antibioprophylaxis in surgery and mdros atelier antibioprophylaxie en chirurgie workshop antibiotica...

Antibioprophylaxis in surgery and MDROs

Atelier antibioprophylaxie en chirurgieWorkshop Antibiotica profylaxe in de chirurgie

Baudouin Byl

Hygiène Hospitalière

et Gestion de l’antibiothérapie

Hôpital Erasme – ULB

Plan

• MDR definition• Prophylaxis – spectrum - principles• Literature – prophylaxis et SSI MDROs• Discussion

Definition MDR

• Clinical microb infec 2011: 18(3), 268-281

Definition MDR

2013 9

Antibioprophylaxiscommon principles

• Limited to well proven indications• Targeted to organisms involved in SSI• Timing of administration• Perop administration if needed• Duration < 24 hrs

2013 10

Antibioprophylaxis

• new recommendations Bratzler DW et al

Am J Health-Sys Pharm

Vol 70, feb1, 2013

previous:

Clin Infect Dis, 1994; 18: 422-427

ASHPIDSASHEASIS

Spectrum

• The narrowest

• Resistance patterns from organisms causing SSI should take precedence over hospitalwide antibiograms

• In some cases, procedure-specific resistance patterns!

Consensus 2013

2013 12

Spectrum

• Skin incision: SSI:

~ 80% Gram positive~ 20% Gram négative

First choice: anti-staph (oxa-S) + anti bgn cef 1 (cef2)

2013 14

From 1994 to 2013 …

• Dramatic decrease in sensitivity to cef1 (cef2)

• MDR ….

2013 15

• R rate cef1 cef2, enterobacterial species Erasme• 1993-2011

1993 1996 2000 2004 2007 20110

5

10

15

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25

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35

40

45

50

czol ambucfur ambuczol hospicfur hospi

2013 16

Rec 2013 - Quid des MDR?

• MRSA• MDR Enterobacteriacae• Pseudomonas aeruginosa

• VRE• …

2013 17

Rec 2013 - Quid des MDR?

Consensus 2013

2013 18

2013/ MRSA

• Glycopeptides en prophylaxie– Consensus 2013

• Cluster of MRSA or MRSE• known MRSA colonisation (or at high risk)

AND who will have a skin incision• !!! vanco less effective on MSSA !!!

– czol+vanco!

• (Specific setting: community MRSA)

2013 19

2013/ MR(S)SA

• From controverse to growing evidence…• S aureus carriage eradication recommended

– Cardiac surgery– Orthopedic surgery– Spinal procedures

• ! Surveillance of R to mupi !• ? Timing? Duration?• ! operational considerations ! (BB)

Consensus 2013

2013 20

MRSA

• Screening vs high risk conditions – Pts/units

• Eradication• + Vancomycine

2013 21

VRE

• Enteroccoccus uncovered by conventional prophylaxis (rare exceptions)

• VRE to be considered in special settings (Li TX, …)

2013 22

Enterobacteriaceae

2013 23

Gram neg / PUBMED

• MDR / prophylaxis / surgery : 0• Carbapenemase / SSI / prophylaxis: 0• Carbapenemase / prophylaxis: 0• ESBL / prophylaxis: 47

– Surgery 12- 7 urology- 4 transplantation- 1 obesity (pharmaco ertapenem)

2013 24

MDR carriage / exposition to antibiotics

• Abundant literature – overlaps between:

– ESBL– UTI– Neutropenic patients– Quinolone use

2013 25

Urology / ciproR

• Urology• Transrectal prostate biopsy• E coli : first causative (75-

90%)• Haute prévalence esbl et

ciproR

• E coli ciproR 17%!!!• Quid proph quinolones?

Qi et al J Urol 2013: 2026

Williamson et al, CID, 2013:267

2013 26

Urology / customized prophylaxis

• FQ vs [ctri or genta or sxt or cefpodox]• Reduction infection / ctrl histor

• by screening and adapted prophylaxis• Reduction infection

Taylor J Urol 2012: 1275

Duplessis et al Urology 2012: 556-563

2013 27

Urology / cipro + amikacin

Kehinde J Urol 2013; 189: 911

Historic contrl : ciproIntervention: cipro+amika

2013 28

ESBL / epidemiology / liver Tx

• Independant risk factors – fecal carriage ESBL– Previous infection with ESBL– Previous Blactam– Previous SBP (quinolones!)

• Need for targeted prophylaxis

Bert , Transplant infect disease, 2013:0: 1-6

2013 29

ESBL / epidemiology / liver Tx

Bert , Transplant infect disease, 2013: 1-6

2002 20100

5

10

15

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25

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35

40

ESBL+ carriageESBL+ infection

%pts

2013 30

Colonisation / Clinical impact

• ICU~7 % infections caused by ESBL+– Among carriers

• 10% first infection and 27% second infection caused by ESBL+

Razazi Int Care Med 2012; 38:1769-1778

2013 31

ESBL / prophylaxis

2013 32

Antibioprophylaxis

• new recommendations Bratzler DW et al

Am J Health-Sys Pharm

Vol 70, feb1, 2013

previous:

Clin Infect Dis, 1994; 18: 422-427

2013 33

Rec 2013

• Transplanted pts (liver, lungs):– Include coverage for any potential pathogen

(isolated < donor / receiver)

• Colo-rectal– czol+ metro– Or ctri+metro (if high R cef1/2)

• [or ertapenem!!]

Consensus 2013

Quid Gram neg MDRO?

2013 35

Quid Gram neg/MDR?

• Consider customising– Urology (trans rectal biopsy)– Local SSI epidemiology

• Screening!(rectal)• Screening high risk• Customize to screening results• Customize to high risk (ex

uro!)

2013 36

Operational considerations

• Preoperative clinical path• Customize vs systematic

screening (lab costs!)

2013 37

Operational considerations

0

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120

Evolution nombre de frottis BMR par mois et unité

mois

No

mb

re

Your opinion?