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Prophylacticantibiotic–timinganddosage
Dr.SanjeevSinghAIMS,Kochi
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Meaning-Webster
MedicalDefinitionofprophylaxispluralpro·phy·lax·es\-ˈlak-ˌsēz\play:measuresdesignedtopreservehealthandpreventthespreadofdisease:protectiveorpreventivetreatment<prophylaxisagainstviraldiseases><apastecontainingfluorinefordentalprophylaxis>
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Definition
• Antibioticprophylaxisreferstothepreventionofinfectioncomplicationsusingantimicrobialtherapy
• Surgicalantibioticprophylaxisisdefinedastheuseofantibioticstopreventinfectionsatthesurgicalsite.
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Indications
• Immunecompromised• Cardiacvalves,prostheticsinbody• Visittoanothercountry• Surgery
SIGN104•Antibioticprophylaxisinsurgery.Anationalclinicalguideline.July2008
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• Asingleantibioticdose,givenimmediatelybeforethestartofsurgery,maybejustaseffectiveinpreventinginfection,whilereducingtheriskofdrugsideeffects
http://www.surgeryencyclopedia.com/Pa-St/Prophylaxis-Antibiotic.html#ixzz407iM1Dr3
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Classification Criteria Risk (%) Clean Elective, not emergency, nontraumatic, primarily closed;
no acute inflammation; no break in technique; respiratory, gastrointestinal, biliary and genitourinary tracts not entered
< 2
Clean-contaminated Urgent or emergency case that is otherwise clean; elective opening of respiratory, gastrointestinal, biliary or genitourinary tract with minimal spillage (e.g., appendectomy) not encountering infected urine or bile; minor technique break
<10
Contaminated Nonpurulent inflammation; gross spillage from gastrointestinal tract; entry into biliary or genitourinary tract in the presence of infected bile or urine; major break in technique; penetrating trauma < 4 hours old; chronic open wounds to be grafted or covered
Approx. 20
Dirty Purulent inflammation(e.g., abscess); preoperative perforation of respiratory, gastrointestinal, biliary or genitourinary tract; penetratinbg trauma > 4 hours old
Approx. 40
Classification of operative wounds and risk of infection
CruzePJ,Ford.Theepidemiologyofwoundinfection.A10-yearprospectivestudyof62,939wounds.SurgClinNorthAm.1980Feb;60(1):27-40.
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Commonsurgicalpathogens
• cleanprocedures-skinflora,includingS.aureusandcoagulase-negativestaphylococci
• clean-contaminatedprocedures(abdominalproceduresandheart,kidney,andlivertransplantations)-gram-negativerodsandenterococciinadditiontoskinflora
ASHPReport.AmJHealth-SystPharm—Vol70Feb1,2013,204-5
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• Theuseofantimicrobialagentsfordirtyproceduresorestablishedinfectionsisclassifiedastreatmentofpresumedinfection,notprophylaxis
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• Choiceofantibioticsshouldbemadeaccordingtodataonpharmacology,microbiology,clinicalexperienceandeconomy
• Antibioticsshouldbechosenwithkineticsthatwillensureadequateserumandtissuelevelsthroughouttheriskperiod.
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Idealantibiotic
• goodtolerability• Lowtoxicity• Highconcentrationatallsites
– systemicvslocal
• Longacting• Cephalosporin
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MIC
MinimumInhibitoryConcentration(MIC)isthelowestconcentrationofanantimicrobialthatwillinhibitthevisiblegrowthofamicroorganismafterovernightincubation.
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Vancomycin• Routineuseofvancomycinprophylaxisisnotrecommendedforanyprocedure
• IncludedintheregimenofchoicewhenaclusterofMRSAcases(e.g.,mediastinitisaftercardiacprocedures)ormethicillinresistantcoagulase-negativestaphylococciSSIshavebeendetectedataninstitution.ScottishIntercollegiateGuidelinesNetwork.Antibioticprophylaxisinsurgery.www.sign.ac.uk/pdf/sign104.pdf(accessed2009Jul30).
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Advantageoflongactingantibiotic
• Asingledosecoversthewholeperioperativeriskperiod-eveniftheoperationisdelayedorlong-lasting
• Repeatadministrationsforprophylaxisarenotnecessary,sothatadditionaldosesarelesslikelytobeforgotten
• Lessriskofdevelopmentofresistanceandlesssideeffects
• Increasedcomplianceandreducederrorsofadministration
• Possiblybetter-effectiveness(lessmaterialandlaborcost,lesssepticperioperativecomplications)
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Factorsthataffectphysicians’compliance
• Culturalfactors• Educationalbackground• Training• Nurseandpharmacistinfluences,• Medicationsupply• Logistics
AliA.Al-Dabbagh,andMazinA.Hajy.HowGoodisCompliancewithSurgicalAntibioticProphylaxisGuidelinesinErbil/Iraq?.2ndInternationalConferenceonMedical,BiologicalandPharmaceuticalSciences(ICMBPS'2013)June17-18,2013London(UK)
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ClevelandClinicGuidelinesforAntimicrobialUsage2012-2013
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AmericanSocietyofHealth-SystemPharmacists.2013
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Timing
• Theantibioticshouldbeadministeredideally30minutesbeforeincisioninordertoachieverelevanttissueconcentration.
• Inoperationslastinglongerthanthreehoursaseconddosageisrecommended.
• Thereisnoevidencetosupportaprolongationofantibioticadministrationto24or48hoursinmostinstances.
• Singledoseischeaperanddoesnotincreasetheriskofthedevelopementofbacterialresistance
ClassenDC,EvansRS,PestotnikSL,HornSD,MenloveRL,BurkeJP.Thetimingofprophylacticadministrationofantibioticsandtheriskofsurgical-woundinfection.NEnglJMed.1992;326:281–286.
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ScottishIntercollegiateguidancenetwork(SIGN).AntibioticprophylaxisinSurgery.Edinburg.2008,updated2014
• Forsurgicalprocedures,intravenousprophylacticantibioticsshouldbegivenwithin60minutesbeforetheskinisincisedandasclosetotimeofincisionaspracticallypossible.
• vancomycinshouldbegivenbyintravenousinfusionstarting90minutespriortoskinincision.
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• FluoroquinolonesandVancomycin,requireadministrationoveronetotwohours
• therefore,theadministrationoftheseagentsshouldbeginwithin120minutesbeforesurgicalincision.
ASHPTherapeuticguidelines
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• NICEandtheInfectiousDiseasesSocietyofAmerica(IDSA)recommendsthat-forCaesareansection,antibioticprophylaxistoreducematernalinfectiouscomplicationscanbegivenpre-incisionoraftercordclamping
•
BratzlerDW,DellingerEP,olsenKM,PerlTM,AuwaerterPG,BolonMK,etal.Clinicalpracticeguidelinesforantimicrobialprophylaxisinsurgery.AmJHealthSystPharm2013;70(3):195-283.
NationalCollaboratingCentreforWomen’sandChildren’sHealth.Caesareansection.London:NICE;2011.[cited01/05/2013].
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Dosage
• Asinglestandardtherapeuticdoseofantibioticissufficientforprophylaxisundermostcircumstances
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Duration
• Asingledoseofantibioticwithalongenoughhalf-lifetoachieveactivitythroughouttheoperationisrecommended.
• upto24hoursofantibioticprophylaxisshouldbeconsideredforarthroplasty.
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Additionaldosage
• Anadditionalintraoperativedosageofantibioticisrecommendedforcardiacsurgerylongerthanfourhourswhenusinganantibioticwithpharmacokineticsequivalenttocefazolin.
ZanettiG,GiardinaR,PlattR.Intraoperativeredosingofcefazolinandriskforsurgicalsiteinfectionincardiacsurgery.EmergingInfectiousDiseases2001;7(5):828-31
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• Intheeventofmajorintraoperativebloodlossinadults(>1,500ml)or(children25ml/kg)additionaldosageofprophylacticantibioticshouldbeconsideredafterfluidreplacement.
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Howmanydays
• Ifprophylacticantibioticgivenmorethan24hoursitisnolongeraprophylaxisbuttherapeuticschedule
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