% GI, Skin.. 10% 4/28 ABA-UMQU- Antibiotics in Surgical Practice

9 Hospital Acquired Infections The most common organisms
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10 Hospital Acquired Infections The most common organisms
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11 ABA-UMQU- Antibiotics in Surgical Practice
Hospital Acquired Infections The most common infections Wound Infections Present if: Wound red or swollen Requiring opening Exudate: Serous or pus Antibiotics are prescibed because of concerns over the wound Clinically: Cellulitis Localized abscess Non clostridial gangrene Clostridial: gas and non gas forming gangrene Wound culture: A positive culture does not prove infection A negative culture does not exclude infection 4/28 ABA-UMQU- Antibiotics in Surgical Practice

12 ABA-UMQU- Antibiotics in Surgical Practice
Hospital Acquired Infections The most common infections Chest infection Risk factors: Age Aspiration Head injury Smoking Intubation Lung injury Upper abdominal incisions Prolonged hospital preoperative hospital stay Organism: 1. 75% gram negative, % S aureus, 3. 5% Candida 4/28 ABA-UMQU- Antibiotics in Surgical Practice

13 Hospital Acquired Infections: The most common infections Others:
Central lines: Treat by Course of antibiotics Replacement, same site Replacement different line Always send tip for micro on removal UTI: Associated with urinary catheters (105 OPM) Intra-abdominal abscess Infection at time of surgery Contamination from perforation,trauma..etc Tertiary peritonitis Infected implants or prosthetic material 4/28 ABA-UMQU- Antibiotics in Surgical Practice

14 Antibiotic resistance
Up to 70% of hospital acquired infections are resistant to antibiotics Causes: Previous exposure to antibiotics Inappropriate use of antibiotics Prolonged hospital stay Poorly inforced infection control measures Lack of nursing staff Mechanism : Beta lactemases DNA gyrases, topisomorase Point mutations…etc 4/28 ABA-UMQU- Antibiotics in Surgical Practice

15 ABA-UMQU- Antibiotics in Surgical Practice
Hospital Acquired Infections Resistance: MRSA (Methicillin Resitant Staph Aureus) Associated with morbidity , mortality, increased hospital stay and treatment cost. Usually nasocomial but community accquied infections are now present. Associated with; Use of broad spectrum antibiotics Macroloids, 2. fluroquinalones, 3. cephlosporins Previous hospital admission Prolonged hospital/ICU stay Entral feeding Surgery 4/28 ABA-UMQU- Antibiotics in Surgical Practice

16 Hospital Acquired Infections Resistance: Others:
Pseudomonas aeruginosa E Coli Enterobacter cloacae Kelbsiella spp 4/28 ABA-UMQU- Antibiotics in Surgical Practice

17 Hospital Acquired Infections 1The Fight:
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18 Hospital Acquired Infections 2The Fight:
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19 Hospital Acquired Infections The Fight: 3
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20 Hospital Acquired Infections The Fight: 4
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21 Antimicrobial Therapy
Antibiotics in surgical practice are only an adjunct to treating surgical infection Before using an antibiotic ask the following Is an antibiotic required? Is it for treatment or prophylaxis? What is the likely pathogen (spectrum)? What is the site AB are required to reach (tissue penetration)? Route of administration? Resistance? Any Allergies? Is the patient Immunocompromised? Toxicity What is the cost? 4/28 ABA-UMQU- Antibiotics in Surgical Practice

22 Classes of Antibiotics
Beta-lactams Amoxicillin, penicillin Penicillins Cephalexin Cephalosporins Imipenem Carbopenems Erythromycin, clarithromycin, zithromycin Macroloids Ciprofloxacin Fluroqiunolons Trimaxazole, trimethoprim Sulphonomids Tetracyclin, doxacyclin Tetracyclins Gentamicin, tobromycin Aminoglycosids 4/28 ABA-UMQU- Antibiotics in Surgical Practice

23 ABA-UMQU- Antibiotics in Surgical Practice
Target Sites Comment Drug Target Bactericidal, Inhibit cell wall synthesis by preventing cross linkage of peptidogycans. Beta lactams (Penicillin, cephalosporins, carbapenems) Vancomysin Cell Wall Bacteriostatic Bacteriostatic/bacteriocidal Bacteriocidal All prevent bacterial protein synthesis Tetracyclin Erythromycin Aminglycosides Ribosomes DNA supercoiling RNA polymerase Ciprofluxacin Rifampacin Nucleic Acid 4/28 ABA-UMQU- Antibiotics in Surgical Practice

24 Summary of Differences
Eukaryotic Prokaryotic Multiple, non-circular Yes No Single and circular DS DNA Chromosome Nuclear Mem Mitochondria Plasmids 4/28 ABA-UMQU- Antibiotics in Surgical Practice

25 ABA-UMQU- Antibiotics in Surgical Practice
Staphylococcus F.anaerob, Moist enviro. Coagulase Cell wall inhibit migration and phagocytosis of macrophages Entrotoxin Epidermotoxin Characteristc Pathogenicity Cellulitis, wound infections, infection of prosthesis. Disease 4/28 ABA-UMQU- Antibiotics in Surgical Practice

26 ABA-UMQU- Antibiotics in Surgical Practice
Streptococcus Lancfeild A, B…… Alpha, Beta, Gamma Charecteristics M protein & phagocytosis Hyaluronidase & streptokinase Stretolysins Pyogenic exotoxins Pathogenicity Cellulitis, erysipilis, rhumatic fever……..etc Diseases 4/28 ABA-UMQU- Antibiotics in Surgical Practice

27 ABA-UMQU- Antibiotics in Surgical Practice
Gram negatives Aerobic e.g. E.coli Obligate Aerobe. Pseudomonas Characteristics Lipopolysaccharid entrotoxins Adhesion molecules Neuro & hemotoxins Pathogenicity Cephalosporins, Gentamicin …………etc Treatment Peritonitis, IP abscess, wound infections, post-op pneumonia, Necrotizing infections, Vasculitis Diseases 4/28 ABA-UMQU- Antibiotics in Surgical Practice

28 ABA-UMQU- Antibiotics in Surgical Practice
Anaerobes Found mainly in GI, mouth, vagina, ischemic, trauma, devitalized tissue, foreign bodies & malignancies, aerobic bacterial growth Characteristics Bacteroides ( entrotoxins), Clostridia ( exotoxins) Pathogenicity Metronidazole Penicillins Treatment Abscess necrotizing fascitis pseudomembraneous colitis neurotoxins Diseases 4/28 ABA-UMQU- Antibiotics in Surgical Practice

29 ABA-UMQU- Antibiotics in Surgical Practice
Beta lactams All have a beta lactam ring as a basic structure Penicillins Benzyle Penicillin……..Staph/Streps Flucloxcacillin…………Staph Co-amoxiclav………… Staph/G-ve/Bacteroids Pipracillin…………… Psuedomonas Cephalosporins 3 groups 10% Cross sensitivity in patients with penicillin allergy 3 generations with Increased G-ve & decreased G+ve in fourth generation. Carbapenenms Truly broad spectrum ( G negative, positive and anaerobes) May provoke seizures May promote highly resistant organisms 4/28 ABA-UMQU- Antibiotics in Surgical Practice

30 ABA-UMQU- Antibiotics in Surgical Practice
Aminoglycosides Active against staph.aureus and aerobic G-ve Narrow theraputic ratio ( easily toxic) Monitor renal function and auto-toxicity Examples: Gentamicn Tobramicin Amicacin 4/28 ABA-UMQU- Antibiotics in Surgical Practice

31 Macroloids & Quinalons
Macroloids e.g. erythromicin, clarithromycin An alternative in penicillin sensitivity New generations have improved bioavailability, better oral absorbtion and fewer GI side effects. Quinalons e.g. Ciproflucloxacillin Good tissue penetration Gram negative activity Attains good levels on oral intake. 4/28 ABA-UMQU- Antibiotics in Surgical Practice

32 ABA-UMQU- Antibiotics in Surgical Practice
The Use of Antibiotics Prophylaxis When anatomical barriers are breached leading to contamination: faeces, bile..etc. When the consequence and risks are unacceptably high In traumatic wounds In immunocompromised Age> 70 Theraputic Emperical therapy The likely organism & antibiotic susceptibility Avoid using a single agent Avoid using agents with inadequate cover Avoid AB with serious side effects. Definitive therapy 4/28 ABA-UMQU- Antibiotics in Surgical Practice

33 ABA-UMQU- Antibiotics in Surgical Practice
Drug administration 1. Route Intravenous if: Patient is seriously ill with inconsistent intestinal absorption or inability to oral medication. IV ensures rapid adequate serum levels. Be aware of theraputic window. Oral step down if : T < 38, Oral intake is tolerated, Good absorbtion, No unexplained tachycardia, No need for high tissue concentrations suitable oral prep available 4/28 ABA-UMQU- Antibiotics in Surgical Practice

34 ABA-UMQU- Antibiotics in Surgical Practice
Drug administration Duration Treatment failure: Wrong AB/ Wrong dosing Other causes of infection Fungal superinfection Inappropriate administration Persistent source of infection 4/28 ABA-UMQU- Antibiotics in Surgical Practice

35 ABA-UMQU- Antibiotics in Surgical Practice
Scenario 1 A 65 year old diabetic gentleman presented with swelling, erythema of his R leg. Clinically he was in septic shock with fowl smell and areas of necrosis, gangrene and crepitation noted on the leg 4/28 ABA-UMQU- Antibiotics in Surgical Practice

36 ABA-UMQU- Antibiotics in Surgical Practice
Scenario 2 A 75 year old gentleman was admitted to ICU following major laparotomy. He was intubated, had a central line and a urinary catheter. 1 weeks following his admission he developed a fever there was a green discharge around the CVP line with areas of consolidation on the R lung base 4/28 ABA-UMQU- Antibiotics in Surgical Practice

37 Principles of Antibiotics Prophylaxis
Choose an AB against the most likely organism AB with low toxicity. Monotherapy A single dose minutes pre-op. A second dose if OP lasts > 4 hours Add 2-3 doses post-op Prolonged use is appropriate when infection is likely or it’s consequence is devastating. 4/28 ABA-UMQU- Antibiotics in Surgical Practice

38 ABA-UMQU- Antibiotics in Surgical Practice
Scenario 3 A 35 year old lady presented with R hypochondrial pain. The diagnosis of cholecystitis is confirmed and laparoscopic cholecystectomy is planned 4/28 ABA-UMQU- Antibiotics in Surgical Practice

39 ABA-UMQU- Antibiotics in Surgical Practice
Scenario 4 An elderly lady is undergoing a total hip replacement for severe osteoarthritis of her hip. 4/28 ABA-UMQU- Antibiotics in Surgical Practice

40 ABA-UMQU- Antibiotics in Surgical Practice
Prophylaxis Cover Organism Operation Type 3rd generation Cephs or vancomycin Staphs, Streps Cardiac Vascular Ortho Ophthalmic Breast & thyroid Clean Cipro 3rd generation Cephs & metronidazole Staphs, streps, anaerobe G- bacilli, enteroccoci G- bacilli, enteroccoci, clostridia G- bacilli, anaerobe Oropharynx Gastric Biliary Colonic Clean contaminated G- bacilli, anaerobe , enteroccoci, clostridia Perforation Traumatic Abscess Dirty 4/28 ABA-UMQU- Antibiotics in Surgical Practice

41 Distribution of Anti-microbial Agents
Comment Area Levels are determined by rate of excretion & protein binding. Efficacy depends on the minimum inhibitory concentration and the time spent above that level. Blood Most agents achieve a urine concentration the serum concentration Ph may influence the spectra of agents Urine Most achieve concentration higher than serum May be influenced by liver disease Bile High concentrations favored by low albumin, prolonged use Interstitial fluids May achieve theraputic levels Low Ph, low oxidative potential, large number of microbes and tissue products all serve to reduce the efficacy of AB Abscesses 4/28 ABA-UMQU- Antibiotics in Surgical Practice

42 Pseudomembraneous colitis
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43 Pseudomembraneous colitis
Cause: clostridium difficile Risk factors: Broad spectrum antibiotics Proton pump inhibitors Clinical features: Voluminous diarrhea colitis Diagnosis: endoscopic veiw, stool toxin ESR/ WBC/ CT Treatment: Vancomicin/ Metronidazole 4/28 ABA-UMQU- Antibiotics in Surgical Practice

44 ABA-UMQU- Antibiotics in Surgical Practice
Allergy 2-3% of patients Anaphylaxis 0.1% Need detailed history of positive reactions Cross-reaction: 8-10% Skin reaction not needed Atopy may an independent risk factor 4/28 ABA-UMQU- Antibiotics in Surgical Practice

45 ABA-UMQU- Antibiotics in Surgical Practice
Miscellaneous Hair removal Shave on morning of surgery, use clippers Hypothermia Avoid Bowel preparation No difference Hyperglycaemia 4/28 ABA-UMQU- Antibiotics in Surgical Practice


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