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

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45

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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

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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

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Evolution nombre de frottis BMR par mois et unité

mois

No

mb

re

Your opinion?