PRINCIPLES OF ANTIBIOTIC

USE IN SURGERY
BY DR. MAIMUNA MUHAMMAD IBRAHIM
 OUTLINE

• INTRODUCTION
• GENERAL PRINCIPLES OF ANTIBIOTICS USE
• ANTIBIOTIC PROPHYLAXIS
• THERAPEUTIC ANTIBIOTIC USE I
• NDISCRIMINATE USE OF ANTIBIOTICS
• TOXICITY OF ANTIBIOTICS
• CONCLUSIONS
 INTRODUCTION

DEFINITION
ANTIBIOTICS ARE PRODUCTS OF VARIOUS SPECIES OF MICROORGANISMS
INCLUDING BACTERIA, FUNGI AND ACTINOMYCETES THAT SUPPRESS GROWTH OR
KILL OTHER MICRO-ORGANISMS
ANTIMICROBIAL (ANTIBACTERIAL) IS A TERM USE TO INCLUDING PURELY
SYNTHETIC AGENTS SUCH AS:
• SULPHONAMIDES
• QUINOLONES
• THE GOAL OF THERAPY IS TO ACHIEVE LEVELS OF ANTIBIOTIC AT SITE OF
INFECTION THAT EXCEED THE MINIMUM INHIBITORY CONCENTRATION FOR THE
PATHOGENS PRESENT.
• MILD INFECTION CAN BE TREATED AT THE OUTPATIENT WITH ORAL ANTIBIOTICS.
• FOR SEVERE INFECTION INTRAVENOUS ANTIBIOTICS WILL BE MOST
APPROPRIATE.
• FOR MOST SURGICAL INFECTION THERE IS NO SPECIFIC DURATION OF
ANTIBIOTIC KNOW TO BE IDEAL.
• ANTIBIOTICS ARE GENERALLY BELIEVED TO SUPPORT
• HISTORICAL PERSPECTIVE
• EARLY 19TH CENTURY - LOUIS PASTEUR DISCOVERED THAT CERTAIN
SAPROPHYTIC BACTERIA CAN KILL ANTHRAX BACILLI.
• 1928 - ALEXANDER FLEMING DERIVED PENICILLIN FROM PENICILLIUM NOTATUM.
• 1939 - TYROTHRICIN WAS ISOLATED FROM CERTAIN SOIL BACTERIA BY RENE
DUBOS.
• 1944 - SELMAN WAKSMAN DERIVED STREPTOMYCIN FROM ACTINOMYCETES.
MODE OF ACTION
BACTERIOSTATIC
• CHLORAMPHENICOL
• TETRACYCLINES
• MACROLIDES
• SULPHONAMIDE
• CLINDAMYCIN
BACTERICIDAL
• PENICILLIN
• AMINOGLYCOSIDE
• CEPHALOSPORIN
• METRONIDAZOLE
• QUINOLONES

BASE ON SPECTRUM OF ACTIVITY

• NARROW SPECTRUM
• EXTENDED SPECTRUM
GENERAL PRINCIPLES OF ANTIBIOTIC
USE
JUSTIFICATION:
• TREATMENT AND PREVENTION OF INFECTION IS A CARDINAL RESPONSIBILITY OF
THE SURGICAL TEAM.
• FAVORABLE OUTCOME OF SURGERIES WERE RECORDED WITH APPROPRIATE USE
OF ANTIBIOTICS
• SSI INCREASE MORTALITY, MORBIDITY, HOSPITAL STAY AND COST OF TREATMENT
SELECTION OF ANTIBIOTICS
• REQUIRES KNOWLEDGE OF
• THE ORGANISM'S IDENTITY AND ITS SENSITIVITY TO A PARTICULAR AGENT
• THE SITE OF THE INFECTION (CNS, BONE, GI, UT)
• THE SAFETY OF THE AGENT
• PATIENT FACTORS
(AGE, PREG., LACTATION, SYS. ILLNESSES, HYPERSENSITIVITY)
• AVAILABILITY, ACCESSIBILITY, AFFORDABILITY OF THE DRUG
 ANTIBIOTIC PROPHYLAXIS
IS THE USE OF ANTIBIOTIC TO PREVENT ANTICIPATED INFECTION
INDICATIONS FOR PROPHYLAXIS IN SURGERY
• WOUNDS
• CLEAN CONTAMINATED AND CONTAMINATED WOUND
• CLEAN WOUND IN WHICH IMPLANTS OR PROSTHESIS ARE INSERTED
• ANIMAL OR HUMAN BITE
• OPEN FRACTURE
• DELAY TO CLEANING > 6HRS
• FOOT/ HAND WOUNDS
• WOUND LENGTH > 5CM
• CRUSH
• WOUND INVOLVING BODY CAVITY/ PERINEUM
• IMMUNO-SUPPRESSED PATIENT
• BURNS
GENERAL CONSIDERATIONS
• NOT A SUBSTITUTE OR ALTERNATIVE TO ASEPTIC PRACTICE AND GOOD
SURGICAL TECHNIQUE.
• NECESSARY ONLY IN HIGH-RISK CASES OF BACTERIAL CONTAMINATION
• PREOP SELECTION OF ANTIBIOTIC SHOULD CONSIDER THE NORMAL FLORA IN
CLEAN CASES AND THE LIKELY CONTAMINANT IN DIRTY CASES
• ADOPTION OF POLICY ON TYPE ANTIBIOTICS TO USE IS IMPORTANT
ANATOMICAL SITE NORMAL FLORA
SKIN STAPHYLOCOCCUS, STREPTOCOCCUS,
PROPIONIBACTERIA
ORAL CAVITY ABOVE, ANEROBES, & GRAM NEGATIVE RODS
NASOPHARYNX STAPH, STREP, H.INFLUENZA, & ANEROBES
THORAX STAPH, STREP, AND PROPIONIBACTERIA
OESOPHAGUS-JEJUNUM FLORA OF NASOPHARYNX ,
ENTEROBACTERIAECEA
LARGE BOWEL GRAM-VE RODS, ENTEROCOCCI &
ANAEROBES
FEMALE GENITAL TRACT FLORA OF LARGE INTESTINE, STAPH, STREP &
H.INFLUENZA
URINARY TRACT NORMALLY STERILE
RECOMMENDED DRUGS FOR SOME
PROCEDURES
PERIOP

• IT SHOULD START WITH PREMEDICATION

• SHOULD BE ADMINISTER 3OMIN- IHR BEFORE THE SURGERY
• SHOULD BE INTRAVENOUS
• AIMING AT A SATURATED TISSUE CONCENTRATION ABOVE MIC AT THE TIME OF SURGERY OR MANIPULATION.
• RE-ADMINISTER AT 1-2 T½ OF THE ANTIBIOTICS FOR PROLONGED
SURGERY
• 24-48 HR IS AS EFFECTIVE AS ADMINISTRATION FOR 7DAYS
 THERAPEUTIC ANTIBIOTIC USE
THERAPEUTIC ANTIBIOTICS ARE GIVEN TO FIGHT INFECTIONS THAT IS ALREADY BEEN ESTABLISHED

 ESTABLISH A CLINICAL DIAGNOSIS AND THE NEED FOR ANTIBIOTICS BASE ON HISTORY AND PHYSICAL EXAMINATION
 DETERMINE THE URGENCY OF THE SITUATION
• NON-URGENT SITUATION: MILD INFECTION OR CHRONIC INFECTION
• URGENT SITUATION:- SUSPECTED SEVERE INFECTION
 OBTAIN AN APPROPRIATE CLINICAL SPECIMENS FOR EXAMINATION, CULTURE AND SENSITIVITY
 REMOVE BARRIER TO CURE BY
• DEBRIDEMENT
• SEQUESTRECTOMY
• I&D
• GOOD WOUND CARE
 DETERMINE THE MOST LIKELY ORGANISM CAUSING THE INFECTION
• FOCUS OF INFECTION
• AGE
• EPIDEMIOLOGIC FEATURES
• PRIOR CULTURE DATA
 IF MULTIPLE ANTIBIOTICS ARE AVAILABLE TO TREAT PATHOGEN, CHOOSE THE BEST AGENT
• PRIOR ANTIBIOTIC ALLERGIES
• ANTIBIOTIC PENETRATION
• POTENTIAL SIDE EFFECTS
• MEDICAL CONDITION OF THE PATIENT
 ANTIBIOTIC COMBINATION CAN BE CONSIDERED TO ACHIEVE SYNERGISM
 ASSESS EFFECTIVENESS OF ANTIBIOTIC THERAPY

- CLINICAL ASSESSMENT -
• TEMPERATURE - 48 HRS 4BC ANTIBIOTICS
• INFLAMMATORY MARKERS - SIGNIF. ICRP < 25 % FROM THE BASELINE WITHIN 24 HRS.
• CONTAGIOUSNESS OF PATIENT -
BC 24 HRS.
BS 5 DAYS
 INITIAL THERAPY MAY NEED MODIFICATION AFTER CULTURE RESULTS ARE AVAILABLE
• MODIFICATION NOT NECESSARY IF THERE IS SIGNIFICANT RELIEF OF SYMPTOMS
• NARROW SPECTRUM OF ANTIBIOTICS SHOULD BE USED (TO DECREASE THE RISK OF COLONIZATION)
• NEGATIVE CULTURES
 DANGERS OF INDISCRIMINATE USE

• WIDESPREAD SENSITIZATION OF POPULACE

• CHANGES OF NORMAL FLORA OF BODY --> OVERGROWTH OF RESISTANT ORGANISMS
• MASKING SERIOUS INFECTION WITHOUT ERADICATING IT (E.G. ABSCESS)
• DIRECT DRUG TOXICITY
• DEVELOPMENT OF DRUG RESISTANCE
• ALTERATION OF INDIVIDUAL AND HOSPITAL BACTERIAL ECOLOGY
• POSSIBILITY OF ANTAGONISM (IE. PENICILLIN AND TETRACYCLIN)
• HIGHER COST OF TREATMENT
• FALSE SENSE OF SECURITY
TOXICITY OF COMMONLY USED ANTIBIOTICS

DRUGS COMMON OCCASIONAL

PENICILLIN ALLERGIC ANAPHYLAXIS
REACTION/DIARRHEA
CEPHALOSPORINS THROMBOPHLEBITIS/GI
AMINOGLYCOSIDES NEPHRO/OTOTOXICITY
ERYTHROMYCIN GI IRRITATION/STOMATITIS
CLINDAMYCIN DIARRHEA/RASH
LEVOFLOXACIN HEADACHE, DIZZINESS OR NEPHROTOXICITY,
LIGHTHEADEDNESS PHOTOTOXICITY
CONCLUSION

• SIGNIFICANT CURRENT ACHIEVEMENTS IN MEDICINE ARE ATTRIBUTED TO

GOOD USE OF ANTIBIOTICS
• SOUND KNOWLEDGE AND APPLICATION OF PRINCIPLE OF ANTIBIOTIC USE WILL
PREVENT DANGERS ASSOCIATED WITH INDISCRIMINATE USE OF ANTIBIOTICS
REFERENCES

• RICHARD A.H, PAMELA C.C: ILLUSTRATED REVIEWS OF PHARMACOLOGY, 2ND EDITION.

• LIPPINCOTT'S 2002
• BERTRAM G. KATZUNG: BASIC AND CLINICAL PHARMACOLOGY, GTH EDITION. LANGE MEDICAL BOOKS 2002.
• AL-FALLOUJI M. A: POST GRADUATE SURGERY, AND EDITION, READ PUBLISHING LTD. 1998
• VANDERPUYE V. IN PRINCIPLE AND PRACTICE OF MEDICINE OF SURGERY INCLUDING PATHOLOGY IN THE
TROPICS, 4TH EDITION 2010.
• SALMON S. E & SARTOLLI A. C, CANCER CHEMOTHERAPY IN BASIC AND CLINICAL PHARMACOLOGY, LANGE
1998. P881-911
• HOSPITAL INFECTION CONTROL POLICY, NHS TRUST DECUMENT NO- HIC 1
• ANTIBACTERIAL, WWW.WILKIPEDIA.COM 2010