1. Timing of Prophylaxis The antibiotic should be administered preoperatively but as close to the time of the incision as is clinically practical. Antibiotics should be administered before induction of anesthesia in most situations. The antibiotic should be administered preoperatively but as close to the time of the incision as is clinically practical. Antibiotics should be administered before induction of anesthesia in most situations. Recommended time for  -lactams is 60 min prior to surgical incision and 120 min for Vancomycin and Flouroquinolns Recommended time for  -lactams is 60 min prior to surgical incision and 120 min for Vancomycin and Flouroquinolns

2. Timing of Prophylaxis  1- Adequate time for complete antibiotic infusion and achievement of SS kinetics  2- Higher serum concentrations during the surgery  3- Measurable drug levels at the end of surgery  4- Adequate tissue concentrations at the time of first incision and wound

3. Repeat Dosing A single IV dose is recommended for surgical procedures lasting less than 4 hours A single IV dose is recommended for surgical procedures lasting less than 4 hours Redosing is recommended for procedures lasting more than 4 hours or when blood loss occurs or the patient is obese. Redosing is recommended for procedures lasting more than 4 hours or when blood loss occurs or the patient is obese. Redosing is indicated every 1 to 2 half lives of antibiotic in patients with normal renal function Redosing is indicated every 1 to 2 half lives of antibiotic in patients with normal renal function

4. Repeat of Dosing Repeat dosing during post-operative period and after wound closure is not necessary and even might increase antimicrobial resistance Repeat dosing during post-operative period and after wound closure is not necessary and even might increase antimicrobial resistance

5. Common mistake 1- broad-spectrum AB 1- broad-spectrum AB 2- extended duration 2- extended duration 3- expensive AB 3- expensive AB 4- timing 4- timing

6. Colorectal Surgery It is recommended to cover gram Θ bacilli, anaerobes and enterococci It is recommended to cover gram Θ bacilli, anaerobes and enterococci Oral prophylaxis appears to be as effective as IV prophylaxis but in USA more than 90% of surgeons use both of them. Oral prophylaxis appears to be as effective as IV prophylaxis but in USA more than 90% of surgeons use both of them. along with administration of mechanical bowel preparation along with administration of mechanical bowel preparation

7. Colorectal Surgery Oral Neomycin (1g)+ Oral Erythromycin base (1g) Oral Neomycin (1g)+ Oral Erythromycin base (1g) Oral Neomycin (2g)+ Oral Metronidazole (2g) Oral Neomycin (2g)+ Oral Metronidazole (2g) Intravenous cefoxitin or cefazolin preoperatively and continued 2 doses or 24 hrs postoperatively Intravenous cefoxitin or cefazolin preoperatively and continued 2 doses or 24 hrs postoperatively

8. Billiary Tract Surgery Prophylaxis is recommended in patients with such risk factors: 1- Age greater than 60 (70) years 1- Age greater than 60 (70) years 2- Acute cholesistis 2- Acute cholesistis 3- Obestructive jaundice 3- Obestructive jaundice 4- Bile duct stones 4- Bile duct stones

9. Billiary Tract Surgery Recommended antibiotics are : Cefazolin (1-2g IV) Cefazolin (1-2g IV) Clindamycin + Anti gram Θ agents (Gentamicin, Aztreonam, Ciprofloxacin) for whom are allergic to beta-lactam antibiotics Clindamycin + Anti gram Θ agents (Gentamicin, Aztreonam, Ciprofloxacin) for whom are allergic to beta-lactam antibiotics

10. Appendectomy Antibiotic prophylaxis is recommended even in patients with non-perforated acute appendicitis Antibiotic prophylaxis is recommended even in patients with non-perforated acute appendicitis 1- Cefazolin (1-2g IV) 1- Cefazolin (1-2g IV) 2- Cefazolin (1-2g IV) + Metronidazole (500 mg IV) 2- Cefazolin (1-2g IV) + Metronidazole (500 mg IV) 3- Clindamycin (600-900mg IV) + Anti gram Θ agents (Gentamicin, Aztreonam, Ciprofloxacin) 3- Clindamycin (600-900mg IV) + Anti gram Θ agents (Gentamicin, Aztreonam, Ciprofloxacin)

11. Vascular Surgery The recommended drugs are: 1- Cefazolin (1-2g IV) 1- Cefazolin (1-2g IV) 2- Cefuroxime (1.5g IV) 2- Cefuroxime (1.5g IV) 3- Vancomycin in patients with allergy to beta- lactam antibiotics (because of the crucial role of Staphylococci and Streptococci) 3- Vancomycin in patients with allergy to beta- lactam antibiotics (because of the crucial role of Staphylococci and Streptococci)

12. Genitourinary Surgery Antibiotic prophylaxis is warranted when the urine culture is positive or urinary catheter is in place Antibiotic prophylaxis is warranted when the urine culture is positive or urinary catheter is in place This decreases not only the risk of sepsis but also the incidence of postoperative bacteriuria This decreases not only the risk of sepsis but also the incidence of postoperative bacteriuria Ciprofloxacin (500mg PO or 400mgIV) or Co- Trimoxazole (2 DS tablets) are recommended Ciprofloxacin (500mg PO or 400mgIV) or Co- Trimoxazole (2 DS tablets) are recommended

13. Cesarean Section Enteric gram negative rods, anaerobes, enterococci and group B streptococci are common pathogens Enteric gram negative rods, anaerobes, enterococci and group B streptococci are common pathogens Antibiotic administration should be undertaken immediately following umbilical cord clamping Antibiotic administration should be undertaken immediately following umbilical cord clamping Cefazolin is the drug of choice but Cefoxitin may also be used. Cefazolin is the drug of choice but Cefoxitin may also be used.

14. Neurosurgery Antimicrobial prophylaxis can reduce the incidence of infection mostly due to gram + bacteria like: Staphylococci and Streptococci Antimicrobial prophylaxis can reduce the incidence of infection mostly due to gram + bacteria like: Staphylococci and Streptococci Cefazolin (1-2g IV) Cefazolin (1-2g IV) Vancomycin (~1g IV) in selected patients Vancomycin (~1g IV) in selected patients

15. Cardiac Surgery Coronary bypass or heart valve replacement are clean with low incidence of SSI procedures Coronary bypass or heart valve replacement are clean with low incidence of SSI procedures In open cardiac surgery, antibiotic prophylaxis is recommended In open cardiac surgery, antibiotic prophylaxis is recommended Cefazolin, Cefuroxime and Vancomycin are the drugs of choice for prophylaxis Cefazolin, Cefuroxime and Vancomycin are the drugs of choice for prophylaxis Naso-pharyngeal and oropharyngeal decontamination are effcetive to reduce the risk of wound infection after cardiac surgery especially due to S. aureous Naso-pharyngeal and oropharyngeal decontamination are effcetive to reduce the risk of wound infection after cardiac surgery especially due to S. aureous

16. Naso-pharyngeal & Oropharyngeal Decontamination Mupirocin and Chlorhexidine gluconate have been tested for this purpose Mupirocin and Chlorhexidine gluconate have been tested for this purpose Mupirocin indicates controvertial effectiveness while for Chlorhexidine the results are beneficial as follows: Mupirocin indicates controvertial effectiveness while for Chlorhexidine the results are beneficial as follows: 1- Overal reduction in nosocomial infection (19.8 vs 26.2 %) 1- Overal reduction in nosocomial infection (19.8 vs 26.2 %) 2- Reduction in S. aureous nasal carriage (18.1 vs 57.5%) 2- Reduction in S. aureous nasal carriage (18.1 vs 57.5%)

17. Hair Removal Most studies have shown an increased risk of SSI in patents undergoing preoperative hair removal Most studies have shown an increased risk of SSI in patents undergoing preoperative hair removal In one study the rates of SSI were highest when shaving was used compared to clipping the hairs or use of depilating creams In one study the rates of SSI were highest when shaving was used compared to clipping the hairs or use of depilating creams Mild hypothermia may promote SSI by triggering vasoconstriction that in turn may decrease SC oxygen tension Mild hypothermia may promote SSI by triggering vasoconstriction that in turn may decrease SC oxygen tension

18. 0 4 8 12 Alexander JW et al. Arch Surg. 1983;118:347–352. Hair-Removal Techniques and SSIs Infection, % 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) PMAMPMAM RazorRazorClipperClipper

19. 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 –Control19%(18/96) –Treatment6%(6/104); P=0.009 Kurz A et al. N Engl J Med. 1996;334:1209–1215.

20. 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 P O 2 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.

21. 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 diabetes1.5% (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)

22. 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%)1.00 200–24921 (29%)154 (17%)2.54 250–29911 (15%)69 (8%)2.97 ≥3005 (7%)28 (3%)3.32

23. Thanks for your attention