수술의예방적항생제사용 - hira.or.kr · Cardiac: pacemaker or defibrillator insertion, and open heart surgery Staphylococci, corynebacteria, enteric gram-negative ... •

수술 방적 항생제 사

상

가 병원

2010. 10. 26 심사평가원실무

1

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)

3

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

6

Antibiotic Prophylaxis

• NRC Wound Classification

– Clean Surgical Procedures *

– Clean Contaminated Procedures

– Contaminated Procedures*

– Dirty Procedures*

--------------------

* not prophylaxis, but treatment

+Prosthesis

7

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?

9

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

10

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

11

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

12

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

14

Prophylactic Antibiotics & Infection Rate

15

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.

16

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%

17

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

18

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

19

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

20

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)

21

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 (?)

22

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

23

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

24

Antimicrobial prophylaxis for specific surgery

25

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

26

Biliary-tract surgery


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

27

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

28

Appendectomy


Antimicrobial

Appendectomy without perforation (if, perforation (+) à

therapeutic usage)

Enteric gram-negative bacilli, anaerobes, enterococci

Cefoxitin or cefotetan

29

Other general surgery


Antimicrobial

Inguinal herninorraphy with mesh repair

Staphylococci, gram-negative bacilli

Ampicillin/sulbactam*, cefazolin

Mastectomy: still controvertial.

Staphylococci Cefazolin

*: Ann Surg 2001;233:26-33

30

Gynecologic surgery


Hysterectomy, vaginal or abdominal

Enteric gram-negative bacilli, anaerobes, enterococci, group B strep

Cefoxitin, cefotetan, or cefazolin

31

Obstetric surgery


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

32

Thoracic surgery


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

33

Vascular surgery


Arterial surgery involving prosthetic material, abdominal aorta, groin incision, leg amutation for arterial insufficiency

Staphylococci, streptococci

Cefazolin

(or vancomycin)

34

Orthopedic surgery


Orthopedic surgery: therapeutic usage for open fracture, not indicated in arthroscopic surgery

Staphylococci Cefazolin

(or vancomycin)

35

Neurosurgery


Neurosurgery Staphylococci Cefazolin

(or vancomycin)

36

Head & Neck surgery


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

37

Urologic surgery


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

38

Opthalmic surgery


Opthalmic surgery: lack of data

Staphylococci, streptococci, gram-negative bacilli including

Pseudomonas aeruginosa

Topical, subconjunctival, or

IV

39

£ 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

41

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)



7 초과 심평원,진흥원(시범)

평균 여수

원 중(경 +비경 ) 심평원

원 중 + 퇴원약 심평원

퇴원 항생제 처방 비 0% 심평원

42

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

43

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 ○ -

44

평가공개

45

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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수술의예방적항생제사용 - hira.or.kr · Cardiac: pacemaker or defibrillator insertion, and open heart surgery Staphylococci, corynebacteria, enteric gram-negative ... •

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