Antibiotic Therapy in Surgical

Practice
Chairpersons:
Prof. U. Bhattacharjee
Dr. D.B.Chowdhury
Speaker:
Parvej Sultan

History
1862

1865
1866
1928
Today

Pasteur
Lister
Semmelweiss
Alexandar Fleming
? Postantibiotic era

<2 %

Classification of Surgical wounds

Category
Clean

Criteria

Infection
Rate(%)

No hollow viscus entered;

No breaks in aseptic
technique

1-3

Hollow viscus entered but

Cleancontaminat controlled; Minor breaks in
ed

5-8

Contaminat Uncontrolled spillage from

viscus; Open traumatic
ed

20-25

aseptic
technique

wound

Before using an antibiotic ask the

following
Is it for treatment or prophylaxis?
What is the likely pathogen
(spectrum)?
What is the site AB are required to
reach?
Route of administration?
Resistance?
Any Allergies?
Is the patient
Immunocompromised?

Classes of
Antibiotics

Target Sites

Staphylococcus

Streptococcus

Gram negatives

Anaerobes

Beta lactams
All have a Beta lactam ring as a basic structure
Penicillins
Benzyl Penicillin..Staph/Streps
FlucloxcacillinStaph
Co-amoxiclav Staph/Strep
Piperacillin Psuedomonas

Cephalosporins
10% Cross sensitivity in patients with penicillin
allergy
4 generations with Increased G-ve & decreased G+ve
in fourth generation.

Carbapenenms
Truly broad spectrum ( Gm negative, positive and
anaerobes)
May provoke seizures
May promote highly resistant organisms

Aminoglycoside
s
Active against Staph.aureus and aerobic
Gm-ve
Narrow theraputic ratio ( easily toxic)
Monitor renal function and oto-toxicity
Examples:
Gentamicin
Tobramycin
Amikacin

Macrolides &
Quinolones
Macrolidess e.g. erythromycin,
clarithromycin
An alternative in penicillin sensitivity
New generations have improved
bioavailability, better oral absorption and
fewer GI side effects.

Quinolones e.g. Ciprofloxacin

Good tissue penetration
Gram negative activity
Attains good levels on oral intake.

The Use of
Antibiotics

Prophylaxis

1. When anatomical barriers are

breached leading to
contamination: faeces, bile..etc.
2. When the consequence and risks
are unacceptably high
3. In traumatic wounds
4. In immunocompromised

The Use of
Antibiotics

Therapeutic
1. Empirical therapy
The likely organism & antibiotic
susceptibility
Avoid using a single agent
Avoid using agents with
inadequate cover
Avoid AB with serious side effects.

Drug
administration
1. Route

Intravenous if:
Patient is seriously ill with inconsistent
intestinal absorption or inability to oral
medication.
IV ensures rapid adequate serum levels.
Be aware of therapeutic window.
Oral step down if :
Oral intake is tolerated,
Good absorption,
No unexplained tachycardia,
No need for high tissue concentrations
suitable oral prep. available

 Treatment failure:

Wrong AB/ Wrong dosing

Other causes of infection
Fungal superinfection
Inappropriate administration
Persistent source of infection

Principles of Antibiotics
Prophylaxis
Appropriate narrow spectrum of
coverage.
Safety.
Monotherapy
Administration within 1 hour prior
to incision.

Repeat dose of prophylactic antibiotic

Prolonged operations
Excessive blood loss
Unexpected contamination occurs
Repeated every 3-4 hours

Antimicrobial Prophylaxis for surgery

Nature of
Operation

Routine
antibiotic

General
surgery/
endocrine
Hepatobiliary

Cefazolin

Cholecystecto
my
(High risk only)
Appendicecto
my
Cardiovascular
and Thoracic

Cefazolin

Cefazolin

2nd gen.
Cephalosporin
Cefazolin/
Cefuroxime

Penicillin or
Cephalosporin
allergy
Clindamycin

Gentamicin and
Metronidazole
Gentamicin

Metronidazole plus
Gentamicin
Vancomycin

Factors Influencing Antibiotic Choice

Activity

against

known/

suspected

pathogens
Disease believed responsible
Antimicrobial resistance patterns
Patient-specific factors
Institutional guidelines/restrictions

Antibacterial Agents for Empirical Use

Antipseudomonal
Piperacillin-Tazobactum, Cefepime,
Ceftazidime

Gram-positive
Glycopeptide( Vancomycin, Televancin)
Oxizolidinone( Linezolid )

Gram-negative
Ceftriaxone)
polymixin B)

Third-generation Cephalosporins( not

Monobactum, Polymixins(Colistin,

Antianaerobic
Metronidazole

Anti-MRSA
Vancomycin, Linezolid, Tigecycline,Telavancin

Important Pathogens for critically Ill patients

Vancomycin -resistant Enterococci

Daptomycin, Linezolid,
Quinupristin-dalfopristin, Tigecycline
MRSA
Linezolid, Vancomycin, Q-D,
Pseudomonas aeruginosa
Meropenem, Doripenem, Imipenem-cilastin
Multidrug-Resistant Enterobactericeae

including Klebsiella species

Carbapenems, Tigecyclin

Antibiotic Toxicities
Beta-Lactum allergy

Most common toxicity

Incidence 7 to 40/1000 treatment course
Cross reactivity between Penicillin,
Cephalosporin
and carbapenem
Red Man Syndrome
With rapid Vancomycin infusion
Tingling and flushing of head, neck or thorax

Antibiotic Toxicities
Nephrotoxicity

Amynoglycosides,

Vancomycin
Polymixin
Ototoxicity
Amynoglycosides
Vancomycin

Antibiotics requiring dosage reduction

for Hepatic and Renal insufficiency:
Hepatic
Cefoperazone
Clindamycin
Rifampicin
Isoniazid
Linezolid
Erythromycin
Tigecycline

Antibiotics requiring dosage reduction

for Hepatic and Renal insufficiency:
Renal
Aminoglycosides
Vancomycin
Fluoroquinolones
Cephalosporins(most)
Carbapenem
Penicillins

Antibiotics in surgical practice are only

an adjunct to treating surgical infection

Thank You