ANTIBIOTICS IN ABDOMINAL

SURGERY: CURRENT Presented by:

Dr. Ritesh Karwaria
GUIDELINES AND PRACTICES
INTRODUCTION
Surgical Site infection is the most common healthcare associated infection among
hospitalised patients and the most common nosocomial infection in surgical wards.
SSI Rates considerably increase when surgery is performed on GI Tract ~30%
compared to other general surgical procedures.
The reason for higher rate of SSI is that the GI Tract harbors a high load of bacteria
including anaerobic organisms from gut mucosa
SSI can be prevented by optimizing patients in peri-operative period with
appropriate glycemic control, maintenance of normothermia, perioperative
supplemental Oxygen.
Surgical Antimicrobial Prophylaxis is also an effective way to reduce SSI.
GENERAL PRINCIPLES
Majority of the operative procedures in the GI tract falls into clean contaminated and
contaminated wound class according to CDC Classification, hence rate of SSI is
higher and requires antibiotics.
In addition to the gram positive skin flora (Streptrococcal species, Staphylococcus
Aureus, CONS), gram negative rods and Enterococci are frequently isolated from
SSI after GI Surgery.
The goal of antimicrobial prophylaxis is to prevent SSI by reducing burden of micro-
organisms at surgical site during operative procedure.
The following considerations are to be taken while giving antimicrobial prophylaxis:
- Appropriate Antibiotic Selection
- Second line Prophylaxis
- Adequate dosing and redosing
- Route of administration
- Optimum timing of antibiotic administration
- Duration of Antimicrobial prophylaxis
ANTIBIOTIC FOR BILIARY
PROCEDURES
1. Elective Laparoscopic Cholecystectomy (0-4% )
Laparoscopic Cholecystectomy is considered the gold standard for symptomatic gall
stone disease and is the most commonly performed minimally invasive procedure in
elective setting.
Traditionally one dose of prophylactic antibiotic was given to all patients undergoing
Laparoscopic cholecystectomy
Prophylaxis is generally recommended only for high risk patients which include age
more than 70 years, ASA Grade >=3, Pregnancy, Diabetes Mellitus, Obesity, Non
functioning Gall bladder, and immunosuppression.
Commonly isolated organisms from SSI of Laparoscopic cholecystectomy include
gram negative bacilli ; E Coli, Klebsiella and Enterococci.
2. Other Biliary procedures
Antibiotic prophylaxis is not recommended in patients undergoing ERCP (Both
therapeutic or diagnostic)
Exception: If patient has features of Cholangitis or Obstructive Jaundice.

Open Cholecystectomy,Bile duct surgeries, Biliary-enteric Anastamoses (1-9%)

Commonly isolated organisms from SSI of Open surgeries include gram negative
bacilli ; E Coli, Klebsiella and Enterococci.
Ocassionaly Clostridium species have been isolated
Less commonly, Skin commensals have been isolated from the postoperative SSI
3. Acute Cholecystitis
Acute Cholecystitis is associated with presence of biliary infections with significant
physiological derangement.
Considering the presence of infection and probability of progression to Severe septic
complications in untreated patients, Biliary tract infections are treated as per
guidelines for complicated intra-abdominal infections

*TOKYO GUIDELINES 2018

Divides Patients into 3 groups
Grade I: Mild
Grade II : Moderate
Grade III : Severe
Commonly Isolated Organisms : Predominantly Enteric Gram Negative Organisms ;
Less commonly Pseudomonas, Enterobacter, Acinetobacter

Severe Cholecystitis patients in addition to antibiotics require fluid resuscitation,

source control by drainage/surgery and management of organ dysfunction.
ANTIBIOTICS FOR ACUTE
APPENDICITIS
Acute Appendicitis is the most common emergency for which operation is performed
and appendectomy remains the mainstay of treatment for both simple and
complicated appendicitis.
Common Organisms isolated from Appendectomy wound infections include
Anaerobic and Aerobic gram negative organisms.
Among the anaerobes Bacteriodes Fragilis is most commonly cultured from the
wound. E Coli is the most commonly isolated aerobe.
Less Frequent: Streptococcus, Staphylococcus, and Enterococcus
Rate of SSI upto 30%
Laparoscopic appendectomy has been shown to have low postoperative wound
complications in terms of superficial and deep SSI compared to open appendectomy.
Considering the mixed aerobic and anaerobic spectrum of bacteria implicated in
appendectomy wound infection, monotherapy using second generation
cephalosporin with anaerobic activity or a first-generation cephalosporin in
combination with metronidazole is considered a reasonable choice.
Third generation Cephalosporin with partial anaerobic activity have been shown to
reduce SSI Rates to less than 5 %
ACUTE PANCREATITIS
Acute pancreatitis is a common abdominal emergency associated with high
morbidity and mortality primarily due to septic complications.
While majority of patients have mild self-limiting acute pancreatitis, a small
proportion develop severe acute pancreatitis.
Early phase (first 2 weeks) of severe pancreatitis is characterized by early systemic
inflammatory response syndrome with or without multiple organ dysfunction
syndrome.
Approximately one-fifth of patients develop secondary bacterial infection and septic
complications that usually occurs 2-3 weeks after the onset of pancreatitis.
Pathogenesis of Infection in Acute Pancreatitis

The routes of infection in acute pancreatitis are:

Bacterial translocation from the gut to the portal system and systemic circulation due
to impaired gut mucosal defense mechanism.
From the biliary system especially in patients with biliary pancreatitis secondary to
stones in the biliary tract
 Ascending infection from the duodenum through the ampulla and pancreatic duct.
• Infection from the colon due to bacterial translocation through lymphatics
Implication of Gut organisms as the primary source of infection is supported by the
commonly isolated organisms in infected pancreatic necrosis are Gram Negative
Bacteria ( E.Coli, Klebsiella) normally seen in Intestinal lumen.
Gram positive bacteria ( Enterococcus, Staphylococcus Aureus), anaerobes and fungi
have also been implicated as a source of infection in approximately 20-30% cases
with acute pancreatitis.
ROLE OF PROPHYLACTIC
ANTIBIOTICS IN ACUTE
PANCREATITIS
The use of antibiotics to prevent infection is still controversial; many authors have
advocated their routine use while others decry it.
The proponents of prophylactic antibiotics suggest that close to 50% of patients with
severe acute pancreatitis develop infection and it contributes to mortality in three-
fourths of patients with necrotizing pancreatitis.
Various studies have concluded that antibiotics for 10-14 days in acute pancreatitis
have shown decreased superinfection of pancreatic tissue and its associated
mortality.
THERAPEUTIC ANTIBIOTICS
FOR INFECTED PANCREATIC
NECROSIS
Unlike sterile pancreatic necrosis there is no controversy in the role of antibiotics for
infected acute pancreatitis.
However, definite diagnosis of infected pancreatic necrosis remains a challenge as
systemic inflammatory response seen in patients with severe pancreatitis often mimics
infection.
The investigation of choice to document infection is CT-guided fine needle aspiration
cytology (FNAC) from the area of pancreatic necrosis as it will also guide
management by selecting appropriate antibiotics.
However, it is an invasive procedure and is associated with high false negative results.
Presence of gas within the necrotic areas on cross sectional imaging also signifies
infection.
Hence , Serum markers are commonly are used to determine infection.
( CRP and WBC Count are highly sensitive)

In cases of pancreatic necrosis, antibiotics known to penetrate necrosis should be

used.
Aminoglycosides have poor penetration
Ureidopencillins and 3rd Generation cephalosporins have intermediate penetration
Quinolones and Carbapenems have good penetration.
In view of widespread resistance to quinolones, carbapenems remain the antibiotic of
choice for critically ill patients with infected pancreatic necrosis.
In addition their activity against commonly implicated gram negative organisms they
are also effective against anaerobes.
Of the antibiotics with intermediate penetration, piperacillin/tazobactam is effective
against bacteria and anaerobes in addition to its efficacy against gram-positive
bacteria and anaerobes and may be the initial empiric antibiotic in patients with acute
pancreatitis.
Probiotics are no longer recommended in acute pancreatitis.
No role of prophylactic antifungal in acute pancreatitis.
However, infection with Candida species is common in patients receiving antibiotics
and treatment with Azoles (Caspofungin) for a minimum duration of 2 weeks is
recommended.
ABDOMINAL SEPSIS
As per the third International Consensus Definitions for Sepsis and Septic Shock
(Sepsis-3) published in February 2016, sepsis is defined as “life threatening organ
dysfunction caused by a dysregulated host response to infection.
Sequential Organ Failure Assessment (SOFA) score is used to objectively determine
organ dysfunction.
An increase in the sepsis related SOFA score by >2 points is considered life
threatening.
As per current recommendations , abdominal sepsis is defined as increase in SOFA
score >= 2 due to abdominal infections
PRINCIPLES OF
MANAGEMENT
The principles of management in patients with abdominal sepsis are:
-Early Diagnosis
-Source control in form of debridement
-Removal of infected devices, drainage of purulent cavities and decompression of
abdominal cavity.
The Surviving Sepsis Campaign (SSC) guidelines for antimicrobial therapy in
patients with abdominal sepsis are:
-Early administration of parenteral antibiotics within 1 hour after admission
-Choice of initial empirical antimicrobial therapy before the availability of culture
and antibiotic susceptibility results should be based on potential causative organisms,
local trend of antibiotic resistance, patient risk factors, severity and source of
infection
-Once the culture and antibiotic susceptibility results are available theantibiotic
spectrum should be narrowed
- De-escalation or withdrawal of antimicrobial therapy should be considered as soon
as possible based on multidisciplinary, daily reevaluation of the critically ill patient.
The aim of these guidelines is to prevent the emergence of multidrug resistant
bacteria and superinfection with fungal pathogens.
 ANTIMICROBIAL THERAPY FOR
ABDOMINAL SEPSIS SEPSIS
Diagnosis Antibiotic regimen-Low risk Antibiotic regimen-High risk
Secondary peritonitis Piperacillin +Tazobactam Imipenem-Cilastatin
Cefoperazone+ Sulbactam Ceftolozane + Meropenem
tazobactam + metronidazole
Ceftazidime+ avibactam+ metronidazole
Moxifloxacin Levofloxacin/
ciprofloxacin + metronidazole

Primary peritonitis Cefotaxime Piperacillin+ Tarobactam

Cefoperazone+ Sulbactam
Imipenem+ Cilastatin
Meropenem
Tertiary peritonitis Imipenem+ Cilastatin (+linezolid) Meropenem
(+linezolid)
Ceftolozane+ tazobactam +
metronidazole(+linezolid)
Ceftazidime + avibactam-
metronidazole(+linezolid)
Tigecycline
DURATION OF THERAPY
In patients with abdominal sepsis, traditionally antibiotics are to be given for a minimum
period of 1 week.
However, in patients not severely ill and in which adequate source control has been
achieved, short course therapy is equally effective.
Use of antibiotics for short duration minimizes drug-related adverse events, avoids
selection of antibiotic resistance, and significantly reduces health care costs.
However, in patients with staphylococcus septicemia (positive blood culture) antibiotics
should be given for two (uncomplicated infection) to four (complicated infection) weeks.
In the presence of on-going abdominal sepsis, the duration of antibiotics should be based
on the clinical assessment Serum markers of sepsis such as procalcitonin can guide in the
determination of duration of antimicrobial therapy
COLORECTAL SURGERY
Surgical site infection is the most common cause of postoperative morbidity in
patients undergoing surgery for colorectal diseases.
While the advent of minimally invasive surgery has reduced the morbidity related to
SSI, SSIs still remain a common postoperative complication in approximately 25%
of patients.
EVOLUTION OF ANTIBIOTICS
IN COLORECTAL SURGERY
Postoperative SSIs have been attributed to fecal flora so initially the aim was to
reduce fecal flora and mitigate infectious complications by reducing fecal load.

Mid 20th century: Mechanical bowel Prepration

End of 20th Century : Shift to micriobiological prepration: Oral antibiotics + MBP
(Oral Neomycin(1g) + Oral Erythromycin(1g) 17-18 hours before surgery)
Early 21st Century: Advent of Parenteral Antibiotics with better bioavailability : shift
to parenteral antibiotics prophylaxis
Current evidence shows the combination of mechanical with microbiological
prepration with parenteral antibiotics, oral antibiotics and MBP should be done for
elective colorectal surgery ( especially left colon and rectal surgery)
ANTIBIOTIC PROPHYLAXIS
FOR ELECTIVE COLORECTAL
SURGERY
Antibiotic Prophylaxis for Elective Colorectal Surgery
There is level 1 evidence for intravenous antibiotic prophylaxis administered within
60 min before incision.
The currently recommended regimen is second or third generation cephalosporin
combined with metronidazole to cover both gram-negative acrobes and anaerobes.
Additional intraoperative or postoperative doses are not recommended when the
antibiotics are given for prophylaxis in the elective setting as it increases the risk of
C difficile colitis
Oral antibiotics are recommended in patients receiving MBP, although the evidence
is not as satisfactory as with parenteral antibiotics
No clear consensus regarding the dosage and duration is present.
The choice of antibiotic regimen is based on surgeon’s choice, institutional antibiotic
protocol and local antibiotic resistance.
ANTIBIOTICS FOR
EMERGENCY COLORECTAL
SURGERY
Emergency surgery is usually performed for obstruction or perforation is patients
presenting with obstruction without signs of systemic sepsis, the parenteral antibiotic
regimen is similar to prophylactic antibiotics given for elective surgery.
Oral antibiotics have limited role as MBP is not given in emergency patients.
Recommendations are similar to that of Abdominal Sepsis.
INTESTINAL ISCHEMIA
Intestinal ischemia is a life-threatening complication secondary to abrupt
interruption of the vascular supply to a segment of bowel.
Globally, the incidence of intestinal ischemia is increasing due to the increase in an
aging population.
Broadly, intestinal ischemia is classified as occlusive or nonocclusive types.
Occlusive type of intestinal ischemia could be due to arterial embolism, arterial
thrombosis, or venous thrombosis.
Irrespective of the etiology the manifestations of intestinal ischemia are dependent
on the duration and severity of vascular occlusion
Microscopic changes of ischemia can be detected in the intestinal mucosa within
minutes of vascular occlusion.
Ischemic damage to mucosa affects intestinal barrier resulting in bacterial
translocation.
Studies have shown that bacteria translocate through the intercellular route between
the intestinal epithelial cells or through ulcerations left by denuded epithelial cells in
patients with ischemic damage
Antibiotic use is based on broad spectrum anti microbial coverage, similar to
Abdominal sepsis.
THANK YOU