Rational use of

antibiotics

January 24, 2023

Dr. Tesfaye, MD, General Surgeon
 Why?

• Drug resistance
• Wastage
• Cost
• Side effects

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 Mechanisms of resistance

 Enzymatic
 Decreased permeability
 Efflux
 Alteration of target cells
 Bind up of antibiotics

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 Factors for selection

• Site of infection
• Bactericidal /static
• Route of administration
• Dosing and tissue levels
• True presence of infection (Topical)
• Co-morbid conditions
• Resistance potential

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 Ideal antibiotics

• Selective toxicity
• Soluble in tissue fluids
• Metabolized slowly
• Less side effect
• Less influence on normal flora of the host
• Less risk of drug resistance
• Low cost
• Good shelf life
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 Causes of non-response

• Resistance
• Incorrect diagnosis
• Choice of antibiotics (Type, Dose, Route)
• Abscess
• Secondary infection

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 Best practices

• Urgent treatment (ICU, Sepsis, meningitis)

• Proper interpretation of antibiotic sensitivities
• Hospital infection control
• Multidisciplinary meetings
• Public health

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 Purpose

 Antibiotics have two uses in surgery:

• To treat established infection
• To prevent postoperative infection
 Less important than:
• Careful aseptic theatre routines
• A thorough wound toilet
• Delayed primary closure
• Making sure there are no foreign bodies, dead tissue, excessive blood
clots, or faeces in the wound
 Antibiotics give you no licence to neglect the classical rules of good
surgery
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• Prophylactic antibiotics- given for the purpose of preventing
infection when infection is not present but the risk of
postoperative infection is present

• Empirical antibiotic therapy — which is aimed at the likely

causative organism to manage an infection until
microbiological culture and susceptibility results are known

• Directed therapy - When the cause of an infection is

confirmed and is aimed at the specific pathogen.
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 Prophylactic Antibiotics

• The aim of prophylaxis is to augment host defense

mechanisms at the time of bacterial invasion.
• Prevention of possible infections
• Prophylaxis is an attempt to attack organisms before they
have a chance to induce infection.
• Decreases bacterial counts at surgical site during incision
• Achieve serum and tissue drug levels, for the duration of
the operation
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 Basic principles

• Single dose
• Maximum serum level during procedure
• Usually at the time of incision
• Narrow spectrum

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 Choosing an antibiotic for prophylaxis

• It is multi-factorial
• Should be based on the
• Type of operation
• Kinetics and toxicity of the drugs
• Microbiologic characteristics of the operative site
• Antibiotic sensitivities specific to the particular hospital
environment

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 Indications

• Clean cases
- Open heart surgery
- Vascular surgery
- Prosthesis and implants
• Clean contaminated
- Obstructive jaundice
- Head and neck, esophagus
- Gynecologic
• Contaminated
- Abdominal
- Trauma

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 Timing of Administration

• Infusion of cephalosporin and Clindamycin should begin

within 60 minutes before incision, and be completed at the time
of incision
• Infusion of vancomycin should begin 2 hours before incision and
should be completed at the time of incision
• Administration of the antimicrobial at the time of anesthesia
induction is safe
• This results in adequate tissue drug levels at the time of incision
• Ideally it should be given within 30 minutes
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Repeat dosing (Intraoperative Re dosing)

 In the vast majority of cases only a single dose of antibiotic is

required

 For procedures lasting more than four hours .

 In the setting of major blood loss(20-25ml/kg)

 Is indicated every one to two half-lives of the drug in patients with

normal renal function.

 Repeat antimicrobial dosing following wound closure

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25,not
2023 16
necessary and may increase antimicrobial resistance.
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 Duration of prophylactic Antibiotic Use

 Antimicrobial prophylaxis after wound closure does not provide

additional protection from SSI

 Continuing prophylactic antibiotics for the duration drains and catheters

are in place has not been shown to reduce SSI rates

 Continuing antibiotic prophylaxis longer than 24 hours after wound

closure is not beneficial and may contribute to the development of
antimicrobial resistance

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 Principles of Antibiotic Prophylaxis

Pre op administration, serum levels adequate

throughout procedure with a drug active
against expected microorganisms.

High Serum Levels During Procedure Duration

1. Preop timing 1. Long half-life 1. None after wound closed
2. IV route 2. Long procedure– 2. 24 hours maximum
3. Highest dose redose
of drug 3. Large blood loss–
redose

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Recommendations
•2nd or 3rd gen. Cephalosporins are preferred
•We can add metronidazole in colonic surgeries
•True beta-lactam allergy: Clindamycin or vancomycin
•Current or prior MRSA infection, MRSA colonization:
vancomycin

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 Empiric therapy

 Used when the risk of a surgical infection is high, based on

• The underlying disease process (e.g., ruptured appendicitis) or
• Intraoperative findings.
 Significant contamination during surgery has occurred
• Inadequate bowel preparation
• Considerable spillage of colon contents.
 In critically ill patients in whom a potential site of infection has been identified
 Severe sepsis or septic shock occurs.
 Should be limited to a short course of drug (3 to 5 days),

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 Monomicrobial infection

• Frequently are nosocomial infections occurring in postoperative patients, such as

UTIs, pneumonia, or bacteremia.
• Appropriate collection of culture specimens to allow for thorough analysis
• Initiate empirical antibiotic therapy which is Broad spectrum as early as possible.
• Delay in appropriate antibiotic treatment increases the mortality.
• Initial drug selection must be based on initial evidence, coupled with institutional
and unit-specific drug sensitivity patterns
• Later narrowing of agents based on patient response and culture and sensitivity
results.

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 Polymicrobial surgical
infections

 Culture results are of lesser importance in managing these types

of infections as it is less important than the clinical course of the
patient.
 The antibiotic regimen should not be modified solely on the
basis of culture information,
 Should receive an antimicrobial agent or agents directed against
aerobes and anaerobes for 3 to 5 days, occasionally longer.
 Conversion from an intravenous to an oral regimen (e.g.,
ciprofloxacin plus metronidazole) can occur.

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 Duration of antibiotic administration

• Prophylaxis is limited to a single dose

• Empiric therapy should be limited to 3 to 5 days or less,
• For UTI -3 to 5 days
• For pneumonia 7 to 10 days,
• For bacteremia 7 to 14 days.
• Osteomyelitis, endocarditis, or prosthetic infections for 6 to 12
weeks.

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Misuse of antimicrobial agents can result

• Enormous financial impact on health care costs

• Adverse reactions due to drug toxicity and allergy
• The occurrence of new infections such as Clostridium difficile colitis
• The development of multiagent drug resistance among nosocomial
pathogens.

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 References

• Schwartz's Principles of Surgery, 10th ed.

• Sabiston text book of surgery, 20th ed.
• Campbelle’s orthopedics 11th ed
• Goodman & gilman’s manual of pharmacology and
therapeutics
• Uptodate 21.6
• Internet

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 Thank you !!!

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