Documente Academic
Documente Profesional
Documente Cultură
By
Prof. ABDEL FATTAH ABDEL SATTAR
HEAD OF ANESTHESIA & PAIN RELIEF
DEPARTMENT
Topics:
Introduction.
Antibiotic Review.
Principles of Antibiotic choice.
Surgical Prophylaxis -- antimicrobial use
ANTIBIOTICS REVIEW
Since the development of Sulphonamides in
1930 and Penicillin in 1940, numerous effective
antibacterial, antifungal and recently antiviral
agents have become available.
The similarities of many of these antibiotics are
more striking than their differences.
The newest antibiotic is often not the best
choice.
Therefore obtaining culture in conjunction with
susceptibility testing is imperative.
3-Fungi:
* Staphylococcus:S.aureus, albus(epidermis).
* Streptococcus:S.pneumoniae, S.pyogenes
S.viridian's, S.faecalis(enterococci).
Gram-positive cocci(Anaerobic):
Gram-positive bacilli(Aerobic):
putridus
* Non-poring: Corynobacterium(c.dipht.),
Listeria (L.monocytogens)..B.Anthrax(Spor).
* Non-sporing: propionibacter(p.acnes)
Actinomycetes(A.israelii).
* Bacteroides(B.fragelis).
PENICILLINS
Penicillins have predictable activity against
gram+ve cocci (Streptococci).
Ampicillin &Amoxycillin some gram-ve bacilli
Methicillin (Staphcillin) Staph albus.
Piperacillin, Ticracillin, Mezlocillin and Azlocillin
Anti-pseudomonas penicillins.
They should be used in combination with an
aminoglycoside or agent with anti- gram-Ve.
They have no anti gram-ve activity.
CEPHALOSPORINS
1st generation active against gram+ve.
e.g.:Cephalexin (Keflex), Cephardine (Velosef)
3 generation active against gram-ve.
e.g.: Cefotaxime (Claforan), Cefoperazine
(Cefobid), Cefotriaxone (Rociphen),
Ceftazidime (Fortum)
2 generation mixed activity.
e.g.: Cefuroxime (Zinnat).
4th generation: gram-ve(p.aureg.) +strept.+staph
+limited activity against anaerobes.
e.g.; Cefipime (Maxipime)
BETA-LACTAMASE INHIBITORS
Beta-Lactamases are bacterial enzymes that
inactivate beta-lactams antibiotics (Penicillins &
cephalosporins).
Beta- lactamase inhibitors bind to the enzymes
preventing them from inactivating antibiotics.
e.g. Sulbactam + ampicillin = Unasyn.
Clavulanate +amoxycillin = Augmentin.
Tazobactam +piperacillin = Tazocin.
They are active against beta-lactamases of
nisseria gonorrhea, K.pneumonia, H.influenza,
s.aureus m.cattaralis but less to Pseudomonas
CARBAPENEBS
Imipenem & Meropnem
They are active against most aerobic and
anaerobic gram +ve & gram ve organisms.
Imipenem (Tienem) Cilastatin sodium to
prevent renal metabolism & nephrotoxicity
but have CNS adverse effect (seizures).
Meropenem (Meronem) no cilastatin
epileptogenic &Renal degradation.
activity against aerobic gram ve bacilli.
MACROLIDES
Erythromycin
Azithromycin
Clarithromycin
All have activity against Clamydia pneumoniae,
Mycoplasma pneumoniae & Ligionella spices.
The latter two have greater activity against H.infleunza
& nontuberculus mycobacterium.
Used in critically ill patients suspected of having
Atypical pneumonias.
QUINOLONES
They bind to bacterial DNA, prevent replication
Excellent bioavailability (effective orally as IV).
Ciprofloxacin, Ofloxacin, Norfloxacin:
Active against gram-ve (anti-pseud.) &Staph.
Limited activity against anaerobes & Strept.
Levofloxacin, Moxifloxacin,Garifloxacin:
activity against Anaerobic&Strept.pneumon.
activity against atypical Pneumon(Ligionella).
VANCOMYCIN
LINEZOLIDS
Oxazolidinones group :
They have a novel mechanism block
bacterial protein synthesis at the ribosome
at a very early stage.
So, it does not share cross-resistance with
other antimicrobial agents
Spectrum Identical to Vancomycin.
Major indication Vancomycin
resistance.
Excellent oral bioavailability.
TRIAZOLES
They are fungistatic drugs.
Fluconazole (Diflucan):
High volume of distribution.
Active against Candida albicans,C tropicalis,
Cryptococcus neoformans.
80% excreted unchanged in urine no need
to adjust for renal insufficiency.
Itraconazole (Itrapex, Itranox):
Greater activity against aspergillus,
Blastoyces dermatidis & Histoplasa capsulat.
AMPHOTERICIN B
Empirical therapy in febrile patient with
neutropenia.
Standard fungicidal drug for treatment of severe
mycoses.
Adverse effect nephrotoxicity.
Pneumonia
Klebsiella pneumoniae
Proteus
Pneumonia
Community-acquired bacterial
pneumonia
Most frequent cause: Streptococcus pneumoniae
(pneumococci)
Other pathogens:
Haemophilus influenzae
Staphylococcus aureus
Klebsiella pneumoniae
occasionally: other gram-negative bacilli and anaerobic
mouth organisms
"Atypical" pathogens:
Legionella
Mycoplasma pneumoniae
Chlamydia pneumoniae
respiratory viruses
tuberculosis
Pneumocystis carinii
Genitourinary
Sepsis
Sepsis
Initial treatment
Life-threatening sepsis and adults:
Third or fourth generation cephalosporin
cefotaxime (Claforan)
ceftizoxime (Cefizox)
ceftriaxone (Rocephin)
cefepime (Maxipime)
ticarcillin (Ticar)/clavulanic acid
piperacillin (Pipracil)/tazobactam
imipenem or meropenem (Merrem IV)
{each together with aminoglycoside
[gentamicin (Garamycin), tobramycin
(Nebcin), or amikacin (Amikin)]}
Sepsis
If methicillin-resistant staphylococci is
a consideration:
vancomycin (Vancocin) alone or
vancomycin (Vancocin) with gentamicin
(Garamycin) and/or rifampin (Rimactane)
If bacterial endocarditisis is a consideration
(prior to pathogen identification):
vancomycin (Vancocin) plus gentamicin
(Garamycin)
Sepsis
Treatment of intra-abdominal or pelvic infection (likely
to involve anaerobes):
ticarcillin (Ticar)/clavulanic acid)
ampicillin (Principen, Omnipen)/sulbactam)
piperacillin (Pipracil)/tazobactam)
imipenem
meropenem
cefoxitin (Mefoxin) or cefotetan (Cefotan)
{each with or without an aminoglycoside,
metronidazole (Flagyl) OR
clindamycin (Cleocin) with an aminoglycoside
Sepsis
gram-negative bacilli:
Third or fourth generation cephalosporins
cefotaxime (Claforan)
ceftizoxime (Cefizox)
cefoperazone (Cefobid)
ceftriaxone (Rocephin)
cefepime (Maxipime)
ceftazidime (plus activity against grampositive cocci)
imipenem, meropenem (Merrem IV),
aztreonam (Azactan )
Sepsis
Cephalosporins (other than cefoperazone
(Cefobid), cefepime (Maxipime), and
ceftazidime (Fortax, Taxidime, Tazicef)):
limited efficacy against Pseudomonas
aeruginosa
Pseudomonas aeruginosa:
effectively treated with imipenem, meropenem
(Merrem IV), and aztreonam (Azactan).
Aztreonam (Azactan): poor activity against
gram-positive organisms and anaerobes
Presumed diagnosis :
community acquired pneumonia in
an immunocompetent host.
Combining either
antipseudomonal cephalosporin (ceftazidine)
or antipseudomonal penicillin (piperacillin +
azobactam) (particularly if anaerobes are
suspected) with either an aminoglycoside
(gentamycin or amikacin) or a
fluoroquinolone (ciprofloxacin).
If an antipseudomonal cephalosporin is used and
PROPHYLACTIC ANTIBIOTICS
Surgical Prophylaxis
antimicrobial use
PROPHYLACTIC ANTIBIOTICS
The prophylactic antibiotics must be in
place already before the bacteria land in
the wound. For prevention of the
postoperative infection,
The antibiotics are usually injected some
30 minutes before the start of the
operation.
In this way the levels of the antibiotic in
the blood will attain concentrations that will
kill occasional bacteria that may land in the
operation wound.
Gastrointestinal diseases
Gastrointestinal diseases
Antibiotic prophylaxis
recommended for esophageal surgery with
obstruction -- obstruction increases infection risk
factors that promote high infection risk after
gastroduodenal surgery:
reduced gastric acidity and gastrointestinal
motility
reduction may occur because of:
obstruction
hemorrhage
gastric ulcer
malignancy
treatment with H2 blocker {ranitidine (Zantac)}
or proton pump, inhibitors {e.g. omeprazole
(Prilosec)}
morbid obesity
Gastrointestinal diseases
Antibiotic prophylaxis not indicated for:
routine gastroesophageal endoscopy
(may be used for high-risk patients
undergoing esophageal dilatation or
sclerotherapy of varicies).
Genitourinary
Genitourinary
Probable pathogens:
enteric gram-negative bacilli,
enterococci
Prophylaxis
high-risk only (urinate culture
positive/unavailable; preoperative
catheter, transrectal prostatic biopsy) -ciprofloxacin (Cipro) {PO or IV}
Neurosurgery
Craniotomy
Probable pathogens: Staphylococcus aureus,
Staphylococcus epidermidis
Prophylaxis: cefazolin (Ancef, Defzol) or vancomycin
(Vancocin) (IV)
Antibacterial prophylaxis
cerebrospinal fluid shunt: conflicting research results
Craniotomy: antistaphylococcal antibiotic -- reduced
infection incidence
Spinal surgery: antibiotics not effective in reducing the
already low postoperative infection rate following
conventional lumbar discectomy.
Questionable effectiveness (not yet demonstrated in
controlled clinical trials) for spinal fusion, prolonged spine
surgery, or insertion of foreign material
Ophthalmic
Ophthalmic
Probable pathogens: Staphylococcus epidermidis,
Staphylococcus aureus, streptococci, enteric gramnegative bacilli, Pseudomonas
Prophylaxis: gentamicin (Garamycin), tobramycin
(Nebcin), ciprofloxacin (Cipro), ofloxacin (Floxin), or
neomycin-gramicidin-polymixin B; cefazolin (Ancef,
Defzol)
Most ophthalmologist use antibiotic eyedrops for
prophylaxis in view of the potential for extremely serious
postoperative endophthalmitis.{limited data to support
effectiveness of prophylactic antimicrobials}
No evidence for the rational basis for use of
prophylactic antibiotics when procedures do not
invade the globe
Orthopedic
Orthopedic
Total joint replacement, internal fracture fixation
Probable pathogens: Staphylococcus aureus,
Staphylococcus epidermidis
Prophylaxis cefazolin (Ancef, Defzol) or vancomycin
(Vancocin) (IV)
Vascular
Vascular
Arterial surgery (involving: a prosthesis,
abdominal aorta, or groin incision)
Probable pathogen: Staphylococcus aureus,
Vascular
Rationale for prophylaxis:
Cephalosporin: reduced likelihood of postoperative
infection incidences following arterial reconstructive
surgery on the abdominal aorta, vascular limb
operations involving groin incisions, and lower
extremity amputation for ischemia
Recommended:
for any vascular prosthetic material implantation (e.g.
grafts supporting hemodialysis)
Not indicated for carotid endarterectomy or brachial
artery repair (assuming no prosthetic material
involved)
Cardiac Surgery
Cardiac Surgery
Prosthetic valve, coronary bypass, other open-heart
procedures, pacemaker/defibrillator implantation
Probable pathogen: -- Staphylococcus
epidermidis, Staphylococcus aureus,
Corynebacterium, enteric gram-negative bacilli
Antibacterial drug:
cefazolin (Ancef, Defzol), cefuroxime
(Zinacef, Ceftin)-- IV
Vancomycin, IV(Vancocin) (if above agents
are ineffective or contraindicated)
Thoracic (noncardiac )
Probable pathogens: Staphylococcus aureus,
Cesarean section
Probable pathogens: Enteric
gram-negatives,
anaerobes, enterococci, Group B strep
Prophylaxis: high-risk {active labor or premature
membrane rupture};
cefazolin (Ancef, Defzol) -- IV after cord clamping
Prophylaxis:
first trimester, high-risk {patients with
previous pelvic inflammatory disease,
previous gonorrhea or multiple sex partners)
-- aqueous penicillin V (Pen-Vee K,
Veetids) or
doxycycline (Vibramycin, Doryx )
PROPHYLACTIC ANTIBIOTICS
Medical Prophylaxis
antimicrobial use
PREVENTION of ENDOCARDITIS
Heart valve lesions or prosthetic valve.
(A)Dental procedure under No or L.Anasth.:
Pt. Havnt endocarditis
Amoxycillin(3g PO) 1h before operation
Clindamycin (600mg PO) Penicill.Allergy
Pt. With endocarcitis ( AS under GA ):
Amoxycillin(1g IV) + Gentamicin(120mg)
Vancomycin(1g IV) Allergy to Penicillin
Or Clindamycin(300mg IV) Over 10 min.
PROPHYLACTIC ANTIBIOTIC
(B)Dental procedure under GA :
Pt. Havnt endocarditis :
Amoxycillin (1g IV at induction) or
(3g PO 4h before induction)
Pt. With endocarditis( At risk) :
Amoxycillin(1g )+ Gentamicin(120mg)
at
induction or 15 min.before induction.
Or Vancomycin 1g + Gentamicin(120mg)
Or Clindamycin 300mg IV over 10 min (15
min before induction).
PROPHYLACTIC ANTIBIOTICS
MENINGITIS (meningococcal-N.menigitidis)
* For close contacts(children& adults).
Rifampicin(600mg)
/12h/2days.
or Ciprofloxacin (500mg)
or Ceftriaxone(250mg)
Single dose
Single dose.
IV:2-MU immediately.
ANTIBIOTIC PROPHYLAXIS
RHEUMATIC FEVER:
Benzathine penicillin (IM)
monthly or
Penicillin V( PO)
twice daily
* or Sulphadiazine (PO) 1g/day
* During childhood & early teenage .
GAS GANGERENE (L.L.Amputation) :
* Penicillin G
300-600mg(5000001000000U)/ 6h/5 days .
*Metronidazole(Allergy to Penicillin)
500 mg/8h.
QUINUPRISTIN/DAFLOPRISTIN
A formulation of two bacteriostatic agents
when combined are bactericidal.
Mechanism inhibit protein synthesis at the
505 ribosome.
Spectrum: Similar to Vancomycin i.e. Active
against Streptococci, S.aureus and
coagulase negative Staph.
Used in treatment of Vancomycin
resistant cases.
Klebsiella pneumoniae
Proteus
ciprofloxacin (Cipro)
(Netromycin
Gastrointestinal diseases
Gastrointestinal diseases
Esophageal/gastroduodenal
Probable pathogens:
Gastrointestinal diseases
Biliary tract
Probable pathogens:
Gastrointestinal diseases
Appendectomy, non-perforated
Probable pathogens:
enteric gram-negative bacilli,
anaerobes, enterococci
Treatment:
Cefoxitin (Mefoxin)
Sepsis
Factors in selecting appropriate drugs to
manage sepsis syndrome:
source of infection
gram stain
immune status
bacterial resistance patterns in the community
and hospital
Sepsis
Factors in selecting appropriate drugs to
manage sepsis syndrome:
source of infection
gram stain
immune status
bacterial resistance patterns in the community
and hospital
ANTIBIOTIC SELECTION
By
Prof. ABDEL FATTAH ABDEL SATTAR
HEAD OF ANESTHESIA & PAIN RELIEF
DEPARTMENT
NATIONAL CANCER INSTITUTE
CAIRO UNIVERSTIY
2007
Cefotaxime + Vancomycin
Gastrointestinal diseases
Esophageal/gastroduodenal
Probable pathogens:
Gastrointestinal diseases
Biliary tract
Probable pathogens:
Gastrointestinal diseases
Appendectomy, non-perforated
Probable pathogens:
enteric gram-negative bacilli,
anaerobes, enterococci
Treatment:
cefoxitin (Mefoxin)
Lorcet (hydrocodone/acetaminophen) (IV)
Thoracic (noncardiac )
Probable pathogens: Staphylococcus aureus,
PROPHYLACTIC ANTIBIOTICS
Pneumococcal meningitis :
* Cefotaxime (Vancomycin if resistant).
H.influenza meningitis :
*Cefotaxime or Chloramphenicol +
Riphampicin (4days before discharge)
Listeria meningitis :
*Amoxycillin +gentamicin