SURGICAL

ANTIBIOTIC
PREPARED BY :
ZHARIF
NABILAH
 WHAT IS ANTIBIOTIC?
Any substance that
inhibits the growth and replication of a bacterium or
kills it outright can be called an antibiotic.

Antibiotics are a type of antimicrobial designed to

target bacterial infections within (or on) the body.
 HOW DO ANTIBIOTICS WORK?

• Some are highly specialised and are only effective against certain
bacteria. Others, known as broad-spectrum antibiotics, attack a wide
range of bacteria, including ones that are beneficial to us.

• There are two main ways in which antibiotics target bacteria. They
either prevent the reproduction of bacteria, or they kill the bacteria,
for example by stopping the mechanism responsible for building their
cell walls.
 Classification of antibiotics
On the On the
basis of On the On the basis
basis of of spectrum basis of
chemical of activity mode of
structure origin
action

On the basis of On the basis

route of of effects of
administration their activity
A] Classification of antibiotics on the basis of chemical structure:

1. Carbohydrate containing Antibiotics

2. Pure saccharides antibiotics: examples; Streptozotocin
3. Aminoglycosides: examples; Streptomycin
4. N/O glycosides: eg. Chromomycin
5. Other: eg; Lincomycin
6. Macrocyclic lactone antibiotics: eg. Erythromycin
7. Quinolones antibiotics; eg. Fluroquinolone
8. N-containing heterocyclic antibiotics: eg. Beta-lactum
9. O-containing heterocyclic antibiotics: eg. Cycloserine
10. Alicyclic antibiotics: eg. Cycloheximide
11. Aromatic antibiotics (Nitrobenzene): eg. Chloramphenicol
12. Aliphatic amine antibiotics: eg. Spermidine
13. Peptide antibiotics: eg. Polymyxin, Bacitracin, Gramicidin
B] Classification of antibiotics on the basis of origin:
1.Microbial origin:
i. Bacterial origin:
• Bacillus polymyxa: Polymyxin
• Chromobacter violaceum: Bacitracin
• Micromonospora spp: Gentamycin
ii. Fungal origin:
• Penicillium notatum: Penicillin
• Cephalosporin spp: Cephalosporin
iii. Actimomycetes origin:
• Streptomyces griseus: Streptomycin
• S. venezuelue: Chloramphenicol
• S. erythreus: Erythromycin
• S. mediterranae: Rifampicin

2. Semi-synthetic antibiotics:
• Examples: Amoxycillin, Ampicillin, Doxycycline, Tigecycline, Sulfonamide etc
3. Synthetic antibiotics:
• Examples: Chloramphenicol, 4-quinolones, Sulfonamide
C] Classification of antibiotics on the basis of spectrum of activity:
1.Narrow spectrum:
• Active towards relatively fewer microorganisms.
• Examples: macrolides, Polymyxin
2. Moderate spectrum:
• Active towards Gram Positive bacteria as well as some systemic and UTI causing Gram
negative bacteria.
• Examples: Aminoglycosides, Sulfonamide
3. Narrow-Broad spectrum:
• Active against Gram positive and gram negative
• Examples: Beta-lactum
4. Broad spectrum:
• Active against Gram positive and Gram negative except Pseudomonas and Mycobacteria.
• Examples: Chloramphenicol, Tetracycline
5. Anti-mycobacterial antibiotics:
• Examples: Ethambutol, Rifampicin, Isoniazid, Pyrazinamid
D] Classification of antibiotics on
the basis of Mode of action:
3. Inhibitor of Nucleic acid synthesis:
1. Inhibitor of cell wall synthesis/ Peptidoglycan • Quinolones
Inhibitor
• Ciprofloxacin
• Beta-lactum; Penicillin
• Nalidixic acid
• Bacitracin
• Cycloserine • Metronidazole
• Phosphomycin • Nitrofurantoin
• Cephalosporin
• Vancomycin 4. Inhibitor of folic acid synthesis (Folate
antagonistic)
2. Inhibitor of protein synthesis: • Sulfonamide
• Streptomycin
• Trimethoprim
• Aminoglycosides
• Fusidic acid
• Tetracycline 5. Inhibitor of cytoplasmic membrane
• Mupirocin • Polymyxin; Colistin
• Chloramphenicol
E] Classification of antibiotics on the basis of effects of
their activity:

1. Bactericidal:
• Kills bacteria
• Examples: Aminoglycosides, Penicillin, Cephalosporin

2. Bacteriostatic:
• Inhibits the growth of bacteria
• Examples: Sulfonamide, tetracycline, chloramphenicol, trimethoprim,
macrolides, Lincosamide
F] Classification of antibiotics on the basis of Route of
administration:

1. Oral antibiotics:
• Acid stable antibiotics,
• Examples; Penicillin V

2. Parenteral route:
• Intravenous administration
• Examples; Penicillin G
• Does choosing the correct antibiotic make a difference?
Patients who receive inappropriate antibiotic therapy are more likely
to experience complications or stay longer in hospital.
Among surgical patients with peritonitis, reoperation, abscess
formation and further infection were two to three times more likely in
those who received inappropriate therapy if one or more of the
pathogens was resistant, compared to those who received
appropriate therapy which was active against the infecting species.

Inappropriate initial antibiotic therapy is also independently

associated with increased mortality.
Q. How do I choose the correct antibiotic?

• The correct antibiotic :

- CORRECT ROUTE
- CORRECT INFECTION
- CORRECT LENGTH OF TIME . This ensures that antibiotic concentrations at the
site of infection are optimal and that the pathogen is eradicated.
- SIDE EFFECT ARE AVOIDED
- COST ARE MINIMIZED
Before starting: must distinguish between antibiotic use for
PROPHYLAXIS and for THERAPEUTIC indications

• The need for therapy should be firmly established : based on the

clinical picture, imaging and inflammatory markers (e.g. leukocyte
count, C-reactive protein, procalcitonin).
• In either case, appropriate specimens must be taken (e.g. blood
culture, sputum, urine, wound swabs, stool) before antibiotics are
started because these cultures may be negative if taken afterwards
THERAPEUTIC USE OF ANTIBIOTIC IN
SUGERY

DEFINITIVE /
EMPIRICAL
TARGETED

Started before Causative organism

definitive and its sensitivities
identification of a have been
causative organism identified
 EMPIRICAL THERAPY
• Having identified a likely focus (e.g. postoperative pneumonia,
surgical-site infection), an appropriate empirical regimen relies on :
- knowledge of the range of organisms likely to be implicated
- local susceptibility patterns

• Usually, empirical regimens give broad-spectrum Gram-positive,

Gram-negative and anaerobic cover
• Other factors must be considered when choosing a regimen

1. Are recent or relevant microbiology results already available?

2. Does the patient have a history of antibiotic-resistant organisms?
3. What other antibiotics has the patient had recently?
4. Where has the patient been admitted from, for how long has he
been an inpatient and what kind of ward is he on
5. Are there abnormalities of renal or liver function and is the patient
allergic to any classes of antibiotic?
Route of administration: IV or oral?

- It is common practice to treat life-threatening infections with parenteral

antimicrobials because delivery to tissues is guaranteed.
- However, oral treatment is usually adequate for less serious infections if
absorption is unimpaired.
- Quinolones, fusidic acid, linezolid, clindamycin and metronidazole have
good oral bioavailability
Q. When to switch from intravenous to oral antibiotics?
- A switch to oral treatment is often appropriate after 48 hours of intravenous therapy, but
depends on the individual and upon local policy.
- The criteria for switching to oral therapy usually includes:
• clinical response
• defervescence
• improvement in inflammatory markers
• absence of comorbidity or immunosuppression that would necessitate intravenous treatment
• absence of gastrointestinal problems causing reduced absorption.

- This allows parenteral antibiotics to be limited to the early phase of treatment, with therapy
completed via the oral route.
- Advantages :
• earlier discharge from hospital
• reduced risk of hospital-acquired infections at cannula-site
• reduced cost.
• Escalation and de-escalation of antibiotic should be done based on
clinical response and aided by C+S result.

• After an initial, appropriate broad-spectrum antibiotic regimen is

prescribed, modification of the regimen with a de-escalation strategy
should occur on the basis of the patient's clinical response and the
results of microbiological testing.
• On the basis of the de-escalation strategy, modification of the initial
antibiotic regimen should include:
(1) decreasing the number and/or spectrum of antibiotics, possibly based on
culture and sensitivity results
(2) shortening the duration of therapy in patients with uncomplicated infections
who are demonstrating signs of clinical improvement
(3) discontinuing antibiotics in patients who have a noninfectious etiology identified
for the patient's signs and symptoms
• Duration of treatment
- Important in order to gain maximum treatment benefit while minimizing
the development of resistance and other adverse effects
- Antibiotics should be given for the shortest duration possible

- A review or stop date should be clearly stated on the prescription chart,

preferably with the need for continued antimicrobial therapy being
reviewed daily
- Negative microbiology results of specimens taken before starting
antibiotics may be reassuring when making a decision to stop treatment.
 PROPHYLACTIC USE OF
ANTIBIOTICS IN SURGERY
- Prophylactic antibiotics are given preoperatively to prevent(not treat) surgical site
infection
- They act in tandem with host immune response and at best, reduce, but cannot
eliminate the risk of sepsis.
- The main factor in deciding the use of prophylactic is : the risk that SSI will occur.
- This depend on:
• Likelihood of contamination
• The type of contaminating bacteria
• Number of host factors
 CLASSIFICATION OF WOUND
TYPE OF CRITERIA EXAMPLE RISK OF INDICATION FOR
WOUND INFECTION SURGICAL
ANTIBIOTIC
PROPHYLAXIS

CLEAN - Uninfected, no inflammation Ex lap, 1-3% Not recommended

- Resp, GI, GU tracts not entered mastectomy,
- Closed primarily neck dissection,
thyroid, vascular,
hernia,
splenectomy

CLEAN- - Resp, GI, GU tracts entered, Chole, SBR, 5-8% Recommended

CONTAMINATED controlled Whipple, liver txp,
- No unusual contamination gastric surgery,
bronch, colon
surgery
 TYPE OF CRITERIA EXAMPLE RISK OF INDICATION FOR
WOUND INFECTION SURGICAL
ANTIBIOTIC
PROPHYLAXIS
CONTAMINATED Open, fresh, accidental wounds Inflamed appy, bile 20-25% Recommended
- Major break in sterile technique spillage in chole,
- Gross Spillage from GI tract diverticulitis,
- Acute nonpurulent inflammation Rectal surgery,
penetrating
wounds

DIRTY - Old traumatic wounds, Abscess I&D, 30-40% Strongly

devitalized tissue perforated bowel, recommended
- Existing infection or perforation peritonitis, wound
- Organisms present BEFORE debridement,
procedure positive cultures
pre-op
• Contaminated and dirty categories require therapeutic antibiotic while
prophylaxis is given for clean contaminated and some clean surgery.
• Prophylaxis is particularly important if prosthetic materials are implanted.
• Antibiotic prophylaxis is recommended if it is likely to result in a reduction
of major morbidity, overall consumption of antibiotic, and hospital cost.

• During clean procedures, skin flora such as coagulase-negative

staphylococci (e.g., Staphylococcus epidermidis) or Staphylococcus aureus
are predominant pathogens in surgical site infections.

• In clean-contaminated procedures, the most commonly found organisms

causing surgical site infections are skin flora, gram-negative rods, and
Enterococci.
Types of incisional infections

• Superficial; Manifest within 30 days of surgery Infection is localized to superficial tissue.

 Criteria:
1. Purulent discharge
2. Pathogens cultured from affected tissue or wound exudate
3. Signs and symptoms of infection (pain, swelling, erythema, fever
• Deep; Manifest within 30 days of surgery without implant or up to one year with an implant
involving deep tissue associated with surgery. At least one of the following
 Criteria:
1. Purulent discharge
2. Spontaneous dehiscence of a deep incision or one deliberately opened when the patient
exhibits fever (>38oC)
3. Painful abscess or other evidence of infection
• Organ/space; Manifest within 30 days of surgery without implant or
up to one year with an implant.Infection appears to be related to
surgery and affects the part of the anatomy opened during surgery
(but not the incision)
 Criteria:
1. Purulent drainage from a drain inserted into the organ/space
2. Pathogens cultured from affected tissue or fluid
3. Abscess or other evidence of infection on inspection.
Infections of skin and soft tissue
• Minor skin infections:
Surgery is rarely indicated for small boils and carbuncles, EXCEPT in the
presence of lymphangitis, lymphadenitis and systemic infection (bacteraemia,
septicaemia).Occasionally may present as large collections of pus (e.g. in the
breast or axilla) requiring surgical drainage. Staphylococcus aureus is the
principal organism causing suppuration and recurrent abscesses can occur even
if antibiotics are used. Recurrence often relates to an underlying disease
process (e.g. hydradenitis suppurativa) which may involve anaerobes (e.g.
Bacteroides spp., coagulase-negative staphylococci, coliforms). There may be
an underlying systemic metabolic disease, which must be excluded. Severe
infections can also develop if bacteria gain access to normally sterile parts of
the body (e.g. from minor traumatic events, during dental hygiene).
• Leg, foot and pressure ulcers;
Support mixed bacterial communities that can include large numbers of
staphylococci, streptococci, pseudomonads, coliforms and anaerobes. Treatment
prioritize the amelioration of underlying conditions (e.g. ischaemia caused by
vascular diseases, diabetes, friction and unrelieved pressure). β-haemolytic
streptococci, pseudomonads or other pathogens must be eliminated (using topical
antimicrobial agents before surgery) if skin grafting or flap closure is considered.
Systemic antibiotics are reserved for evidence of invasive infection and if a harmful
pathogen (e.g. Streptococcus pyogenes) is present. Changes in social and
recreational activities (e.g. drug abuse, body piercing, tattooing, exotic travel,
sporting activities, AIDS) raise the possibility of infected wounds with unexpected
flora, so the unusual pathogen must be considered if patients do not respond to
conventional therapy.
• Cellulitis:
Rapid spread of infection from localized cellulitis via lymph nodes to the
blood stream is life threatening.
Characterstic symptoms; Generalized erythema, increased oedema,
bullae and lymphangitis systemic signs of fever with rigors and
confusion suggest bacteraemia and septicaemia. Successful
management of cellulitis relies on early diagnosis and antibiotics.
Common causative agents are Streptococcus pyogenes, Staphylococcus
aureus, Pseudomonas aeruginosa; Gram-negative enteric bacteria are
less commonly associated with cellulitis.
 Necrotizing fasciitis
• Rare, life-threatening infection that presents challenges to diagnosis
and treatment because early recognition is difficult. Synonyms include
Fournier’s gangrene, Meleney’s synergistic gangrene, phagedena
gangrenosum, and haemolytic streptococcal gangrene. The lower
limbs are the most commonly affected, with patients exhibiting
exquisite pain, swelling and fever on hospital admission. Tenderness,
erythema and warm skin are the early signs; small bullae develop as
the infection progresses and bullae with serous fluid are
characteristic. Late signs are large haemorrhagic bullae, necrosis,
fluctuance and crepitus (gas in the tissues is not exclusive to
clostridial gas gangrene.
Why so dangerous??!!!
• Extensive destruction of subcutaneous tissue with bacteraemia, septic
shock, multiple-organ failure and death may soon follow. Bacterial
toxins and surface superantigens cause recruitment of T- cells to the
infected tissue, which in turn secrete proinflammatory cytokines that
activate effector cells to elicit systemic inflammation and massive
tissue damage.
Q. WHICH ANTIBIOTICS?
- Most SSI are caused by contamination with the endogenous flora of the
patient.
- Antibiotic are chosen to cover likely contaminating flora to the surgical site
(e.g coliform and anaerobe from intestinal lumen and colorectal surgery) but
to be as narrow as possible to minimize disturbance of the normal flora.
- Staphylococcus alone account for about 40% of SSI, so it should always be
covered.
- The choosen antibiotic must reach tissue levels at the site of surgery that are
active against contaminating species and toxicity should be minimal.
ALLERGY ?

- It is essential to exclude history of allergic reaction or related antibiotic which

would prohibit its use.
- The most encountered allergy is to penicillin.
- Approximately 3-9% of individualwho are allergic to penicillin are also allergic
to cephalosporin, so the latter should be avoided if thre is history of severe
reaction to penicillin.
ROUTE OF ADMINISTRATION

- In general, prophylactic antibiotic are given by IV route to ensure reliable

concentration in serum and tissue. Except :
• Topical antibiotic in ophthalmology
• Oral antibiotic for gut decontamination
• Antibiotic impregnated prosthetic material
- The IM, or rectal or ral route can be used if IV access is not available but
differences in pharmacokinetic must be considered.
Q. Timing prophylaxis. When should we give ad for how long?
- Serum and issue concentration of antibiotic should be therapeutic at the
time of incision.
- In order to achieve this, administration should be between 30 min to one
hour (no longer than 2 hours) before incision and usually at the induction of
anesthesia.
- If a patient is already receiving an antibiotic for another infection before
surgery, and it is appropriate for surgical prophylaxis, an extra dose of the
antibiotic can be administered within 60 minutes of the incision.
- Watchout for any contraindication or allergy
- One dose regime. The duration of an adequate tissue level of the antibiotic
need not exceed the operative period. The duration of administration is
extended only in special circumstances, such as gross contamination
secondary to a ruptured viscus or severe trauma.
• SPECIAL CONSIDERATION
- For pregnant women or patient with renal impairment or liver impairment,
myasthenia gravis, or acute porphyria. These patient may require alternative
antibiotics or regimen or dosage reduction.
- Example : Aminoglycoside and quinolone can exacerbate myasthenia gravis,
flucloxacillin associated with porphyric crises
- Post splenectomy : more susceptible to infection caused by encapsulated
bacteria ( strept. Pneumoniae, hemophilus influenza, nisseria meningitis ) –
lifelong prophylaxis against strep pneumonia with penicillin, or if allergic with
erythromycin. Immunization against pneumococcus or hemophilus influenza
and meningococcus. Annual immunization against influenza should be
advised.
 TYPE OF
Superficial Incisional SSI
SURGICAL
Deep Incisional SSI
1. Skin or subcutaneous tissue is
involved
2. Occurs within 30/7 postop
3. and fulfill one of the following
criteria:
- purulent drainage from incision with
or without diagnostic laboratory
testing (culture)
- isolated organisms from aseptically
obtained fluid or tissue C+S
- at least one sign or symptom of
clinical infection: localized pain,
edema, erythema, warmth and the
superficial incision is deliberately
opened by a surgeon (unless culture
of incision is negative)
SITE
INFECTION
Organ/Space SSI
1. Deep soft tissues (fascia/muscle)
2. Occurs within 30/7 postop without
implant, occurs within 1 year if
implant is in place and infection
appears to be directly related to
surgical procedure
3. and fulfill one of the following
criteria:
- purulent drainage from incision but placed via stab incision into the
not from the organ/space of the site
dehiscence
- deliberate opening by the surgeon
from the deep incision when patient
has at least one of the following sign organ/space
& sx of clinical infection
- abscess /evidence of infection is
found during WI, reoperation, or
pathologic or radiologic exam
1. Involves any part of the anatomy
other than the incision
2. Occurs within 30/7 postop
without implant, occurs within 1
year if implant is in place
3. and must fulfill one of the
following:
- purulence from a drain that was
organ/space (infection of drain site is
not an SSI)
- isolated organisms from aseptically
obtained fluid or tissue from the
- abscess/evidence of infection is
found
• Antibiotics form only one part of the treatment of surgical infection;
collections must be drained and free drainage restored because the
penetration of antibiotics into enclosed spaces is poor and pus may render
the agent inactive.
• Foreign bodies reduce the effectiveness of antibiotics and should be
removed wherever possible, particularly if the clinical response is poor.
• This also applies to intravascular devices and blood cultures from the
individual lumina of a long catheter (as well as peripheral blood) should be
taken as part of the investigation of fever in a surgical patient.
• Whilst some line infections can be managed with the catheter in situ, others,
such as Staphylococcus aureus and Candida spp., nearly always mandate
catheter removal
• *OGFDUJPODPOUSPM
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 Antimicrobial Resistance
• Antibiotic resistance has raged on with relentless speed so much so that
in 2011, the World Health Organization (WHO) declared it a global
health threat. This phenomenon has been driven mainly by the use and
misuse of antibiotics.
• Widespread antibiotic use has contributed to increasing antibiotic
resistance among common bacterial species.
e.g. methicillin resistant Staphylococcus aureus (MRSA)
metronidazole-resistant anaerobes
multiply-resistant Gram-negative species
vancomycin resistant enterococci.
• Main factors contributing :
1. Excess antibiotic usage
2. Increasing number of patients who are more susceptible to
infections (e.g. elderly, immunosuppressed)
3. Early treatment using broad-spectrum antibiotics.
4. Increasing need for hospital beds results in a tendency to treat
empirically rather than wait for a firm diagnosis.
5. Incorrect use of broad spectrum agent
6. Incorrect dosing
7. Non-compliance
THANK YOU