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See all Premium member Presentation Transcript USE OF ANTIBIOTICS IN COLON & RECTAL SURGERY : USE OF ANTIBIOTICS IN COLON & RECTAL SURGERY DR SANOOP K ZACHARIAH Consultant Surgeon & Assistant Professor MOSC Medical College Kolenchery Kerala, India THE REALITY------- : THE REALITY------- “SINCE ANTIQUITY THE PROBLEM OF INFECTION HAS BEEN CLOSELY LINKED WITH SURGICAL THERAPY” 2 Slide 3: COLORECTAL SURGEONS HAVE TO DEAL WITH A LOT OF BOWEL BACTERIA THE FACT 3 FEACAL MATTER : FEACAL MATTER ONE DROP OF FEACES = 400 SPECIES OF BACTERIA 1012 BACTERIA PER GRAM OF WET FEACES 40-50% OF SOLID FEACES=BACTERIA Slide 5: THE EQUATION COLORECTAL SURGERY= LOT OF BACTERIA OUR DEFENCES : OUR DEFENCES PATIENTS IMMUNE SYSTEM PROPER SURGICAL TECNIQUE & SKILL KNOWLEDGE OF PREDICTABLE GUT MICROFLORA OUR WEAPON------ANTIBIOTICS 6 SURGICAL INFECTIONS : SURGICAL INFECTIONS 1992-CENTRE FOR DISEASE CONTROL, USA (CDC) (REVISED DEFNITION) SURGICAL INFECTIONS RESULT OF A SURGICAL PROCEDURE(SSI) REQUIRES A SURGICAL PROCEDURE ( eg.ABSCESS DRAINAGE) SURGICAL SITE INFECTIONS(SSI) DEFN: INFECTIONS ALONG THE SURGICAL TRACT WITHIN 0 TO 30 DAYS OF SURGERY OR ONE YEAR FOLLOWING IMPLANTS SECOND MOST COMMON NOSOCOMIAL INFECTION (20%) INCREASES MORBITIDY,HOSPITALIZATION COSTS,MORTALITY(3%) ARCHIVES OF SURGERY ,OCT 2006;141:1014-1018 7 Slide 8: SUPERFICIAL SSI DEEP SSI ORGAN SPACE SSI SKIN SUBCUTANEOUS DEEP SOFT TISSUE FASCIA&MUSCLE INTRAPERITONEAL SSI, CDC CLASSIFICATION 1)HORAN ET AL,INFECT CONTROL HOSP EPIDEMOL 1992;13(10);606-8 2)AMJ INFECT CONTROL,2008:36:309-32 8 SSI RATES(%) FOR SELECTED PROCEDURES-(ACCORDING TO RISK INDEX)NHSN DATA-2006-2007,AMJ INFECT CONTROL-2008 : SSI RATES(%) FOR SELECTED PROCEDURES-(ACCORDING TO RISK INDEX)NHSN DATA-2006-2007,AMJ INFECT CONTROL-2008 9 NUMBER OF RISK FACTORS SSI-COLORECTAL SURGERY : SSI-COLORECTAL SURGERY Without Antibiotic Prophylaxis= 40% SSI The Risk Of Death Is Doubled (Relative Risk (RR) 2.2, 95% Confidence Interval (CI) 1.1 To 4.5) Intensive Care Unit Admission Is More Likely (RR 1.6, 95% Ci 1.3 To 2.0) Average Hospital Stay Is Lengthened By Five Days the risk of hospital readmission is greatly increased (RR 5.5, 95% CI 4.0 to 7.7) 10 Baum 1981, (Kirkland 1999), (Smith 2004), PATHOGENS IN SURGICAL INFECTION : PATHOGENS IN SURGICAL INFECTION 11 SOURCE OF PATHOGENS : SOURCE OF PATHOGENS ENDOGENOUS-SKIN & GIT EXOGENOUS SKIN STAPHYLOCOCCUS sp CORNYFORMS MICROCOCCI 12 Slide 13: 13 MICROBIOLOGICAL COMPOSITION AND DISTRIBUTION OF THE GUT GUT MICROFLORA“The forgotten Organ” : GUT MICROFLORA“The forgotten Organ” COMMENSALS SYMBIOTIC PRIMARILY LARGE BOWEL R >L >4OO SPECIES 14 CONCENTRATION OF BACTERIA PRESENT IN HUMAN COLON INTRA-ABDOMINAL INFECTIONS : INTRA-ABDOMINAL INFECTIONS 15 Slide 16: LYMPHATICS,BLOOD BOWEL EXTRA INTESTINAL SITES BACTERIAL TRANSLOCATION 16 Slide 17: SPILLAGE/CONTAMINATION >105=INFECTION 17 ANTIBIOTICS : ANTIBIOTICS THERAPEUTIC-FOR ESTABLISHED INFECTION PROPHYLATIC-ADMINISTERED IN ABSENCE OF INFECTION TO REDUCE SEVERITY OR PREVENT INFECTION FOLLOWING SURGICAL INTERVENTION 18 PRINCIPLES OF ANTIBIOTIC PROPHYLAXIS : 19 PRINCIPLES OF ANTIBIOTIC PROPHYLAXIS TO PREVENT INFECTION FOR A DEFINED PERIOD VULNERABLE/GOLDEN PERIOD INCISION TO CLOSURE ANYTHING BEYOND SKIN CLOSURE =THERAPY PRINCIPLES OF ANTIMICROBIAL USE : PRINCIPLES OF ANTIMICROBIAL USE PROVIDE, AS FAR AS POSSIBLE ,THE PRECISE COVERAGE MINIMAL EFFECT ON PTS NORMAL BACTERIAL FLORA MINIMAL ADVERSE EFFECTS MINIMAL CHANGE ON HOST DEFENCES USAGE SHOULD BE SUPPORTED BY EVIDENCE OF EFFECTIVENESS 20 COMMON QUERIES ? : COMMON QUERIES ? SHOULD I USE ANTIBIOTICS ? WHICH ANTIBIOTIC? SINGLE OR COMBINATION? WHEN TO START? HOW LONG TO CONTINUE? ROUTE-IV/ORAL? WHAT OTHER FACTORS SHOULD I CONSIDER? 21 SHOULD I USE ANTIBIOTICS ? : SHOULD I USE ANTIBIOTICS ? NATIONAL RESEARCH COUNCIL GROUP 1964(NRC) TAXONOMY OF SURGICAL WOUNDS 22 INFECTION RATES IN VARIOUS CATEGORIES(SSI) : INFECTION RATES IN VARIOUS CATEGORIES(SSI) PROPHYLATIC ANTIBIOTICS ARE DEFINITELY REQUIRED-2, 3 & 4 CATEGORIES COLORECTAL PROCEDURES FALL INTO CATEGORIES 2,3 & 4 ABSENCE OF ANTIMICROBIAL PROPHYLAXIS- WOUND INFECTION-32-58% INFECTIOUS COMPLICATIONS-UPTO 75% 23 WHICH ANTIBIOTICS DO I USE ? : WHICH ANTIBIOTICS DO I USE ? ??PENICILLIN AMINOGLYCOSIDE CEPHALOSPORINS METRONIDAZOLE,…….????????? 24 Slide 25: THE COMMONEST BACTERIA ISOLATED FROM POST-OP WOUND INFECTIONS AFTER VARIOUS COLORECTAL PROCEDURES -E.COLI ,BACTERIODES FRAGILIS AND STAPH. ENDOTOXIN GENERATING FACULTATIVE AND GM –IVE AEROBES E.COLI,OBLIGATE ANAEROBES-BACTERIODES AIM AT THE TARGET GROUP 25 ANTIBIOTICS WITH PREDOMINANTLY AEROBIC / ANAEROBIC BROAD SPECTRUM ACTIVITY : ANTIBIOTICS WITH PREDOMINANTLY AEROBIC / ANAEROBIC BROAD SPECTRUM ACTIVITY CHOOSE ONE FROM EACH EMPIRICALLY 26 WHEN TO START ?(TIMMING) : WHEN TO START ?(TIMMING) THE RISK FOR INFECTIONS BEGINS WITH THE INCISION ANTIBIOTICS SHOULD ALREADY BE PRESENT IN THE TISSUES AT THE TIME OF INSCISION(SKIN,COLON) FIRST DOSE-ATLEAST WITHIN 30 MINUTES OF INDUCTION ANTIBIOTICS STARTED 3HRS AFTER CONTAMINATION ARE LESS EFFECTIVE THE GOAL –TO ACHIEVE CONCENTRATION THAT EXCEEDS MIC BY 3-4 TIMES AT LEAST ¾ OF THE TIME BETWEEN SUCCESSIVE DOSES PROLONGED SURGERIES-RPT DOSES AT INTERVALS OF 1-2 HALF LIFES OF THE DRUG 27 Slide 28: 28 HOW LONG TO CONTINUE? : HOW LONG TO CONTINUE? AVOID –BLIND,INDISCRIMINATE,PROLONGED POST OP ANTIBIOTICS THE DURATION OF AN ADEQUATE TISSUE LEVEL OF THE ANTIBIOTIC NEED NOT EXCEED THE OPERATIVE PERIOD. EVOLVING POLICY- MINIMAL ANTIBIOTIC ADMINISTRATION SURGEONS SHOULD UNDERSTAND DIFFERENCE BETWEEN CONTAMINATION ,INFLAMMATION, INFECTION STERILE INFLAMMATION IS COMMON AFTER ANY OPERATION MANIFESTS AS LOCAL INFLAMMATORY RESPONSE(LIRS) SO,PYREXIA OR LEUKOCYTOSIS NEED NOT MEAN INFECTION LIRS RESOLVES WITHOUT ANTIBIOTICS 29 SURGICAL INFECTION SOCIETY GUIDELINES FOR DURATION OF ANTIMICROBIAL THERAPY FOLLOWING SOURCE CONTROL 2002 : SURGICAL INFECTION SOCIETY GUIDELINES FOR DURATION OF ANTIMICROBIAL THERAPY FOLLOWING SOURCE CONTROL 2002 ONLY CONDITIONS APPLICABLE TO COLORECTAL SURGERY ARE INCLUDED 30 ROUTE –ORAL/IV ? : ROUTE –ORAL/IV ? DEBATED TOPIC IMPAIRED GI FUNCTION- INTRAVENOUS ROUTE IS PREFERRED PROPHYLAXIS BY I.V IS THE ONLY METHOD SUPPORTED BY A SUBSTANTIAL BODY OF EVIDENCE ADDITION OF ORAL TO PARAENTERAL---NO PROVEN BENEFIT DOSE-IV? A SINGLE DOSE OF ANTIBIOTIC AT THERAPUETIC COMBINATION USUALLY SUFFICES FOR PROPHYLAXIS FOR LONGER PROCEDURES, READMINISTRATION OF THE DRUG AT INTERVALS OF 1-2 TIMES THE HALF-LIFE OF THE DRUG (USING THE SAME DOSE).) 31 POPULAR ORAL/INTRALUMINAL REGIMENS : POPULAR ORAL/INTRALUMINAL REGIMENS ERYTHROMYCIN AND NEOMYCIN 1GM OF EACH 1PM,2PM &11 PM FIRST DOSE 19 HRS BEFORE SURGERY METRONIDAZOLE =ERYTHROMYCIN KANAMYCIN=NEOMYCIN 32 WHAT OTHER FACTORS DO I CONSIDER? : WHAT OTHER FACTORS DO I CONSIDER? 1)BLOOD LOSS & 2) FLUID REPLACEMENT HERE SERUM ANTIBIOTIC CONCENTRATIONS --REDUCED BLOOD LOSS>1500ml HAEMODILUTION >15ml/kg ADDITIONAL DOSE DIABETES CORTICOSTEROIDS OBESITY EXTREMES OF AGE ADDITIONAL RISK FACTORS MALNUTRITION MASSIVE TRANSFUSION 3 OR MORE COMORBID CONDITIONS ASA CLASS 3,4,5 33 THE NEW 4-POINT NNIS RISK STRATIFICATION : THE NEW 4-POINT NNIS RISK STRATIFICATION A new simple risk stratification for SSI-BY (NATIONAL NOSOCOMIAL INFECTION SURVEILENCE SYSTEM) 34 FOR LAPAROSCOPIC COLECTOMY AND CHOLECYSTECTOMY 1 POINT IS SUBTRACTED Slide 35: USE OF ANTIBIOTICS IN COLOPROCTOLOGY 35 Slide 36: 36 IN ANORECTAL ABCESS, FISTULA, PILONIDAL ABCESS COMMONEST ORGANISMS ISOLATED WERE GUT SPECIFIC ORGANISMS & STAP.AUREUS Whitehead et al 1982 BJS DISADVANTAGES : DISADVANTAGES RESISTANCE. COLITIS (ANTIBIOTIC ASSOCIATED COLITIS) 37 ANTIBIOTIC RESISTANCEEMERGENCE OF THE SUPERBUGS …………….. : ANTIBIOTIC RESISTANCEEMERGENCE OF THE SUPERBUGS …………….. HA-MRSA, CA-MRSA VRSA,VISA ESBL MRSA PSEUDOMEMBRANOUS COLITIS : PSEUDOMEMBRANOUS COLITIS Suppression of normal gut flora Overgrowth of toxigenic strains of C.Difficile Effects- toxin a-mildly cytopathic toxin b-highly cytopathic Strain-bi/na1/027-new highly toxigenic strain-a,b toxins- Common antibiotics- penicillin, clindamycin, cephalosporin 39 PROHYLATIC ANTIBIOTICS &SSI –COLORECTAL SURGERYRESULTS FROM COCHRANE TRIALS DATA BASE : PROHYLATIC ANTIBIOTICS &SSI –COLORECTAL SURGERYRESULTS FROM COCHRANE TRIALS DATA BASE 40 Slide 41: DNA mRNA DNA GYRASE PENICILLIN CEPHALOSPORIN VANCOMYCIN AMPHOTERICIN BACITRACIN GENTAMICIN METRONIDAZOLE CIPROFLOXACIN SITE OF ACTION 41 t-RNA LINEZOLID INTESTINAL ANTISEPSIS : INTESTINAL ANTISEPSIS MECHANICAL PREP REMOVES FEACAL BULK NOT BACTERIA RISK OF INFECTION WITH MEC.PREP ALONE=25-30% ROUTINE USE OF MECHANICAL PREP HAS BEEN QUESTIONED 42 SYSTEMATIC REVIEW OF RCTS : SYSTEMATIC REVIEW OF RCTS Cochrane Database of Systematic Reviews 2010 Issue 3, (Data Source-medline, Pubmed ,Cochrane Data Base, embase January, 1980 to December, 2007 Objective –To Evaluate Efficacy Of Antimicrobial Prophylaxis In Pts Undergoing Colorectal Surgery DATA- 182-RCT trials, 30,880patients >70 different antibiotic regimens, 50 different antibiotics 43 Nelson RL, Glenny AM, Song -ANTIMICROBIAL PROPHYLAXIS IN COLORECTAL SURGERY ,SYST REWIEW OF RCT–HEALTH TECH ASSMT 1998/2010-updated SYSTEMATIC REVIEW OF RCTS : SYSTEMATIC REVIEW OF RCTS Antimicrobial prophylaxis versus no treatment control/placebo Short- versus long-term use of an antimicrobial Regimen with additional aerobic coverage versus same regimen with no additional aerobic coverage Regimen with additional anaerobic coverage versus same regimen with no additional anaerobic coverage Orally versus intravenous administration Orally and intravenous (iv) versus iv alone Antibiotic prophylaxis of any antibiotic compared to an established gold-standard prophylaxis regimen( oral neomycin/erythromycin base, iv cefoxitin or cefotetan, and iv doxycycline.) 44 DESCRIPTION OF STUDIES Slide 45: Without prophylaxis SSI= 40% No advantage with longer dosing (RR1.06, 95%CI 0.89 to 1.27 (P value 0.51) Addition of aerobic coverage to anaerobic coverage significantly reduced the incidence of SWI (RR 0.41, 95% CI 0.23 to 0.71 (P value 0.002)) Addition of anaerobic coverage to aerobic coverage resulted in a statistically significant reduction in SWI rates (RR 0.55, 95% CI 0.35 to 0.85 (P value 0.008) ORAL VS IV-no statistically significant difference in SWI incidence A statistically significant benefit in favour of combined oral and intravenous, compared to intravenous alone (RR 0.55, 95% CI 0.41 to 0.74 (P value less than 0.0001) A statistically significant benefit for combined oral and intravenous, compared to oral prophylaxis alone (RR 0.34, 95% CI 0.13 to 0.87 (P value 0.02) 45 RESULTS Slide 46: Without prophylaxis SSI= 40% Overall rate of SSI-11.1%(prophylaxis) Prophylactic antibiotics reduce the risk of postoperative SSI by 75% Single dose as effective as multidose-no significant diff in SSI Oral combined with iv is better. No convincing evidence -2/3 gen cephalosporin's better than 1 gen. Efficacy of different regimens similar –difficult to identify best regimen Monotherapy with metronidazole,piperacillin,-ineffective Further research is required to establish adverse effects such as Clostridium difficile pseudomembranous colitis. SONG F,GLENNY AM-ANTIMICROBIAL PROPHYLAXIS IN COLORECTAL SURGERY ,SYST REWIEW OF RCT–HEALTH TECH ASSMT 1998 46 CONCLUSIONS RECOMMENDATIONS (COLORECTAL SURGERY) : RECOMMENDATIONS (COLORECTAL SURGERY) SIGN(SCOTTISH INTERCOLLEGIATE GUIDELINES NETWORK) PROPHYLATIC ANTIBIOTICS IS HIGHLY RECOMMENDED AHSP(AMERICAN SOCIETY OF HEALTH SYSTEM PHARMACISTS CEFUROXIME WITH METRONIDAZOLE- PREFERRED COMBINATION 47 TAKE HOME MESSAGE : TAKE HOME MESSAGE Antibiotic prophylaxis proven septic complications ,-definitely required in colorectal surgery It is unethical to perform colorectal surgery without prophylaxis The target coverage-aerobes & anaerobes GOLD STANDARD REGIMEN is yet to be defined Paraenteral and oral combination are preferred choice Mono/combination therapy –active –anaerobes+aerobes Timing of first dose is important Further doses depend on operative findings Avoid misuse/prolonged use-additional dosing=resistance/colitis Should consider basing practice on updated guidelines, evidence based medicine 48 Slide 49: 49 THANK YOU You do not have the permission to view this presentation. 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ANTIBIOTICS IN COLORECTAL SURGERY SANOOPKZ Download Post to : URL : Related Presentations : Share Add to Flag Embed Email Send to Blogs and Networks Add to Channel Uploaded from authorPOINT lite Insert YouTube videos in PowerPont slides with aS Desktop Copy embed code: (To copy code, click on the text box) Embed: URL: Thumbnail: WordPress Embed Customize Embed The presentation is successfully added In Your Favorites. Views: 634 Category: Education License: All Rights Reserved Like it (18) Dislike it (0) Added: June 30, 2010 This Presentation is Public Favorites: 0 Presentation Description AN EVIDENCE BASED APPROACH TO THR ROLE OF ANTIBIOTICS IN COLORECTAL SURGERY Comments Posting comment... By: sissy2007 (6 month(s) ago) very good Saving..... Post Reply Close Saving..... Edit Comment Close By: kermalak (13 month(s) ago) thanQQ Saving..... Post Reply Close Saving..... Edit Comment Close By: drahmaed (17 month(s) ago) good Saving..... Post Reply Close Saving..... 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See all Premium member Presentation Transcript USE OF ANTIBIOTICS IN COLON & RECTAL SURGERY : USE OF ANTIBIOTICS IN COLON & RECTAL SURGERY DR SANOOP K ZACHARIAH Consultant Surgeon & Assistant Professor MOSC Medical College Kolenchery Kerala, India THE REALITY------- : THE REALITY------- “SINCE ANTIQUITY THE PROBLEM OF INFECTION HAS BEEN CLOSELY LINKED WITH SURGICAL THERAPY” 2 Slide 3: COLORECTAL SURGEONS HAVE TO DEAL WITH A LOT OF BOWEL BACTERIA THE FACT 3 FEACAL MATTER : FEACAL MATTER ONE DROP OF FEACES = 400 SPECIES OF BACTERIA 1012 BACTERIA PER GRAM OF WET FEACES 40-50% OF SOLID FEACES=BACTERIA Slide 5: THE EQUATION COLORECTAL SURGERY= LOT OF BACTERIA OUR DEFENCES : OUR DEFENCES PATIENTS IMMUNE SYSTEM PROPER SURGICAL TECNIQUE & SKILL KNOWLEDGE OF PREDICTABLE GUT MICROFLORA OUR WEAPON------ANTIBIOTICS 6 SURGICAL INFECTIONS : SURGICAL INFECTIONS 1992-CENTRE FOR DISEASE CONTROL, USA (CDC) (REVISED DEFNITION) SURGICAL INFECTIONS RESULT OF A SURGICAL PROCEDURE(SSI) REQUIRES A SURGICAL PROCEDURE ( eg.ABSCESS DRAINAGE) SURGICAL SITE INFECTIONS(SSI) DEFN: INFECTIONS ALONG THE SURGICAL TRACT WITHIN 0 TO 30 DAYS OF SURGERY OR ONE YEAR FOLLOWING IMPLANTS SECOND MOST COMMON NOSOCOMIAL INFECTION (20%) INCREASES MORBITIDY,HOSPITALIZATION COSTS,MORTALITY(3%) ARCHIVES OF SURGERY ,OCT 2006;141:1014-1018 7 Slide 8: SUPERFICIAL SSI DEEP SSI ORGAN SPACE SSI SKIN SUBCUTANEOUS DEEP SOFT TISSUE FASCIA&MUSCLE INTRAPERITONEAL SSI, CDC CLASSIFICATION 1)HORAN ET AL,INFECT CONTROL HOSP EPIDEMOL 1992;13(10);606-8 2)AMJ INFECT CONTROL,2008:36:309-32 8 SSI RATES(%) FOR SELECTED PROCEDURES-(ACCORDING TO RISK INDEX)NHSN DATA-2006-2007,AMJ INFECT CONTROL-2008 : SSI RATES(%) FOR SELECTED PROCEDURES-(ACCORDING TO RISK INDEX)NHSN DATA-2006-2007,AMJ INFECT CONTROL-2008 9 NUMBER OF RISK FACTORS SSI-COLORECTAL SURGERY : SSI-COLORECTAL SURGERY Without Antibiotic Prophylaxis= 40% SSI The Risk Of Death Is Doubled (Relative Risk (RR) 2.2, 95% Confidence Interval (CI) 1.1 To 4.5) Intensive Care Unit Admission Is More Likely (RR 1.6, 95% Ci 1.3 To 2.0) Average Hospital Stay Is Lengthened By Five Days the risk of hospital readmission is greatly increased (RR 5.5, 95% CI 4.0 to 7.7) 10 Baum 1981, (Kirkland 1999), (Smith 2004), PATHOGENS IN SURGICAL INFECTION : PATHOGENS IN SURGICAL INFECTION 11 SOURCE OF PATHOGENS : SOURCE OF PATHOGENS ENDOGENOUS-SKIN & GIT EXOGENOUS SKIN STAPHYLOCOCCUS sp CORNYFORMS MICROCOCCI 12 Slide 13: 13 MICROBIOLOGICAL COMPOSITION AND DISTRIBUTION OF THE GUT GUT MICROFLORA“The forgotten Organ” : GUT MICROFLORA“The forgotten Organ” COMMENSALS SYMBIOTIC PRIMARILY LARGE BOWEL R >L >4OO SPECIES 14 CONCENTRATION OF BACTERIA PRESENT IN HUMAN COLON INTRA-ABDOMINAL INFECTIONS : INTRA-ABDOMINAL INFECTIONS 15 Slide 16: LYMPHATICS,BLOOD BOWEL EXTRA INTESTINAL SITES BACTERIAL TRANSLOCATION 16 Slide 17: SPILLAGE/CONTAMINATION >105=INFECTION 17 ANTIBIOTICS : ANTIBIOTICS THERAPEUTIC-FOR ESTABLISHED INFECTION PROPHYLATIC-ADMINISTERED IN ABSENCE OF INFECTION TO REDUCE SEVERITY OR PREVENT INFECTION FOLLOWING SURGICAL INTERVENTION 18 PRINCIPLES OF ANTIBIOTIC PROPHYLAXIS : 19 PRINCIPLES OF ANTIBIOTIC PROPHYLAXIS TO PREVENT INFECTION FOR A DEFINED PERIOD VULNERABLE/GOLDEN PERIOD INCISION TO CLOSURE ANYTHING BEYOND SKIN CLOSURE =THERAPY PRINCIPLES OF ANTIMICROBIAL USE : PRINCIPLES OF ANTIMICROBIAL USE PROVIDE, AS FAR AS POSSIBLE ,THE PRECISE COVERAGE MINIMAL EFFECT ON PTS NORMAL BACTERIAL FLORA MINIMAL ADVERSE EFFECTS MINIMAL CHANGE ON HOST DEFENCES USAGE SHOULD BE SUPPORTED BY EVIDENCE OF EFFECTIVENESS 20 COMMON QUERIES ? : COMMON QUERIES ? SHOULD I USE ANTIBIOTICS ? WHICH ANTIBIOTIC? SINGLE OR COMBINATION? WHEN TO START? HOW LONG TO CONTINUE? ROUTE-IV/ORAL? WHAT OTHER FACTORS SHOULD I CONSIDER? 21 SHOULD I USE ANTIBIOTICS ? : SHOULD I USE ANTIBIOTICS ? NATIONAL RESEARCH COUNCIL GROUP 1964(NRC) TAXONOMY OF SURGICAL WOUNDS 22 INFECTION RATES IN VARIOUS CATEGORIES(SSI) : INFECTION RATES IN VARIOUS CATEGORIES(SSI) PROPHYLATIC ANTIBIOTICS ARE DEFINITELY REQUIRED-2, 3 & 4 CATEGORIES COLORECTAL PROCEDURES FALL INTO CATEGORIES 2,3 & 4 ABSENCE OF ANTIMICROBIAL PROPHYLAXIS- WOUND INFECTION-32-58% INFECTIOUS COMPLICATIONS-UPTO 75% 23 WHICH ANTIBIOTICS DO I USE ? : WHICH ANTIBIOTICS DO I USE ? ??PENICILLIN AMINOGLYCOSIDE CEPHALOSPORINS METRONIDAZOLE,…….????????? 24 Slide 25: THE COMMONEST BACTERIA ISOLATED FROM POST-OP WOUND INFECTIONS AFTER VARIOUS COLORECTAL PROCEDURES -E.COLI ,BACTERIODES FRAGILIS AND STAPH. ENDOTOXIN GENERATING FACULTATIVE AND GM –IVE AEROBES E.COLI,OBLIGATE ANAEROBES-BACTERIODES AIM AT THE TARGET GROUP 25 ANTIBIOTICS WITH PREDOMINANTLY AEROBIC / ANAEROBIC BROAD SPECTRUM ACTIVITY : ANTIBIOTICS WITH PREDOMINANTLY AEROBIC / ANAEROBIC BROAD SPECTRUM ACTIVITY CHOOSE ONE FROM EACH EMPIRICALLY 26 WHEN TO START ?(TIMMING) : WHEN TO START ?(TIMMING) THE RISK FOR INFECTIONS BEGINS WITH THE INCISION ANTIBIOTICS SHOULD ALREADY BE PRESENT IN THE TISSUES AT THE TIME OF INSCISION(SKIN,COLON) FIRST DOSE-ATLEAST WITHIN 30 MINUTES OF INDUCTION ANTIBIOTICS STARTED 3HRS AFTER CONTAMINATION ARE LESS EFFECTIVE THE GOAL –TO ACHIEVE CONCENTRATION THAT EXCEEDS MIC BY 3-4 TIMES AT LEAST ¾ OF THE TIME BETWEEN SUCCESSIVE DOSES PROLONGED SURGERIES-RPT DOSES AT INTERVALS OF 1-2 HALF LIFES OF THE DRUG 27 Slide 28: 28 HOW LONG TO CONTINUE? : HOW LONG TO CONTINUE? AVOID –BLIND,INDISCRIMINATE,PROLONGED POST OP ANTIBIOTICS THE DURATION OF AN ADEQUATE TISSUE LEVEL OF THE ANTIBIOTIC NEED NOT EXCEED THE OPERATIVE PERIOD. EVOLVING POLICY- MINIMAL ANTIBIOTIC ADMINISTRATION SURGEONS SHOULD UNDERSTAND DIFFERENCE BETWEEN CONTAMINATION ,INFLAMMATION, INFECTION STERILE INFLAMMATION IS COMMON AFTER ANY OPERATION MANIFESTS AS LOCAL INFLAMMATORY RESPONSE(LIRS) SO,PYREXIA OR LEUKOCYTOSIS NEED NOT MEAN INFECTION LIRS RESOLVES WITHOUT ANTIBIOTICS 29 SURGICAL INFECTION SOCIETY GUIDELINES FOR DURATION OF ANTIMICROBIAL THERAPY FOLLOWING SOURCE CONTROL 2002 : SURGICAL INFECTION SOCIETY GUIDELINES FOR DURATION OF ANTIMICROBIAL THERAPY FOLLOWING SOURCE CONTROL 2002 ONLY CONDITIONS APPLICABLE TO COLORECTAL SURGERY ARE INCLUDED 30 ROUTE –ORAL/IV ? : ROUTE –ORAL/IV ? DEBATED TOPIC IMPAIRED GI FUNCTION- INTRAVENOUS ROUTE IS PREFERRED PROPHYLAXIS BY I.V IS THE ONLY METHOD SUPPORTED BY A SUBSTANTIAL BODY OF EVIDENCE ADDITION OF ORAL TO PARAENTERAL---NO PROVEN BENEFIT DOSE-IV? A SINGLE DOSE OF ANTIBIOTIC AT THERAPUETIC COMBINATION USUALLY SUFFICES FOR PROPHYLAXIS FOR LONGER PROCEDURES, READMINISTRATION OF THE DRUG AT INTERVALS OF 1-2 TIMES THE HALF-LIFE OF THE DRUG (USING THE SAME DOSE).) 31 POPULAR ORAL/INTRALUMINAL REGIMENS : POPULAR ORAL/INTRALUMINAL REGIMENS ERYTHROMYCIN AND NEOMYCIN 1GM OF EACH 1PM,2PM &11 PM FIRST DOSE 19 HRS BEFORE SURGERY METRONIDAZOLE =ERYTHROMYCIN KANAMYCIN=NEOMYCIN 32 WHAT OTHER FACTORS DO I CONSIDER? : WHAT OTHER FACTORS DO I CONSIDER? 1)BLOOD LOSS & 2) FLUID REPLACEMENT HERE SERUM ANTIBIOTIC CONCENTRATIONS --REDUCED BLOOD LOSS>1500ml HAEMODILUTION >15ml/kg ADDITIONAL DOSE DIABETES CORTICOSTEROIDS OBESITY EXTREMES OF AGE ADDITIONAL RISK FACTORS MALNUTRITION MASSIVE TRANSFUSION 3 OR MORE COMORBID CONDITIONS ASA CLASS 3,4,5 33 THE NEW 4-POINT NNIS RISK STRATIFICATION : THE NEW 4-POINT NNIS RISK STRATIFICATION A new simple risk stratification for SSI-BY (NATIONAL NOSOCOMIAL INFECTION SURVEILENCE SYSTEM) 34 FOR LAPAROSCOPIC COLECTOMY AND CHOLECYSTECTOMY 1 POINT IS SUBTRACTED Slide 35: USE OF ANTIBIOTICS IN COLOPROCTOLOGY 35 Slide 36: 36 IN ANORECTAL ABCESS, FISTULA, PILONIDAL ABCESS COMMONEST ORGANISMS ISOLATED WERE GUT SPECIFIC ORGANISMS & STAP.AUREUS Whitehead et al 1982 BJS DISADVANTAGES : DISADVANTAGES RESISTANCE. COLITIS (ANTIBIOTIC ASSOCIATED COLITIS) 37 ANTIBIOTIC RESISTANCEEMERGENCE OF THE SUPERBUGS …………….. : ANTIBIOTIC RESISTANCEEMERGENCE OF THE SUPERBUGS …………….. HA-MRSA, CA-MRSA VRSA,VISA ESBL MRSA PSEUDOMEMBRANOUS COLITIS : PSEUDOMEMBRANOUS COLITIS Suppression of normal gut flora Overgrowth of toxigenic strains of C.Difficile Effects- toxin a-mildly cytopathic toxin b-highly cytopathic Strain-bi/na1/027-new highly toxigenic strain-a,b toxins- Common antibiotics- penicillin, clindamycin, cephalosporin 39 PROHYLATIC ANTIBIOTICS &SSI –COLORECTAL SURGERYRESULTS FROM COCHRANE TRIALS DATA BASE : PROHYLATIC ANTIBIOTICS &SSI –COLORECTAL SURGERYRESULTS FROM COCHRANE TRIALS DATA BASE 40 Slide 41: DNA mRNA DNA GYRASE PENICILLIN CEPHALOSPORIN VANCOMYCIN AMPHOTERICIN BACITRACIN GENTAMICIN METRONIDAZOLE CIPROFLOXACIN SITE OF ACTION 41 t-RNA LINEZOLID INTESTINAL ANTISEPSIS : INTESTINAL ANTISEPSIS MECHANICAL PREP REMOVES FEACAL BULK NOT BACTERIA RISK OF INFECTION WITH MEC.PREP ALONE=25-30% ROUTINE USE OF MECHANICAL PREP HAS BEEN QUESTIONED 42 SYSTEMATIC REVIEW OF RCTS : SYSTEMATIC REVIEW OF RCTS Cochrane Database of Systematic Reviews 2010 Issue 3, (Data Source-medline, Pubmed ,Cochrane Data Base, embase January, 1980 to December, 2007 Objective –To Evaluate Efficacy Of Antimicrobial Prophylaxis In Pts Undergoing Colorectal Surgery DATA- 182-RCT trials, 30,880patients >70 different antibiotic regimens, 50 different antibiotics 43 Nelson RL, Glenny AM, Song -ANTIMICROBIAL PROPHYLAXIS IN COLORECTAL SURGERY ,SYST REWIEW OF RCT–HEALTH TECH ASSMT 1998/2010-updated SYSTEMATIC REVIEW OF RCTS : SYSTEMATIC REVIEW OF RCTS Antimicrobial prophylaxis versus no treatment control/placebo Short- versus long-term use of an antimicrobial Regimen with additional aerobic coverage versus same regimen with no additional aerobic coverage Regimen with additional anaerobic coverage versus same regimen with no additional anaerobic coverage Orally versus intravenous administration Orally and intravenous (iv) versus iv alone Antibiotic prophylaxis of any antibiotic compared to an established gold-standard prophylaxis regimen( oral neomycin/erythromycin base, iv cefoxitin or cefotetan, and iv doxycycline.) 44 DESCRIPTION OF STUDIES Slide 45: Without prophylaxis SSI= 40% No advantage with longer dosing (RR1.06, 95%CI 0.89 to 1.27 (P value 0.51) Addition of aerobic coverage to anaerobic coverage significantly reduced the incidence of SWI (RR 0.41, 95% CI 0.23 to 0.71 (P value 0.002)) Addition of anaerobic coverage to aerobic coverage resulted in a statistically significant reduction in SWI rates (RR 0.55, 95% CI 0.35 to 0.85 (P value 0.008) ORAL VS IV-no statistically significant difference in SWI incidence A statistically significant benefit in favour of combined oral and intravenous, compared to intravenous alone (RR 0.55, 95% CI 0.41 to 0.74 (P value less than 0.0001) A statistically significant benefit for combined oral and intravenous, compared to oral prophylaxis alone (RR 0.34, 95% CI 0.13 to 0.87 (P value 0.02) 45 RESULTS Slide 46: Without prophylaxis SSI= 40% Overall rate of SSI-11.1%(prophylaxis) Prophylactic antibiotics reduce the risk of postoperative SSI by 75% Single dose as effective as multidose-no significant diff in SSI Oral combined with iv is better. No convincing evidence -2/3 gen cephalosporin's better than 1 gen. Efficacy of different regimens similar –difficult to identify best regimen Monotherapy with metronidazole,piperacillin,-ineffective Further research is required to establish adverse effects such as Clostridium difficile pseudomembranous colitis. SONG F,GLENNY AM-ANTIMICROBIAL PROPHYLAXIS IN COLORECTAL SURGERY ,SYST REWIEW OF RCT–HEALTH TECH ASSMT 1998 46 CONCLUSIONS RECOMMENDATIONS (COLORECTAL SURGERY) : RECOMMENDATIONS (COLORECTAL SURGERY) SIGN(SCOTTISH INTERCOLLEGIATE GUIDELINES NETWORK) PROPHYLATIC ANTIBIOTICS IS HIGHLY RECOMMENDED AHSP(AMERICAN SOCIETY OF HEALTH SYSTEM PHARMACISTS CEFUROXIME WITH METRONIDAZOLE- PREFERRED COMBINATION 47 TAKE HOME MESSAGE : TAKE HOME MESSAGE Antibiotic prophylaxis proven septic complications ,-definitely required in colorectal surgery It is unethical to perform colorectal surgery without prophylaxis The target coverage-aerobes & anaerobes GOLD STANDARD REGIMEN is yet to be defined Paraenteral and oral combination are preferred choice Mono/combination therapy –active –anaerobes+aerobes Timing of first dose is important Further doses depend on operative findings Avoid misuse/prolonged use-additional dosing=resistance/colitis Should consider basing practice on updated guidelines, evidence based medicine 48 Slide 49: 49 THANK YOU