ANTIBIOTICS IN

SURGERY
Tuan Ahmad Zulkarnain
Nur-Liyana
Supervisor: Dr. Zalikha

OUTLINE
Introduction
Antibiotics Classification
Uses of Antibiotics in Surgery

Prophylaxis
Therapeutic

Take home messages

ANTIBIOTICS

A substance which has the capacity to kill or

inhibit the growth/ spread of microorganism

NORMAL FLORA

ANTIBIOTICS CLASSIFICATION

Principles of Antibiotics
in Surgery
Indication (prophylaxis vs. therapeutic)
Susceptibility vs. empirical
Pharmacokinetic
Pharmacodynamics
Combination ?
Cost
Availability
Monitoring
Compliance

Antibiotics Prophylaxis in
Surgery

Use of antibiotic where there is no evidence of infection

but expected to be exposed to pathogens that constitutes

a major risk of infection.

Single dose regime, based on the most common

organism, which is given at the time of induction

to ensure the minimum inhibitory concentration
during skin incision reduces risk of surgical site
infection (SSI) and post op infection

 Usually a single dose is sufficient. A second dose

may be required in the following situations:

a. in prolonged operations
b. when there is contamination during operation
Giving more than 1 or 2 doses postoperatively is
generally not advised. The practice of continuing
prophylactic antibiotics until surgical drains have
been removed is not recommended.
(NAG 2008)

General Principles of Surgical

Prophylaxis
A single preoperative dose of antibiotic is as
effective as full five days course of therapy
assuming uncomplicated procedure.

Prophylactic antibiotics should be administered

within 1 hour prior to incision, preferably with
induction of anesthesia.

Prophylactic antibiotics should target

anticipated organisms.

 Prophylaxis is generally recommended for

clean-contaminated (risk of infection is 6%)

and contaminated (risk of infection is 15%)
operations

In clean operation prophylaxis is also

indicated under certain conditions i.e. where

there is prosthesis implanted, high risk
perforation where infection is catastrophic
e.g. neurosurgery or cardiac surgery.

Classification of Surgical Wound

Goals of Antibiotic
Prophylaxis
Reduce the incidence of surgical site infection

(SSI)
Minimize the effect on the patients normal
bacterial flora.
Minimize adverse side effects of antibiotics.
Minimize the emergence of antibiotics
resistant strains of bacteria.
Cost effectiveness.

GUIDELINES FOR SURGICAL

PROPHYLACTIC ANTIBIOTICS
PROCEDURE

SUGGESTED ANTIBIOTIC

1. GI surgery
2. HBS surgery

IV Cefoperazone 1g PLUS IV
Metronidazole 500mg

1. Hernia repair with mesh

(includes laparoscopic repair)
2. Breast
(not recommended for minor
excision
3.Burns

IV Cloxacillin 1G

Vascular Operation

IV Ampicillin/Sulbactam 1.5g

Neurosurgery

IV Ceftriaxone 1g AND
IV Metronidazole 500mg

Urology

IV Amoxicillin / clavulanate 1.2g

THERAPEUTIC
ANTIBIOTICS

Synergism/
Additive
therapy

Combinati
on

Multiple
pathogen
s

Prevent
resistan
ce

Site of
infection

C&S

Therapeut
ic
Antibiotic
s:
PRINCIPLE
S

Pharmacodynamics
& TDM

Host
status

THERAPEUTI
C
ANTIBIOTIC
S
Empirical
Initiation of treatment
prior to determination
of a firm diagnosis

Definitive
Specific to organism
isolated in C&S

EMPIRIC THERAPY
When to start ?

Risk of surgical infection is high - based on the

underlying disease process (e.g. perforated appendicitis)
[prophylaxis empiric]

Significant contamination during surgery has occurred

(e.g. considerable spillage of colon contents)

In critically ill patients potential site of infection has

been identified

Severe sepsis or septic shock

Short course (3-5 days)

Stop if the presence of a local site or systemic
infection is not revealed

MONOMICROBIAL VS
POLYMICROBIAL
Monomicrobial infections:

Nosocomial which occurred in postoperative patients,

e.g. UTI, pneumonia, catheter-related infection

Polymicrobial infections:

culture results less helpful

Thus, antibiotic regimen should not be modified

solely on culture information. Clinical course is
more important.

Systemic Inflammatory
Response Syndrome (SIRS)
Empiric antibiotics are not indicated for all

patients with SIRS

Indications for antibiotic therapy include the
following:

Suspected or diagnosed infectious etiology (e.g. UTI,

pneumonia, cellulitis)

Neutropenia or other immunocompromised states

Asplenia - Due to the potential for overwhelming
postsplenectomy infection

Stomach & Duodenum:

HBS:
H. pylori
1) Liver
Enterobacteriacea
Clarithromycin &
Flagyl
or
e,
Enterococci,
Amoxycillin
Bacteroides
Cefobid & Flagyl Jejunum,
Ileum, Large
penetrate
well
bowel: into abscess
Pancreas:
Enterobacteriaceae,
cavity
Enterobacteriacea
Enterococci,
Ampicillin
&
e, B. fragilis
Bacteroides
&
Gentamicin
Ciprofloxacin/Flag
Ampicillin
&
Flagyl
yl, Carbapenems
&
2) Gentamicin
GB
Metronidazole
E. coli, Klebsiella,
Broad
spectrum
(3rd
Strep.
faecalis
generation
Only certain
Cephalosporins)
& be
antibiotics can
Flagyl
excreted in bile
Unasyn, Cefobid &
Flagyl
Cholangitis
Imipenem, Tazocin

 Abdominal trauma 3

generation
Cephalosporins, Cefuroxime, Augmentin, Unasyn
Perforated viscus, Peritonitis - 3rd generation
Cephalosporins & Flagyl
Breast abscess (S. aureus) Cloxacillin
Mycotic pseudoaneurysm Cloxacillin
Prostethic graft infection - 3rd generation
Cephalosporins
MRSA - Vancomycin
rd

DURATION OF THERAPY
Duration should be long enough to prevent

relapse yet not excessive, as it can increase

side effects and resistance
Factors such as decreasing trend of WBCs
and lack of fever guide the length of therapy
The search for extra abdominal source of
infection or a residual /ongoing source of
intra abdominal infection should be sought

DURATION OF THERAPY
Penetrating GI trauma without extensive

contamination
12-24hours
Perforated/gangrenous appendicitis
3-5days
Peritoneal soilage due to perforated viscus
with moderate degrees of contamination
5-7days
Extensive peritoneal
soilage/immunocompromised host
7-14days

SIDE EFFECTS
Antibiotic

Side Effects

Penicillins

Allergy (serious anaphylaxis)

Cephalosporins

Allergy

Aminoglycosides

Hearing loss
Vertigo
Renal dysfunction

Carbapenems

Seizures (Imipenem)
Rashes

Macrolides

Prolonged QT interval
(Erythromycin)
Hearing loss
Jaundice

ANTIBIOTIC RESISTANCE
Resistance of a microorganism to an

antimicrobial agent to which it was

previously sensitive
Resistant organisms are able to withstand
attack by antimicrobial medicines so that
standard treatments become ineffective
and infections persist and may spread to
others

ANTIBIOTIC RESISTANCE
Intrinsic
Drug target is not present in the bacterias
metabolic pathways
Acquired
Mutation
Transfer of genetic material from resistant to
susceptible organisms (plasmids, transposons,
bacteriophages)

Main factors contributing to resistance are:

Excess antibiotic usage

Incorrect use of broad spectrum agents
Incorrect dosing
Non compliance

TAKE HOME MESSAGES

Prophylactic antibiotic should be given in clean surgery which involves

prosthetic implants, in clean-contaminated and contaminated surgeries

Prophylactic antibiotics should be administered within 1 hour prior to
incision
Therapeutic antibiotic should be started for dirty wound
Empirical therapy should be altered according to the sensitivity of the
culture
Escalation and de-escalation of antibiotics should be done based on
clinical response and aided by culture and sensitivity results
Therapeutic drug monitoring is done in antibiotics with narrow
therapeutic range (Amikacin, Gentamycin, Vancomycin)
Allergic reactions include anaphylaxis, fever, rashes, nephritis,
granulocytopenia & hemolytic anemia are possible side effects of
Penicillins and Cephalosporins
Appropriate choice of antibiotics, dosage, compliance should be ensured
to avoid emergence of resistance

THANK YOU
References:
National Antibiotic Guideline 2008
Schwartzs Principles of Surgery
Niederman MS. Principles of appropriate antibiotic
use
Medscape
Enterococcal Resistance An Overview (YA Marothi,
H Agnihotri, D Dubey) Indian Journal of Medical
Microbiology, (2005) 23 (4):214-9
Antibiotics in the treatment of biliary infection (J S
Dooley,J M Hamilton-Miller,W Brumfitt, andS
Sherlock) Gut. 1984 Sep; 25(9): 988998.