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