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PEMBERIAN ANTIBIOTIK PROFILAKSIS DALAM PEMBEDAHAN OBSTETRI DAN GINEKOLOGI
Dr. Budi Iman Santoso, SpOG(K)
Divisi Urologi RekonstruksiDepartemen Obstetri dan Ginekologi
Fakultas Kedokteran Universitas IndonesiaRumah Sakit Dr. Cipto Mangunkusumo, Jakarta
1. Praoperatifa. Persiapan pasienb. Antisepsis tim bedahc. Penaganan personal bedah yang
terkena infeksid. Antibiotik profilaksis
1. Intra operatifa. Ventilasi b. Membersihkan dan desinfeksi
lingkunganc. Sampling mikrobiologid. Sterilisasi instrumen bedahe. Perlindungan tubuh f. Tehnik bedah dan asepsis
2. Perawatan luka pasca bedah3. surveilens
MENCEGAH INFEKSI LUKA OPERASI:
PENGGUNAAN ANTIBIOTIK DALAM KLINIK
Profilaksis:diberikan pada pasien sebelum kontaminasi atau infeksi terjadi
Antisipasi:termasuk situasi dimana kontaminasi sudah terjadi dan pengobatan diberikan untuk meminimalkan infeksi pasca bedah
Empirik : pengobatan tidak langsung terhadap tidak teridentifikasinya patogen
Langsung: patogen teridentifikasi
HUBUNGAN PEMBEDAHAN DENGAN INFEKSI
Diperkirakan 60% pasien yang berobat ke rumah sakit menjalani pembedahan
Insiden : tergantung dari jenis pembedahan, faktor risiko dan anti mikroba yang dipakai
Diperkirankan lebih dari 70% merupakan infeksi nosokomial
BERBAGAI FAKTOR YANG BERHUBUNGAN DENGAN PENINGKATAN RISIKO INFEKSI BEDAH
Host Factors• Older age• Obesity• Malnutrition• Diabetes mellitus• Immunocompromising
diseases or therapies• Presence of other
infections• Skin diseases
Preoperative Factors• Prolonged pre-op stay• Shaving the skin• Inadequate antibiotic prophylaxis
Surgical Factors• Inadequate skin antisepsis• Emergency procedure• Prosthetic implants• Prolonged procedure• Use of drains• Poor technique• Unexpected contamination
Environmental Factors• Staph. or Strep. carrier• Excessive activity in OR• Contaminated antiseptics• Inadequate ventilation• Inadequately sterilized equipment
PATOGENESIS INFEKSI LUKA BEDAH
Infeksi pada luka bedah terjadi bila inokulum kuman pada luka melampaui mekanisme pertahanan tubuh sehingga terjadi pertumbuhan kuman
KLASIFIKASI KONDISI LUKA OPERASI
Bersih Bersih terkontaminasiTerkontaminasi kotor
ANGKA INFEKSI LUKA OPERASI ANGKA INFEKSI LUKA OPERASI SURVEY PREVALENS WHOSURVEY PREVALENS WHO
Mayon-White et al. An international survey of the prevalence of hospital-acquired infection. J Hosp Infect 1988
Conducted in 47 hospitals in 14 countries during 1983-85
Wound Class Prevalence x 100 post-op patients
Clean 13.3Clean-contaminated 16.4Contaminated 28.9
All 16.6(range 4.6-34.4)
Olson & Lee. Continuous, 10-year wound infection surveillance. Arch Surg 1990;125:794.
Annual Surgical Site Infection Rate by Wound Class in a Large U.S. Hospital
0
2
4
6
8
10
12
14
'77 '78 '79 '80 '81 '82 '83 '84 '85 '86
# SS
I per
100
pro
cedu
res
AllCleanClean-contaminatedContaminated/Dirty-Infected
ENAM ATURAN PEMBERIAN ANTIBIOTIK PROFILAKSIS DALAM UPAYA MENCEGAH INFEKSI LUKA BEDAH
1. Gunakan antibiotik bila risiko infeksi tinggi atau sequalae tinggi
1. Jangan diberikan terlalu cepat atau lambat dan kadarnya dalam jaringan mencapai puncak ketika pisau mulai menyayat
PENGARUH SAAT PEMBERIAN ANTIBIOTIK PROFILAKSIS TERHADAP ANGKA INFEKSI
2847 patients undergoing elective clean or clean-contaminated surgical procedures.Patients divided into 4 categories based upon timing of administration of antibiotic
Early 2-24 hours before surgeryPre-operatively 0-2 hours before surgeryPerioperative 0-3 hours after surgeryPost-operative 3-24 hours after surgery
Timing Infection Rate
Early 3.8%
Pre-op 0.6%
Peri-op 1.4%
Post-op 3.3%
Classen DC, et al:N Engl J Med 1992
1. Berikan antibiotik yang tepat
Antibiotik profilaksis yang memadai : Efektif melawan kuman penyebab infeksi Tidak perlu membunuh seluruh kuman yang potensial patogen Mencapai kadar jaringan lokal yang adekuatEfek samping yang minimal MurahTidak menggangu keseimbangan flora mikrobial pada pasien maupun rumah sakit
YANG TIDAK DIANJURKAN SEBAGAI ANTIBIOTIK PROFILAKSIS
Third-generation cephalosporins (Cefotaxime, Ceftriaxone, Cefoperazone, Ceftazidime or Ceftizoxime) Fourth-generation cephalosporins: e.g. cefepime
Why : ExpenseSome are less active than 1ST generation against staphylococciNon-optimal spectrum of action (activity against organisms not commonly encountered in elective surgery) Widespread use for prophylaxis encourages emergence of resistance
1. BERIKAN INTRAVENA DAN DOSIS EFEKTIF BERDASARKAN BERAT BADAN
CONTOHCephalosporin (cefazolin)
< = 70 kg : 1g> 70 kg : 2 g
1. GUNAKAN TAMBAHAN DOSIS INTRA OPERATIF APABILA MEMANG DIBUTUHKAN:
CONTOHLama operasi lebih dari 2 jamPerdarahan banyak
1. PERTAHANKAN DOSIS PASCA OPERATIF SEMINIMAL MUNGKIN:
Dosis 0 pada umumnya memadai untuk kebanyakan prosedur
Dosis sampai 48 jam pada prosedur tertentu
Endogenous Pathogens Commonly Isolated from Postoperative Pelvic Infections
Aerobic gram-positive cocciViridans and nongroup A, B, and D streptococciGroup B streptococciEnterococcusStrept faecalis, Staphylococcus aureusStaphylococcus epidermidis
Aerobic gram-negative bacilliEscherichia coliKlebsiella speciesProteus mirabilisGardnerella vaginalis
Anaerobic organismsPeptostreptococcus speciesBacteroides fragilis groupPrevotella biviaPrevotella disiensFusobacterium species
MycoplasmasMycoplasma hominisUreaplasma urealyticum
Clinical infection in Obst.gyn. : Maclean A, 1995.
Observations in Obgyn surgical infections
Febrile morbidity is more common after abdominal than after vaginal hysterectomy
Age has inconsistently been shown to be a risk factor after hysterectomy, with premenopausal women shown to be at increased risk in some studies, especially after vaginal hysterectomy
Clinical infection in Obst.gyn. : Maclean A, 1995.
Observations in Obgyn surgical infections
Bacterial vaginosis has been associated with an increased risk of infection after abdominal hysterectomy
Patients scheduled for elective hysterectomy should be screened for bacterial vaginosis; one month before the planned procedure. Those found to have bacterial vaginosis should be treated and allowed several weeks to reestablish a normal lactobacillus-dominant flora before surgery
Clinical infection in Obst.gyn. : Maclean A, 1995.
Observations in postC.S infection
Pelle et al. Wound infection after cesarean section. Infect Control 1986;7:456.
Duration of rupture membrane & postC.S infection
0
2
4
6
8
10
12
No rupture <1 hour 1-3 hours >3 hours# SS
I per
100
ces
area
n se
ctio
ns
ANTIBIOTIC PROPHYLAXISCesarean section
There are sufficient data to recommend routine antibiotic prophylaxis in CS.
1st and 2nd generation cephalosporins and Augmentin have similar efficacy in reducing postoperative infection & endometritis.
Despite the theoretic need to cover gram-negative and anaerobic organisms, studies have not demonstrated a superior result with broad-spectrum antibiotics compared with 1st and 2nd generation cephalosporins.
The Cochrane Library, 1, 2004
ANTIBIOTIC PROPHYLAXIS INGYNAECOLOGICAL SURGERY
Clean Procedures : Antibiotic prophylaxis is considered optional for most clean procedures, although it may be indicated for certain patients that fulfill specific risk criteria
Rationale: Likely infecting organism are gram-positive cocci (S. aureus or S. epidermidis) and aerobic coliforms (E. coli).
Agents: Cefazolin, cefuroxime, augmentin or metronidazole.
ACOG Practice Bulletin. Antibiotic prophylaxis for gynecologic procedures. Obstet Gynecol 2001;23:2.
ANTIBIOTIC PROPHYLAXIS IN GYNAECOLOGICAL
SURGERY
Vaginal/abdominal hysterectomy : . Augmentin 1.2 g single dose . Cefazolin 1 - 2 g single dose ± Metronidazole 500 mg IV single
dose . Cefuroxime 1.5 g IV single dose ± Metronidazole 500 mg IV single
doseLaparotomy : In high risk patientsLaparoscopy : NoneHysteroscopy : None
ACOG Practice Bulletin. Antibiotic prophylaxis for gynecologic procedures. Obstet Gynecol 2001;23:2.
ANTIBIOTIC PROPHYLAXIS IN GYNAECOLOGICAL
SURGERY
Infertility promoting surgery :. Augmentin 1.2 g single dose. Cefazolin 1 - 2 g or Cefuroxime 1.5 g IV single dose ±
Metronidazole 500 mg IV single dose. In salpingostomy for hydrosalpinx; extend prophylaxis
up to one week (doxycycline + metronidazole OR Augmentin)
ACOG Practice Bulletin. Antibiotic prophylaxis for gynecologic procedures. Obstet Gynecol 2001;23:2.
ANTIBIOTIC PROPHYLAXIS IN GYNAECOLOGICAL
SURGERY
D&C: missed abortion or induced abortion with risk factors, (e.g. history of previous PID, multiple partners, young, known gonococcal or chlamydia infections)
200 mg Doxycycline one hour before, followed by 100 mg x 2 daily x 4 days
IUCD insertion and HSG with risk factors : Prohylaxis is probably indicated - Doxycycline as above
ACOG Practice Bulletin. Antibiotic prophylaxis for gynecologic procedures. Obstet Gynecol 2001;23:2.
ANTIBIOTIC PROPHYLAXIS IN OBSTETRIC AND GYNAECOLOGICAL
SURGERY
Penicillin/Cephalosporin allergy
Clindamycin, IV, 150 mg 6 hourly for 2–3 doses may be used for such patients
ACOG Practice Bulletin. Antibiotic prophylaxis for gynecologic procedures. Obstet Gynecol 2001;23:2.
Endocarditis prophylaxis
High-risk patients Ampicillin, 2 g IM or IV, plus gentamicin, 1.5 mg/ kg
(not to exceed 120 mg) within 30 minutes of starting the procedure; six hours later, ampicillin, 1 g IM/IV, or amoxicillin, 1 g orally
Patients allergic to ampicllin / amoxicillin Vancomycin, 1 g IV over 1-2 hours, plus gentamicin,
1.5 mg/ kg IV/IM (not to exceed 120 mg); injection/infusion within 30 minutes of starting the procedure
ACOG Practice Bulletin. Antibiotic prophylaxis for gynecologic procedures. Obstet Gynecol 2001;23:2.
Other Important Factors in Preventing Surgical Infection
Remove hair by clipping, not shaving, immediately before operationVigilance for breaks in aseptic technique by operating room teamLimit sutures and ligaturesUse monofilament suturesEmploy closed suction rather than open drainage; use no drainage if possible
Other Important Factors in Preventing Surgical Infection
Exercise meticulous skin closureAdminister high intraoperative and postoperative inspired oxygenMaintain normothermia during operationUse surveillance of wound infection with review of preventive measures
RANGKUMAN
Pemberian antibiotik profilaksis diberikan pada hampir semua tindakan pembedahan dengan kategori bersih terkontaminasi
Dosis tunggal prabedah cukup memadai pada hampir semua kasus kecuali pada pembedahan yang lama dan perdarahan banyak
Generasi pertama atau generasi kedua sefalosporin memberikan cakupan yang adekuat pada kebanyakan kasus bersih dan bersih terkontaminasi
Pemilihan antibiotik dipengaruhi oleh kuman penyebab infeksi pada jenis pembedahan, biaya dan ketersediaan antibiotika