Glorieaster B.

Sabando

I.

DDM-4A

PHARMA

Aug. 28, 2015

MEDICAL PROBLEM THAT NEEDS ANTIBIOTIC PROPHYLAXIS

SURGICAL SITE INFECTION (SSI):

Antibiotic prophylaxis is effective for preventing surgical site infections in certain procedures.
However, the use of antibiotics for prophylaxis carries a risk of adverse effects
(including Clostridium difficile-associated disease) and increased prevalence of antibioticresistant bacteria. The choice of antibiotic prophylaxis should cover the organisms most likely to
cause infection and be influenced by the strength of the association between the antibiotic used
and these adverse effects. Using a local antibiotic formulary should ensure that the most
appropriate antibiotic, dose, timing of administration and duration are used for effective
prophylaxis.
Surgical site infection (SSI) is one of the most common complications of surgery in both adults
and children. The purpose of the present review is to highlight the progress in the understanding
of SSIs and the current role of antimicrobial prophylaxis (AMP).
An SSI is diagnosed by a constellation of clinical findings occurring within 30 days of surgery.
Pathologic organisms responsible for the development of an SSI are mainly limited to Grampositive bacteria. Two well documented risk factors for the development of SSI in children are
wound classification by the Centers for Disease Control (CDC) and procedure duration.
Administration of appropriate AMP prior to skin incision has been shown to reduce the incidence
of SSI in selected procedures. However, there is a lack of consensus on which procedures in
children require AMP.
Improvement in the perioperative care of children has reduced both the incidence and outcomes
of SSI. However, several controversies still exist in the use of AMP in children. Future work by
pediatricians, pediatric surgeons, and pediatric infectious disease specialists will enable us to
better understand the specific indications and appropriate AMP in children.
In 2014, the Infectious Diseases Society of America issued the following practice guidelines for
the management of surgical site infections (SSIs):
Suture removal plus incision and drainage should be performed for SSIs (strong recommendation,

low-quality evidence)
Adjunctive systemic antimicrobial therapy is not routinely indicated but, in conjunction with

incision and drainage, may be beneficial for SSIs associated with a significant systemic response, such as
erythema and induration extending more than 5 cm from the wound edge, temperature exceeding 38.5C,
heart rate higher than 110 beats/min, or white blood cell (WBC) count higher than 12,000/L (weak
recommendation, low-quality evidence)

Glorieaster B. Sabando

DDM-4A

PHARMA

Aug. 28, 2015

A brief course of systemic antimicrobial therapy is indicated in patients with SSIs after clean

operations on the trunk, head and neck, or extremities that also have systemic signs of infection (strong
recommendation, low-quality evidence)
A first-generation cephalosporin or an antistaphylococcal penicillin for methicillin-sensitive S

aureus (MSSA)or vancomycin, linezolid, daptomycin, telavancin, or ceftaroline where risk factors for
methicillin-resistant S aureus (MRSA) are high (nasal colonization, prior MRSA infection, recent
hospitalization, or recent antibiotics)is recommended (strong recommendation, low-quality evidence)
Agents active against gram-negative bacteria and anaerobes, such as a cephalosporin or

fluoroquinolone in combination with metronidazole, are recommended for infections after operations on
the axilla, gastrointestinal tract, perineum, or female genital tract (strong recommendation, low-quality
evidence)
Antibiotic Prophylaxis:
The use of antibiotics was a milestone in the effort to prevent wound infection. The concept of
prophylactic antibiotics was established in the 1960s when experimental data established that
antibiotics had to be in the circulatory system at a high enough dose at the time of incision to be
effective.
It is generally agreed that prophylactic antibiotics are indicated for clean-contaminated and
contaminated wounds. Antibiotics for dirty wounds are part of the treatment because infection is
established already. Clean procedures might be an issue of debate. No doubt exists regarding the
use of prophylactic antibiotics in clean procedures in which prosthetic devices are inserted;
infection in these cases would be disastrous for the patient. However, other clean procedures (eg,
breast surgery) may be a matter of contention.
Criteria for the use of systemic preventive antibiotics in surgical procedures are as follows:
Systemic preventive antibiotics should be used in the following cases: A high risk of infection is

associated with the procedure (eg, colon resection); consequences of infection are unusually severe (eg,
total joint replacement); the patient has a high NNIS risk index
The antibiotic should be administered preoperatively but as close to the time of the incision as is

clinically practical Antibiotics should be administered before induction of anesthesia in most situations

The antibiotic selected should have activity against the pathogens likely to be encountered in the

procedure

Glorieaster B. Sabando

DDM-4A

PHARMA

Aug. 28, 2015

Postoperative administration of preventive systemic antibiotics beyond 24 hours has not been

demonstrated to reduce the risk of SSIs

Qualities of prophylactic antibiotics include efficacy against predicted bacterial
microorganisms most likely to cause infection, good tissue penetration to reach wound involved,
cost effectiveness, and minimal disturbance to intrinsic body flora (eg, gut).

Glorieaster B. Sabando
II.

DDM-4A

PHARMA

Aug. 28, 2015

DENTAL PROBLEM THAT NEEDS ANTIBIOTIC PROPHYLAXIS

DENTAL PATIENTS WITH TOTAL JOINT REPLACEMENTS:

Antibiotic prophylaxis recommendations exist for two groups of patients: those with heart
conditions that may predispose them to infective endocarditis; those who have a prosthetic
joints and may be at risk for developing hematogenous infections at the site of the prosthetic.

Patients at potential increased risk of hematogenous total joint infection:

All Patients During the First Two Years Following Joint Replacement
Immunosuppressed Patients:
Inflammatory arthropathies such as rheumatoid arthritis, systemic lupus
erythematosus, Drug- or radiation-induced immunosuppression
Hematogenous infections may appear at any time after joint replacement operations. As
distinguished from delayed infections where general symptoms of infection are absent,
hematogenous infections cause malaise, chills and fever, usually of the septic type.
Roentgenograms of the joint at an early stage of hematogenous infection do not show any sign of
infection as these take time to develop. Nor is the scintigram positive at an early stage. The
diagnosis is beyond doubt only when the same strain of bacteria is cultured from the joint, a
primary focus and blood.

After a prosthesis is implanted, host defenses begin to deposit tissue onto the foreign-body
surface and a layer of glycoprotein begins to develop around the artificial material. This
glycoprotein film can facilitate bacterial adherence to the prosthesis. Once bacteria adhere to the
surface of the prosthesis, a complex biofilm develops that surrounds the bacteria with a protective
glycocalyx layer. This biofilm creates a unique ecosystem on the surface of the prosthesis that
allows the bacteria to adhere to the prosthesis and multiply while inhibiting the ability of
antibiotics and leukocytes to penetrate to the bac-teria. This glycocalyx layer may also make it
difficult to recover organisms during joint aspiration and from intraoperative culture samples.

Microorganisms can be introduced to prosthetic material by either contiguous spread or

hematogenous dissemination. Most prosthetic joint infections probably result from contiguous
spread. This may occur by direct contamination of the prosthesis during the intraoperative
procedure via airborne pathogens in the operating room or from microorganisms from the skin of
the patient and/or the operating room staff. Trauma or the direct spread of microorganisms to the
underlying prosthesis from infected overlying tissue can also result in infection. Finally,
hematogenous seeding of the joint by bacterial pathogens can occur from a number of anatomic
sites, including the oropharynx, respiratory tract, urinary tract, GI tract, and the skin and soft
tissues.

Glorieaster B. Sabando

DDM-4A

PHARMA

Aug. 28, 2015

The most common microorganisms associated with prosthetic joint infections are the
staphylococci. In one retrospective review of 3051 total hip arthroplasties, 47 infections
developed. Staphylococcus aureus was the most common isolate (33%), followed by the gramnegative rods Escherichia coli and Pseudomonas species (38% total), Staphylococcus
epidermidis (12%), and Enterococcus species (10%). In another study, S epidermidis was the
pathogen most commonly isolated (40%), followed by S aureus (19%). In that series, other
recovered isolates were Streptococcus species (11%), gram-negative rods
(7%),Enterococcus species (8%), and anaerobes (2%). Early infections (defined as those
occurring in the first postoperative year) were most commonly caused by S epidermidis,S
aureus, and Streptococcusspecies. Late postoperative infections (after the first postoperative year)
were also primarily caused by staphylococci, but gram-negative rods were commonly recovered
as well.

Glorieaster B. Sabando

DDM-4A
III.

PHARMA

Aug. 28, 2015

DENTAL PROCEDURES THAT DOES NOT NEED

ANTIBIOTIC PROPHYLAXIS

Taking dental radiographs

Dental impressions
Routine dental anesthetic injections through non- infected tissues
Fissure sealants
Supragingival restorations
Placement of removable prosthesis
Adjustment of orthodontic appliances
Placement of orthodontic brackets supragingival
Root canal treatment, if not penetrating the apex
Shedding of deciduous teeth
Bleeding from trauma to the lips and oral mucosa
IV.

ANTIBIOTIC PROPHYLAXIS FOR DENTAL PROCEDURE: