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Sepsis in Surgical Practice Dr A. Badrek-Amoudi FRCS

Sepsis in Surgical Practice Dr A. Badrek-Amoudi FRCS. Historical Overview. Contagious disease- The concept1830 Bacteria as a cause of disease, leeuwenhoek 1850. Hand washing, Semmelweis 1850. Introduction of the principle of aseptic surgery (Carbolic acid), Lister 1880.

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Sepsis in Surgical Practice Dr A. Badrek-Amoudi FRCS

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  1. Sepsis in Surgical Practice Dr A. Badrek-AmoudiFRCS

  2. ABA-UMQU- Antibiotics in Surgical Practice

  3. Historical Overview • Contagious disease- The concept1830 • Bacteria as a cause of disease, leeuwenhoek1850. • Hand washing, Semmelweis 1850. • Introduction of the principle of aseptic surgery (Carbolic acid), Lister 1880. • Steam sterilization, Schimmelbusch & Octave 1990 • Early 20th century Halstedintroduced the use of gloves. • 1928 Alexander Fleming discovered Penicillin ABA-UMQU- Antibiotics in Surgical Practice

  4. ABA-UMQU- Antibiotics in Surgical Practice

  5. Antisepsis • OR environment. • Drapes and instruments • Hand washing • Gloves and other barrier methods • Short preoperative stay • Treat remote infections • Skin and bowel preparation • Improved host defences • Improved surgical technique • Minimization of cross infection • Infection control • ? Hair removal ABA-UMQU- Antibiotics in Surgical Practice

  6. Nasocomial)) Hospital Acquired Infections Infections that become clinically evident with in 48 hours of admission Found: • Common postoperative infections • In critically ill patients (ICU) Significance: • Increased postoperative mortality • Increased Hopspital stay • Increased cost of surgical care • Afflicated by multiresistanct organisms ABA-UMQU- Antibiotics in Surgical Practice

  7. Hospital Acquired Infections Risk factors: • Age > 70 • Shock • Steroids • Chemotherapy • ICU > 3 days • Mechanical ventilation • Invasive monitoring • Indwelling catheter > 10 days • Surgical • Acute renal failure ABA-UMQU- Antibiotics in Surgical Practice

  8. Hospital Acquired InfectionsThe most common infections • Blood stream infections 28% • Lower respiratory tract infections 21% • Wound Infections:7% • Urinary tract infections 15% • GI, Skin.. 10% ABA-UMQU- Antibiotics in Surgical Practice

  9. Hospital Acquired InfectionsThe most common organisms ABA-UMQU- Antibiotics in Surgical Practice

  10. Hospital Acquired InfectionsThe most common organisms ABA-UMQU- Antibiotics in Surgical Practice

  11. Hospital Acquired InfectionsThe most common infectionsWound Infections • Present if: • Wound red or swollen • Requiring opening • Exudate: Serous or pus • Antibiotics are prescibed because of concerns over the wound • Clinically: • Cellulitis • Localized abscess • Non clostridial gangrene • Clostridial: gas and non gas forming gangrene • Wound culture: • A positive culture does not prove infection • A negative culture does not exclude infection ABA-UMQU- Antibiotics in Surgical Practice

  12. Hospital Acquired InfectionsThe most common infectionsChest infection • Risk factors: • Age • Aspiration • Head injury • Smoking • Intubation • Lung injury • Upper abdominal incisions • Prolonged hospital preoperative hospital stay • Organism: 1. 75% gram negative, 2 . 20 % S aureus, 3. 5% Candida ABA-UMQU- Antibiotics in Surgical Practice

  13. Hospital Acquired Infections: The most common infectionsOthers: • Central lines: Treat by • Course of antibiotics • Replacement, same site • Replacement different line • Always send tip for micro on removal • UTI: Associated with urinary catheters (105 OPM) • Intra-abdominal abscess • Infection at time of surgery • Contamination from perforation,trauma..etc • Tertiary peritonitis • Infected implants or prosthetic material ABA-UMQU- Antibiotics in Surgical Practice

  14. Antibiotic resistance • Up to 70% of hospital acquired infections are resistant to antibiotics • Causes: • Previous exposure to antibiotics • Inappropriate use of antibiotics • Prolonged hospital stay • Poorly inforced infection control measures • Lack of nursing staff • Mechanism : • Beta lactemases • DNA gyrases, topisomorase • Point mutations…etc ABA-UMQU- Antibiotics in Surgical Practice

  15. Hospital Acquired InfectionsResistance:MRSA (MethicillinResitant Staph Aureus) • Associated with morbidity , mortality, increased hospital stay and treatment cost. • Usually nasocomial but community accquied infections are now present. • Associated with; • Use of broad spectrum antibiotics • Macroloids, 2. fluroquinalones, 3. cephlosporins • Previous hospital admission • Prolonged hospital/ICU stay • Entral feeding • Surgery ABA-UMQU- Antibiotics in Surgical Practice

  16. Hospital Acquired Infections Resistance: Others: • Pseudomonas aeruginosa • E Coli • Enterobacter cloacae • Kelbsiellaspp ABA-UMQU- Antibiotics in Surgical Practice

  17. Hospital Acquired Infections 1The Fight: ABA-UMQU- Antibiotics in Surgical Practice

  18. Hospital Acquired Infections 2The Fight: ABA-UMQU- Antibiotics in Surgical Practice

  19. Hospital Acquired InfectionsThe Fight: 3 ABA-UMQU- Antibiotics in Surgical Practice

  20. Hospital Acquired InfectionsThe Fight: 4 ABA-UMQU- Antibiotics in Surgical Practice

  21. Antimicrobial Therapy Antibiotics in surgical practice are only an adjunct to treating surgical infection Before using an antibiotic ask the following • Is an antibiotic required? • Is it for treatment or prophylaxis? • What is the likely pathogen (spectrum)? • What is the site AB are required to reach (tissue penetration)? • Route of administration? • Resistance? • Any Allergies? • Is the patient Immunocompromised? • Toxicity • What is the cost? ABA-UMQU- Antibiotics in Surgical Practice

  22. Classes of Antibiotics ABA-UMQU- Antibiotics in Surgical Practice

  23. Target Sites ABA-UMQU- Antibiotics in Surgical Practice

  24. Summary of Differences ABA-UMQU- Antibiotics in Surgical Practice

  25. Staphylococcus ABA-UMQU- Antibiotics in Surgical Practice

  26. Streptococcus ABA-UMQU- Antibiotics in Surgical Practice

  27. Gram negatives ABA-UMQU- Antibiotics in Surgical Practice

  28. Anaerobes ABA-UMQU- Antibiotics in Surgical Practice

  29. Beta lactams • All have a beta lactam ring as a basic structure Penicillins Benzyle Penicillin……..Staph/Streps Flucloxcacillin…………Staph Co-amoxiclav………… Staph/G-ve/Bacteroids Pipracillin…………… Psuedomonas Cephalosporins 3 groups 10% Cross sensitivity in patients with penicillin allergy 3 generations with Increased G-ve & decreased G+ve in fourth generation. Carbapenenms Truly broad spectrum ( G negative, positive and anaerobes) May provoke seizures May promote highly resistant organisms ABA-UMQU- Antibiotics in Surgical Practice

  30. Aminoglycosides • Active against staph.aureus and aerobic G-ve • Narrow theraputicratio ( easily toxic) • Monitor renal function and auto-toxicity • Examples: • Gentamicn • Tobramicin • Amicacin ABA-UMQU- Antibiotics in Surgical Practice

  31. Macroloids & Quinalons • Macroloidse.g. erythromicin, clarithromycin • An alternative in penicillin sensitivity • New generations have improved bioavailability, better oral absorbtion and fewer GI side effects. • Quinalons e.g. Ciproflucloxacillin • Good tissue penetration • Gram negative activity • Attains good levels on oral intake. ABA-UMQU- Antibiotics in Surgical Practice

  32. Prophylaxis When anatomical barriers are breached leading to contamination: faeces, bile..etc. When the consequence and risks are unacceptably high In traumatic wounds In immunocompromised Age> 70 Theraputic Emperical therapy The likely organism & antibiotic susceptibility Avoid using a single agent Avoid using agents with inadequate cover Avoid AB with serious side effects. Definitive therapy The Use of Antibiotics ABA-UMQU- Antibiotics in Surgical Practice

  33. Drug administration 1. Route Intravenous if: • Patient is seriously ill with inconsistent intestinal absorption or inability to oral medication. • IV ensures rapid adequate serum levels. • Be aware of theraputic window. Oral step down if : • T < 38, • Oral intake is tolerated, • Good absorbtion, • No unexplained tachycardia, • No need for high tissue concentrations • suitable oral prep available ABA-UMQU- Antibiotics in Surgical Practice

  34. Drug administration • Duration • Treatment failure: • Wrong AB/ Wrong dosing • Other causes of infection • Fungal superinfection • Inappropriate administration • Persistent source of infection ABA-UMQU- Antibiotics in Surgical Practice

  35. Scenario 1 A 65 year old diabetic gentleman presented with swelling, erythema of his R leg. Clinically he was in septic shock with fowl smell and areas of necrosis, gangrene and crepitation noted on the leg ABA-UMQU- Antibiotics in Surgical Practice

  36. Scenario 2 A 75 year old gentleman was admitted to ICU following major laparotomy. He was intubated, had a central line and a urinary catheter. 1 weeks following his admission he developed a fever there was a green discharge around the CVP line with areas of consolidation on the R lung base ABA-UMQU- Antibiotics in Surgical Practice

  37. Principles of Antibiotics Prophylaxis • Choose an AB against the most likely organism • AB with low toxicity. • Monotherapy • A single dose 30-60 minutes pre-op. • A second dose if OP lasts > 4 hours • Add 2-3 doses post-op • Prolonged use is appropriate when infection is likely or it’s consequence is devastating. ABA-UMQU- Antibiotics in Surgical Practice

  38. Scenario 3 A 35 year old lady presented with R hypochondrial pain. The diagnosis of cholecystitis is confirmed and laparoscopic cholecystectomy is planned ABA-UMQU- Antibiotics in Surgical Practice

  39. Scenario 4 An elderly lady is undergoing a total hip replacement for severe osteoarthritis of her hip. ABA-UMQU- Antibiotics in Surgical Practice

  40. Prophylaxis ABA-UMQU- Antibiotics in Surgical Practice

  41. Distribution of Anti-microbial Agents ABA-UMQU- Antibiotics in Surgical Practice

  42. Pseudomembraneous colitis ABA-UMQU- Antibiotics in Surgical Practice

  43. Pseudomembraneous colitis • Cause: clostridium difficile • Risk factors: • Broad spectrum antibiotics • Proton pump inhibitors • Clinical features: • Voluminous diarrhea • colitis • Diagnosis: • endoscopic veiw, stool toxin • ESR/ WBC/ CT • Treatment: Vancomicin/ Metronidazole ABA-UMQU- Antibiotics in Surgical Practice

  44. Allergy • 2-3% of patients • Anaphylaxis 0.1% • Need detailed history of positive reactions • Cross-reaction: 8-10% • Skin reaction not needed • Atopy may an independent risk factor ABA-UMQU- Antibiotics in Surgical Practice

  45. Miscellaneous • Hair removal Shave on morning of surgery, use clippers • Hypothermia Avoid • Bowel preparation No difference • Hyperglycaemia Avoid ABA-UMQU- Antibiotics in Surgical Practice

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