Rational Use of Antibiotics

Rational use of
antibiotics
January 24, 2023

Dr. Tesfaye, MD, General Surgeon
Why?
• Drug resistance
• Wastage
• Cost
• Side effects
Rational Use of Antibiotics January, 25, 2023 2

Mechanisms of resistance
 Enzymatic
 Decreased permeability
 Efflux
 Alteration of target cells
 Bind up of antibiotics

Factors for selection
• Site of infection
• Bactericidal /static
• Route of administration
• Dosing and tissue levels
• True presence of infection (Topical)
• Co-morbid conditions
• Resistance potential

Ideal antibiotics
• Selective toxicity
• Soluble in tissue fluids
• Metabolized slowly
• Less side effect
• Less influence on normal flora of the host
• Less risk of drug resistance
• Low cost
• Good shelf life
Causes of non-response
• Resistance
• Incorrect diagnosis
• Choice of antibiotics (Type, Dose, Route)
• Abscess
• Secondary infection

Best practices
• Urgent treatment (ICU, Sepsis, meningitis)

• Proper interpretation of antibiotic sensitivities
• Hospital infection control
• Multidisciplinary meetings
• Public health

Purpose
 Antibiotics have two uses in surgery:

• To treat established infection
• To prevent postoperative infection
 Less important than:
• Careful aseptic theatre routines
• A thorough wound toilet
• Delayed primary closure
• Making sure there are no foreign bodies, dead tissue, excessive blood
clots, or faeces in the wound
 Antibiotics give you no licence to neglect the classical rules of good
surgery
• Prophylactic antibiotics- given for the purpose of preventing
infection when infection is not present but the risk of
postoperative infection is present
• Empirical antibiotic therapy — which is aimed at the likely

causative organism to manage an infection until
microbiological culture and susceptibility results are known
• Directed therapy - When the cause of an infection is

confirmed and is aimed at the specific pathogen.
Prophylactic Antibiotics
• The aim of prophylaxis is to augment host defense

mechanisms at the time of bacterial invasion.
• Prevention of possible infections
• Prophylaxis is an attempt to attack organisms before they
have a chance to induce infection.
• Decreases bacterial counts at surgical site during incision
• Achieve serum and tissue drug levels, for the duration of
the operation
Basic principles
• Single dose
• Maximum serum level during procedure
• Usually at the time of incision
• Narrow spectrum

Choosing an antibiotic for prophylaxis
• It is multi-factorial
• Should be based on the
• Type of operation
• Kinetics and toxicity of the drugs
• Microbiologic characteristics of the operative site
• Antibiotic sensitivities specific to the particular hospital
environment

Indications
• Clean cases
- Open heart surgery
- Vascular surgery
- Prosthesis and implants
• Clean contaminated
- Obstructive jaundice
- Head and neck, esophagus
- Gynecologic
• Contaminated
- Abdominal
- Trauma

Timing of Administration
• Infusion of cephalosporin and Clindamycin should begin

within 60 minutes before incision, and be completed at the time
of incision
• Infusion of vancomycin should begin 2 hours before incision and
should be completed at the time of incision
• Administration of the antimicrobial at the time of anesthesia
induction is safe
• This results in adequate tissue drug levels at the time of incision
• Ideally it should be given within 30 minutes
Repeat dosing (Intraoperative Re dosing)
 In the vast majority of cases only a single dose of antibiotic is

required
 For procedures lasting more than four hours .
 In the setting of major blood loss(20-25ml/kg)
 Is indicated every one to two half-lives of the drug in patients with

normal renal function.
 Repeat antimicrobial dosing following wound closure

Rational Use of Antibiotics January,is
25,not
2023 16
necessary and may increase antimicrobial resistance.
Duration of prophylactic Antibiotic Use
 Antimicrobial prophylaxis after wound closure does not provide

additional protection from SSI
 Continuing prophylactic antibiotics for the duration drains and catheters

are in place has not been shown to reduce SSI rates
 Continuing antibiotic prophylaxis longer than 24 hours after wound

closure is not beneficial and may contribute to the development of
antimicrobial resistance

Principles of Antibiotic Prophylaxis
Pre op administration, serum levels adequate

throughout procedure with a drug active
against expected microorganisms.
High Serum Levels During Procedure Duration

1. Preop timing 1. Long half-life 1. None after wound closed
2. IV route 2. Long procedure– 2. 24 hours maximum
3. Highest dose redose
of drug 3. Large blood loss–
redose

Recommendations
•2nd or 3rd gen. Cephalosporins are preferred
•We can add metronidazole in colonic surgeries
•True beta-lactam allergy: Clindamycin or vancomycin
•Current or prior MRSA infection, MRSA colonization:
vancomycin

Empiric therapy
 Used when the risk of a surgical infection is high, based on

• The underlying disease process (e.g., ruptured appendicitis) or
• Intraoperative findings.
 Significant contamination during surgery has occurred
• Inadequate bowel preparation
• Considerable spillage of colon contents.
 In critically ill patients in whom a potential site of infection has been identified
 Severe sepsis or septic shock occurs.
 Should be limited to a short course of drug (3 to 5 days),

Monomicrobial infection
• Frequently are nosocomial infections occurring in postoperative patients, such as

UTIs, pneumonia, or bacteremia.
• Appropriate collection of culture specimens to allow for thorough analysis
• Initiate empirical antibiotic therapy which is Broad spectrum as early as possible.
• Delay in appropriate antibiotic treatment increases the mortality.
• Initial drug selection must be based on initial evidence, coupled with institutional
and unit-specific drug sensitivity patterns
• Later narrowing of agents based on patient response and culture and sensitivity
results.

Polymicrobial surgical
infections
 Culture results are of lesser importance in managing these types

of infections as it is less important than the clinical course of the
patient.
 The antibiotic regimen should not be modified solely on the
basis of culture information,
 Should receive an antimicrobial agent or agents directed against
aerobes and anaerobes for 3 to 5 days, occasionally longer.
 Conversion from an intravenous to an oral regimen (e.g.,
ciprofloxacin plus metronidazole) can occur.

Duration of antibiotic administration
• Prophylaxis is limited to a single dose

• Empiric therapy should be limited to 3 to 5 days or less,
• For UTI -3 to 5 days
• For pneumonia 7 to 10 days,
• For bacteremia 7 to 14 days.
• Osteomyelitis, endocarditis, or prosthetic infections for 6 to 12
weeks.

Misuse of antimicrobial agents can result
• Enormous financial impact on health care costs

• Adverse reactions due to drug toxicity and allergy
• The occurrence of new infections such as Clostridium difficile colitis
• The development of multiagent drug resistance among nosocomial
pathogens.

References
• Schwartz's Principles of Surgery, 10th ed.

• Sabiston text book of surgery, 20th ed.
• Campbelle’s orthopedics 11th ed
• Goodman & gilman’s manual of pharmacology and
therapeutics
• Uptodate 21.6
• Internet

Thank you !!!

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Rational use of

January 24, 2023

Rational Use of Antibiotics January, 25, 2023 2

Rational Use of Antibiotics January, 25, 2023 3

Rational Use of Antibiotics January, 25, 2023 4

Rational Use of Antibiotics January, 25, 2023 6

• Urgent treatment (ICU, Sepsis, meningitis)

Rational Use of Antibiotics January, 25, 2023 7

 Antibiotics have two uses in surgery:

• Empirical antibiotic therapy — which is aimed at the likely

• Directed therapy - When the cause of an infection is

• The aim of prophylaxis is to augment host defense

Rational Use of Antibiotics January, 25, 2023 11

Rational Use of Antibiotics January, 25, 2023 12

Rational Use of Antibiotics January, 25, 2023 13

• Infusion of cephalosporin and Clindamycin should begin

 In the vast majority of cases only a single dose of antibiotic is

 For procedures lasting more than four hours .

 In the setting of major blood loss(20-25ml/kg)

 Is indicated every one to two half-lives of the drug in patients with

 Repeat antimicrobial dosing following wound closure

 Antimicrobial prophylaxis after wound closure does not provide

 Continuing prophylactic antibiotics for the duration drains and catheters

 Continuing antibiotic prophylaxis longer than 24 hours after wound

Rational Use of Antibiotics January, 25, 2023 18

Pre op administration, serum levels adequate

High Serum Levels During Procedure Duration

Rational Use of Antibiotics January, 25, 2023 19

Rational Use of Antibiotics January, 25, 2023 20

 Used when the risk of a surgical infection is high, based on

Rational Use of Antibiotics January, 25, 2023 21

• Frequently are nosocomial infections occurring in postoperative patients, such as

Rational Use of Antibiotics January, 25, 2023 22

 Culture results are of lesser importance in managing these types

Rational Use of Antibiotics January, 25, 2023 23

• Prophylaxis is limited to a single dose

Rational Use of Antibiotics January, 25, 2023 24

• Enormous financial impact on health care costs

Rational Use of Antibiotics January, 25, 2023 25

• Schwartz's Principles of Surgery, 10th ed.

Rational Use of Antibiotics January, 25, 2023 26

Rational Use of Antibiotics January, 25, 2023 27

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