Antibiotics in

Surgical Practice
Department of Surgery, UHWI
Introduction
 Antibiotic use may be
prophylactic or therapeutic
 Must decide which use is
appropriate
 The decision to use and how is the
surgeon’s responsibility
 Antibiotic use is often unscientific
and haphazard
 This will encourage resistance and
negatively influence outcomes
Factors Influencing Antibiotic
Use In Surgical Patients
 Pre Operative Factors:
 Intercurrent diseases (DM, AIDS,
Prostheses)
 Wound Factors (soilage, location)

 Operative Factors
 Duration,Location, Contamination,
Instrumentation
 Post Operative Factors
Pre Operative Factors
 Patient Parameters: Age
Extremes, DM, AIDS, Steroids
 Wound Parameters: Skin prep,
wound soilage, devitalization,
wound size and location
 Surgeon/Op Theatre Parameters:
Theatre protocol, surgeon
preference
Principles of Wound
Infection Prophylaxis-(1)
 Select effective AB for likely
pathogens
 Single agent almost always
effective
 1/2-life must be enough to maintain
levels throughout operation
 First dose not more than 2 hrs
before skin incision, preferably
immediately before incision
Principles of Wound
Infection Prophylaxis-(2)
 Give second dose if procedure
>3hrs or 2x 1/2-life of AB
 Post-op doses generally
uneccessary beyond 24 hr
 If it is felt that AB required beyond
24 hours then give a full
therapeutic course, to discourage
development of resistant
organisms
Intra Operative Factors
 Meticulous Operative Technique
 Duration
 Haemostasis/perfusion
 Spaces
 Tissue Handling
 Cautery use

 Use of implantable prostheses or

devices
Procedure Classification
 Clean
 Clean-Contaminated
 Contaminated
 Dirty/Infected
Clean Case
 Nontraumatic
 No inflammation encountered
 No break in technique
 Resp, GI, GU tracts not entered
 NO NEED FOR PROPHYLACTIC
ANTIBIOTICS unless:
 indwelling
catheter(dialysis or TPN)
 OHS, Vasc.Graft, Ortho
 3 concomitant diag, OP>2hr,
abdominal OP
Clean-Contaminated Case
 GI or Resp tracts entered w/o
significant spillage
 Appendicectomy
 Oropharynx entered
 Vagina entered
 GU entered w/o infected urine
 Biliary tract entered w/o infected
bile
 Minor break in technique
Clean-Contaminated Case,
cont’d
 All such cases should receive
prophylactic broad spectrum
antibiotics (anticipate
contamination)
 IV cephalosporin at induction of
anaesthesia
 IV vancomycin if methicillin-
resistant organisms common
Contaminated Case
 Major break in technique
 Gross GI tract spillage
 Traumatic wound
 GU or Biliary tract entrance in
presence of infected urine/bile

 THERAPEUTIC COURSE OF
APPROPRIATE ANTIBIOTIC
USUALLY REQUIRED
Dirty or Infected Case
 Acute bacterial inflammation w/o
pus
 Transection of clean tissue to allow
access to collection of pus
 Traumatic wound with devitalized
tissue, FB, Faeces
 Fresh wound caused by dirty
source
 Delayed treatment of traumatic
wound
Dirty or Infected Case,
con’td

 Always require
THERAPEUTIC
COURSE OF
ANTIBIOTICS
Special Cases-(1)
 Endocarditis Prevention
 Valvular Heart Disease
 VSD
 PDA
 Prostheses
 Cardiac

 Vascular

 Bowel Preparation
 Neomycin
Special Cases-(2)
 Superficial Abcess
 Non-diabetic or
immunosuppressed patient
 Non-vital location
 No prostheses

 NO NEED FOR ANTIBIOTICS

Special Cases-(3)
 Superficial Abcesses
 Diabetic or Immunosuppressed
 Extremes of Age
 Vital area
 Genitalia

 Hands

 Face/Scalp

 THERAPEUTIC ANTIBIOTICS
REQUIRED
Summary
 Antibiotics used judiciously can
improve outcomes
 Use/abuse of antibiotics is
surgeon’s responsibility