수술의예방적항생제사용 - hira.or.kr · cardiac: pacemaker or defibrillator insertion,...
TRANSCRIPT
Introduction
• Surgical site infection (SSI)
– Infection at the site of an operation (usually an
incision) that is caused by the operation
– Defined by clinical, laboratory, survey data
• 2nd~3rd most common cause of Hospital
Acquired Infection
– 2~5% of extra-abdominal operation
– 20% of intra-abdominal operation
2
Impact of SSI, 1990-1995
Infected Uninfected
Mortality 7.8% 3.5%
ICU admission 29% 18%
Readmission 41% 7%
Median initial L.O.S
11 days 6 days
Median total L.O.S
18 days 7 days
Initial excess cost + $3,644
Total excess cost + $5,038(NNIS, 1997)
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나라 병원 감염
SSTI
8%
Other
6%
SSI
15%
BSI
14%
GI inf
8%
UTI
31%
Pneumonia
17%
“1996년도 국내 병원 감염률 조사연구”, 한 병원감염관리학회, 1997.
4
Consequences of surgical site infection
• Additional hospital stay
– Mean 20.4 days*
• Additional cost
– 3,317,812~3,945,829 (won) *
• Morbidity & mortality
* “수술부 감염이 의료비용 재원기간에 미치는 향에 한 연구”,
한병원감염관리학회, 1999
5
SSI Risk Factors
• Patients– Age
– Nutrition status
– Diabetes
– Smoking
– Coexistent infections at a remote body site
– Colonization with microorganisms
– Altered immune response
– Length of preoperative stay
• Operation– Duration of surgical scrub
– Skin antisepsis
– Preoperative shaving
– Preoperative skin prep
– Duration of operation
– Antimicrobial prophylaxis
– Operating room ventilation
– Inadequate sterilization of instruments
– Foreign material in the surgical site
– Surgical drain
– Surgical technique
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Antibiotic Prophylaxis
• NRC Wound Classification
– Clean Surgical Procedures *
– Clean Contaminated Procedures
– Contaminated Procedures*
– Dirty Procedures*
--------------------
* not prophylaxis, but treatment
+Prosthesis
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Antibiotic Prophylaxis -Benefit
• G.I. procedures (including appendicitis)
• Oropharyngeal procedures
• Obstetrical and gynecological procedures
• Vascular (abd. & leg) procedures, prosthesis
• Open heart procedures
• Orthopaedic hardware placement
• Craniotomy
• Some “clean” procedures
8
Optimal Antibiotic Prophylaxis
• Which drug should you use?
• Which route should you use?
• When should you start?
• How much should you give?
• How long should antibiotics be continued?
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Common Pathogens for SSI
• SSI for a skin wound at any site
: Staphylococcus aureus
• Additional pathogens
– Head & Neck : Oral anaerobes
– Below the waist (colon & GY)
: Anaerobes / E. coli (Enterobacteriaceae)
– Insertion of prosthesis
: CNS, S. aureus
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Published Guidelines on Selection of Antibiotics for Surgical Prophylaxis
Operations Recommendation
Colon Cefoxitin or cefotetan / Cefazolin + metronidazole
Ampicillin/sulbactam
Hysterectomy Cefazolin, cefotetan, cefoxitin, cefuroxime, ampicillin/sulbactam
Cardiothoracic Cefazolin, cefuroxime, cefamandole
If b-lactam allergy or high risk of MRSA
: vancomycin, clindamycin
Hip or Knee Cefazolin, cefuroxime
If b-lactam allergy or high risk of MRSA
: vancomycin, clindamycin
Vascular Cefazolin, cefuroxime
If b-lactam allergy : vancomycin, clindamycin
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Use of Vancomycin
• Major Surgical Procedures
– Cardiac and vascular procedures
– Total hip replacement
• High risk of MRSA
– At institutions with a high rate of MRSA infections
: > 20% of surgical wound infections
• Maximum 2 doses
– Repeat dose in massive blood loss, > 6 hours op.
• Risk of VRE
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Route of Administration
• IV : Majority of procedure
• Oral : Gut decontamination in colon surgery
• Topical (paste, irrigation)
: only in Ophthalmologic procedure
13
Timing of Antibiotic Prophylaxis
• Grouping of timing of prophylaxis
– Early : 2 – 24 hours prior to incision
– Preoperative : 0 – 2 hours prior to incision
– Perioperative : 0 – 3 hours after incision
– Postoperative : 3 – 24 hours after incision
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First – Dosing Timing
• All other antibiotics (Cefazolin, etc)
: Start 30 – 60 min. before incision
• Vancomycin
: Start within 120 min. before incision
• Infuse before tourniquet inflated in OS cases
• Infuse after cord clamp in C-section
• Oral : 19 hours before the surgery in colon
prep.
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Size of Patient and Size of Dose
• In Obese patients
: Cefazolin levels lower than in non-obese
patients at same dose
: Cefazolin dose changed from 1g to 2g
Infection rate at 1g : 16.5%
Infection rate at 2g : 5.6%
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Antibiotic Dose
Antibiotics Half-life (h) Standard dose Weight-based dose recommendation
Aztreonam 1.5-2 1-2g 2g maximum
Ciprofloxacin 3.5-5 400mg 400mg
Cefazolin 1.2-2.5 1-2g 20-30mg/kg
(<80kg, use 1g;
>80kg, use 2g)
Cefuroxime 1-2 1.5g 50mg/kg
Cefamandole 0.5-2.1 1g
Cefoxitin 0.5-1.1 1-2g 20-40mg/kg
Cefotetan 2.8-4.6 1-2g 20-40mg/kg
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Antibiotic Dosing
• Redose during surgery if the procedure is still
underway 2 half-lives the drug is given
• Ensure an adequate, weight-based dose of
the antibiotics
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Antibiotic Dose
Antibiotics Half-life (h)
Standard dose
Weight-based dose
recommendation
Recommended redosing interval, hr
Aztreonam 1.5-2 1-2g 2g maximum 3-5
Ciprofloxacin 3.5-5 400mg 400mg 4-10
Cefazolin 1.2-2.5 1-2g 20-30mg/kg
(<80kg, use 1g; >80kg, use 2g)
4
Cefuroxime 1-2 1.5g 50mg/kg 3-4
Cefamandole 0.5-2.1 1g 3-4
Cefoxitin 0.5-1.1 1-2g 20-40mg/kg 3
Cefotetan 2.8-4.6 1-2g 20-40mg/kg 6
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Effect of Duration of Operation
Op. Duration Infection Incidence
< 3 hours 0/17
3 – 4 hours 2/25 (8%)
> 4 hours 5/14 (36%)
(Kaieser, Ann Surgery 198:525, 1983)
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Duration of Prophylaxis
• Most studies have confirmed efficacy of
prophylactic antibiotics within 24 hours
after surgery
• Many studies have shown efficacy of a
single does
• Whenever compared, the shorter course
has been as effective as the longer course
• Cardiothoracic Surgery : <72 hours (?)
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Problems with prolonged antibiotic prophylaxis
• Increased risk for C. difficile infection
• Increased risk for resistant bacteria
• Increased risk for drug reaction
• Increased incidence of MRSA
infection/colonization
• Increased cost
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Goal of Prophylactic Antibiotics
• Prevent postop. Infection of the surgical site
• Prevent postop. Infectious morbidity and
mortality
• Reduce the duration and cost of health care
• Produce no adverse effects
• Have no adverse consequences for the
microbial flora
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Upper GI surgery
• Lower incidence of infect than lower GI surgery– Gastric acidity, low number of commensals
Procedure Likely pathogens
Antimicrobial
Esophageal, gastroduodenal in high risk patients*
Enteric gram-negative bacilli,
Gram-positive cocci
cefazolin
Endoscopic esophageal dilatation, varix ligation, percutanues endoscopic gastrostomy
*: gastric ulcer surgery, duodenal ulcer with hemorrhage, obstruction or perforation, morbid obesity, malignancy, H2-block or proton-pump inhibitor
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Biliary-tract surgery
Procedure Likely pathogens
Antimicrobial
Biliary tract surgery or ERCP in high risk patients*
Enteric gram-negative bacilli, enterococci, clostridia
Cefazolin, cefoxitin, cefotetan
*: age> 70 years, acute cholecystitis, nonfunctioning gall bladder, obstructive jaundice, previous history of cholangitis, or common duct stones
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Colorectal surgery
Procedure Likely pathogens Antimicrobial
Colorectal surgery Enteric gram-negative bacilli, enterococci, anaerobes
Oral: neomycin plus
erythromycin base
IV: cefoxitin, cefotetan, or
cefazolin+ Metronidazole
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Appendectomy
Procedure Likely pathogens
Antimicrobial
Appendectomy without perforation (if, perforation (+) à
therapeutic usage)
Enteric gram-negative bacilli, anaerobes, enterococci
Cefoxitin or cefotetan
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Other general surgery
Procedure Likely pathogens
Antimicrobial
Inguinal herninorraphy with mesh repair
Staphylococci, gram-negative bacilli
Ampicillin/sulbactam*, cefazolin
Mastectomy: still controvertial.
Staphylococci Cefazolin
*: Ann Surg 2001;233:26-33
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Gynecologic surgery
Procedure Likely pathogens Antimicrobial
Hysterectomy, vaginal or abdominal
Enteric gram-negative bacilli, anaerobes, enterococci, group B strep
Cefoxitin, cefotetan, or cefazolin
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Obstetric surgery
Procedure Likely pathogens
Antimicrobial
Cesarean section, in a patient with active labor or premature rupture of membranes
Enteric gram-negative bacilli, anaerobes, enterococci, group B strep.
Cefazolin after cord clamping
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Thoracic surgery
Procedure Likely pathogens Antimicrobial
Cardiac: pacemaker or defibrillator insertion, and open heart surgery
Staphylococci, corynebacteria, enteric gram-negative bacilli
Cefazolin, cefuroxime,
(or vancomycin)
Non-cardiac: lobectomy, pneumonectomy, chest tube insertion with severe chest trauma such as hemothorax
(not in spontaneous pneumothorax)
Staphylococci, streptococci, enteric gram-negative bacilli
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Vascular surgery
Procedure Likely pathogens Antimicrobial
Arterial surgery involving prosthetic material, abdominal aorta, groin incision, leg amutation for arterial insufficiency
Staphylococci, streptococci
Cefazolin
(or vancomycin)
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Orthopedic surgery
Procedure Likely pathogens Antimicrobial
Orthopedic surgery: therapeutic usage for open fracture, not indicated in arthroscopic surgery
Staphylococci Cefazolin
(or vancomycin)
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Neurosurgery
Procedure Likely pathogens Antimicrobial
Neurosurgery Staphylococci Cefazolin
(or vancomycin)
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Head & Neck surgery
Procedure Likely pathogens Antimicrobial
Head and neck: with incision through oral or pharyngeal mucosa, cochlear implant
Oral anaerobes, gram-negative bacilli, Staphylococci
Ampicillin/sulbactam, clindamycin plus gentamicin, or
cefazolin
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Urologic surgery
Procedure Likely pathogens
Antimicrobial
Genitourinay: high-risk patients only*
Enteric gram-negative bacilli, enterococci
Ciprofloxacin, trimethoprim-
sulfamethoxazole
*: urine culture positive or unavailable, preoperative bladder catheter, transrectal prostatic biopsy
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Opthalmic surgery
Procedure Likely pathogens Antimicrobial
Opthalmic surgery: lack of data
Staphylococci, streptococci, gram-negative bacilli including
Pseudomonas aeruginosa
Topical, subconjunctival, or
IV
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£ 수술 절개 전 방적 항생제 :절개 1시간 내여
£ 수술 종료 후 방적 항생제 여 간 : POD 5내
£ 방적 항생제 택– 1 cephalosporin계 항생제 metronidazole 병
합사– 2 cephaslosporin계 항생제 단 사 또
metronidazole 병합 사– 3 cephalosporin계 항생제 단 사 또
metronidazole 병합 사– Aminoglycoside계 수술 가 반드시 필 하다고 하
경
항문학회 고안(2007.9)40
평가 상 수술
상과 수술 평가
흉 과 심 수술,CABG 심평원,진흥원
정형 과고 절 전/ 치환술 심평원,진흥원
슬 절 전치환술 심평원,진흥원
과
수술 심평원,진흥원
절제술 심평원,진흥원
담낭절제술 심평원
산 과적출술 심평원,진흥원
제 절개술 심평원
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평가 지표지표 평가 준 평가
피 절개 전 1시간 내 여 비 100% 심평원,진흥원
항생제 병 여 비 0% 심평원
피해야 할항생제조합
병 여비
2개 상 cepha계 항생제 0% 진흥원
cepha+penicillin 0% 진흥원
cepha+aminoglycoside 0% 진흥원
3rd cepha 0% 심평원,진흥원
aminoglycoside 0% 심평원,진흥원
수술 후항생제
여중단시
1 내
단축고
심평원,진흥원(시범)
1~3 내 심평원,진흥원(시범)
3~5 내 심평원,진흥원(시범)
5~7 내 심평원,진흥원(시범)
7 초과 심평원,진흥원(시범)
평균 여수
원 중(경 +비경 ) 심평원
원 중 + 퇴원약 심평원
퇴원 항생제 처방 비 0% 심평원
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2011년 수술 방적 항생제 사추 평가 계획(안)
• 7개 진료과 11종 수술
– 존 상 : 4개 진료과 8종 수술
– 신규 상 : 3개 진료과 3종 수술
진료과 수술 종 수술
존 평가 상
과
수술 전절제술, 아전절제술
수술 결 절제술, 직 및 에스 절제술, 결 및 직 전절제술
복강경하담낭수술 복강경하 담낭절제술
정형 과고 절치환술 고 절전치환술, 고 절 치환술
슬 절치환술 슬 절전치환술
산 과적출술 전 적출술, 질식 전적출술
제 절개술 1태아 신 초회 초산 및 경산, 반복
흉 과 심 수술 동맥간 회 조 술, 판 형술, 공판 치환술
‘10년 신규 평가
상
신경 과 개 술
개 술 또 개절제술, 혈종제거 한 개 술, 종양절제
한 개 술, 뇌동맥 수술, 뇌동정맥 형적출술, 개강내혈
문합술, 뇌엽절단술, 뇌엽절제술, 개강내뇌신경수술
비뇨 과 전 절제술전 적출술, 전 정낭전적출술,
경 적전 절제술, 택적 전 화술
안 과 녹내 녹내 수술, 녹내 플란 삽 술
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평가 지표
• 총 12개 지표
– 존 : 9개 지표
– 신규 : 3개 지표 추가
지표 존 8개 수술 신규 3개 수술
방적 항생제
지표
최초
여시
○ 피 절개 전 1시간 내에 최초 방적 항생제 여 ○○
(녹내 수술 제 )
○ Proximal tourniquet inflation 전 방적 항생제 여 슬 절치환술 적 -
항생제 택
○ Aminoglycoside 계열 여 ○ ○
○ 3 상 Cephalosporin 계열 여 ○ ○
○ 방적 항생제 병 여 ○ ○
여 간
○ 퇴원 시 항생제 처방 ○ ○
○ 방적 항생제 총 평균 여 수(병원 내 여+퇴원처방) ○ ○
○ 항생제 알러지 ○ ○
○ ASA class ○ ○
환 지표
○ 수술 후 혈당 조절 환 비 심 수술 적 -
○ 적절한 제 환 비○
(슬 절치환술 제 )-
○ 수술 후 정상 체 지 환 비 ○ -
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Summary
• Prophylaxis should be started shortly before incision
• “Short duration” generally as effective as “long”
• Prophylaxis should be discontinued in most operations within 24 hours after the incision is closed (except cardiac op)
• Prolonged prophylaxis results in resistance, adverse patient events, and increasing cost.
46
Main References
• Bratzler DW, Houck PM, Surgical Infection Prevention Guidelines Writers Workgroup. Antimicrobial Prophylaxis for Surgery: An Advisory Statement from the National Surgical Infection Prevention Project.Clinical Infectious Diseases 2004; 38:1706–15
• 양수. 방적 항균 법. 항생제 제3판2008;59-63
• Classen DC, Evans RS, Pestotnik SL, Horn SD, Menlove RL, Burke JP. The timing of prophylactic administration of antibiotics at the risk of surgical-wound infection. N Engl J Med. 1992;326(5):281-6
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