Antibioprophylaxis in surgery and mdros
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Atelier antibioprophylaxie en chirurgie W orkshop Antibiotica profylaxe in de chirurgie. Antibioprophylaxis in surgery and MDROs. Baudouin Byl Hygiène Hospitalière e t Gestion de l’antibiothérapie Hôpital Erasme – ULB. Plan. MDR definition Prophylaxis – spectrum - principles

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Antibioprophylaxis in surgery and MDROs

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Antibioprophylaxis in surgery and mdros

Atelier antibioprophylaxie en chirurgie

Workshop Antibiotica profylaxe in de chirurgie

Antibioprophylaxis in surgery and MDROs

  • Baudouin Byl

    • Hygiène Hospitalière

    • et Gestion de l’antibiothérapie

  • Hôpital Erasme – ULB


Antibioprophylaxis in surgery and mdros

Plan

  • MDR definition

  • Prophylaxis – spectrum - principles

  • Literature – prophylaxis et SSI MDROs

  • Discussion


Definition mdr

Definition MDR

  • Clinicalmicrobinfec 2011: 18(3), 268-281


Definition mdr1

Definition MDR


Antibioprophylaxis common principles

Antibioprophylaxiscommonprinciples

  • Limited to wellproven indications

  • Targeted to organismsinvolved in SSI

  • Timing of administration

  • Perop administration if needed

  • Duration < 24 hrs

2013


Antibioprophylaxis

Antibioprophylaxis

  • new recommendations

    Bratzler DW et al

    Am J Health-Sys Pharm

    Vol 70, feb1, 2013

ASHP

IDSA

SHEA

SIS

previous:

Clin Infect Dis, 1994; 18: 422-427

2013


S pectrum

Spectrum

  • The narrowest

  • Resistance patterns fromorganismscausingSSI shouldtakeprecedenceover hospitalwideantibiograms

  • In somecases, procedure-specificresistancepatterns!

Consensus 2013


S pectrum1

Spectrum

  • Skin incision:

    SSI:

    ~ 80% Gram positive

    ~ 20% Gram négative

    First choice:

    anti-staph (oxa-S) + anti bgn

    cef 1 (cef2)

2013


From 1994 to 2013

From 1994 to 2013 …

  • Dramaticdecrease in sensitivity to cef1 (cef2)

  • MDR ….

2013


Antibioprophylaxis in surgery and mdros

  • R rate cef1 cef2, enterobacterialspecies Erasme

  • 1993-2011

2013


Rec 2013 quid des mdr

Rec 2013 - Quid des MDR?

  • MRSA

  • MDR Enterobacteriacae

  • Pseudomonas aeruginosa

  • VRE

2013


Rec 2013 quid des mdr1

Rec 2013 - Quid des MDR?

Consensus 2013

2013


2013 mrsa

2013/ MRSA

  • Glycopeptides en prophylaxie

    • Consensus 2013

      • Cluster of MRSA or MRSE

      • known MRSA colonisation (or at high risk)

        ANDwhowill have a skin incision

      • !!! vancoless effective on MSSA !!!

        • czol+vanco!

  • (Specific setting: community MRSA)

2013


2013 mr s sa

2013/ MR(S)SA

  • From controverse to growingevidence…

  • S aureus carriageeradicationrecommended

    • Cardiacsurgery

    • Orthopedicsurgery

    • Spinal procedures

  • ! Surveillance of R to mupi !

  • ? Timing? Duration?

  • ! operationalconsiderations! (BB)

Consensus 2013

2013


Antibioprophylaxis in surgery and mdros

MRSA

  • Screening vs high risk conditions

    • Pts/units

  • Eradication

  • + Vancomycine

2013


Antibioprophylaxis in surgery and mdros

VRE

  • Enteroccoccusuncovered by conventionalprophylaxis (rare exceptions)

  • VRE to beconsidered in special settings (Li TX, …)

2013


Enterobacteriaceae

Enterobacteriaceae

2013


Gram neg pubmed

Gram neg / PUBMED

  • MDR / prophylaxis / surgery : 0

  • Carbapenemase / SSI / prophylaxis: 0

  • Carbapenemase / prophylaxis: 0

  • ESBL / prophylaxis: 47

    • Surgery 12

      - 7 urology

      - 4 transplantation

      - 1 obesity (pharmaco ertapenem)

2013


Mdr carriage exposition to antibiotics

MDR carriage / exposition to antibiotics

  • Abundantliterature – overlapsbetween:

    • ESBL

    • UTI

    • Neutropenic patients

    • Quinolone use

2013


Urology cipror

Urology / ciproR

  • Urology

  • Transrectal prostate biopsy

  • E coli : first causative (75-90%)

  • Haute prévalence esbl et ciproR

  • E coli ciproR 17%!!!

  • Quid proph quinolones?

Williamson et al, CID, 2013:267

Qi et al J Urol 2013: 2026

2013


Urology customized prophylaxis

Urology / customizedprophylaxis

  • FQ vs [ctri or genta or sxt or cefpodox]

    • Reduction infection / ctrl histor

  • by screening and adaptedprophylaxis

    • Reductioninfection

  • Duplessis et al Urology 2012: 556-563

    Taylor J Urol 2012: 1275

    2013


    Urology cipro amikacin

    Urology / cipro + amikacin

    Kehinde J Urol 2013; 189: 911

    Historiccontrl : cipro

    Intervention: cipro+amika

    2013


    Esbl epidemiology liver tx

    ESBL / epidemiology / liverTx

    • Independantriskfactors – fecalcarriage ESBL

      • Previous infection with ESBL

      • PreviousBlactam

      • Previous SBP (quinolones!)

    • Need for targetedprophylaxis

    Bert , Transplant infect disease, 2013:0: 1-6

    2013


    Esbl epidemiology liver tx1

    ESBL / epidemiology / liverTx

    %pts

    2013

    Bert , Transplant infect disease, 2013: 1-6


    Colonisation clinical impact

    Colonisation / Clinical impact

    • ICU

      ~7 % infections caused by ESBL+

      • Among carriers

        • 10% first infection and 27% second infection caused by ESBL+

    Razazi Int Care Med 2012; 38:1769-1778

    2013


    Esbl prophylaxis

    ESBL / prophylaxis

    2013


    Antibioprophylaxis1

    Antibioprophylaxis

    • new recommendations

      Bratzler DW et al

      Am J Health-Sys Pharm

      Vol 70, feb1, 2013

    previous:

    Clin Infect Dis, 1994; 18: 422-427

    2013


    Rec 2013

    Rec 2013

    • Transplanted pts (liver, lungs):

      • Includecoverage for anypotentialpathogen (isolated < donor / receiver)

    • Colo-rectal

      • czol+ metro

      • Or ctri+metro (if high R cef1/2)

        • [or ertapenem!!]

    Consensus 2013

    2013


    Antibioprophylaxis in surgery and mdros

    Quid Gram neg MDRO?


    Quid gram neg mdr

    Quid Gram neg/MDR?

    • Considercustomising

      • Urology (trans rectal biopsy)

      • Local SSI epidemiology

    • Screening!(rectal)

    • Screening high risk

    • Customize to screening results

    • Customize to high risk (ex uro!)

    2013


    Operational considerations

    Operationalconsiderations

    • Preoperativeclinicalpath

    • Customize vs systematic screening (labcosts!)

    2013


    Operational considerations1

    Operationalconsiderations

    2013


    Antibioprophylaxis in surgery and mdros

    Your opinion?


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