Home Current issue Ahead of print Search About us Editorial board Archives Submit article Instructions Subscribe Contacts Login 

 Table of Contents  
EDITORIAL
Year : 2020  |  Volume : 39  |  Issue : 1  |  Page : 1-10

Egyptian consensus for the use of antimicrobial therapy in Preoperative prophylaxis, surgical site infections and diabetic foot infections


1 Department of Surgery, Faculty of Medicine, Kasr Alainy University, Kasr Alainy, Egypt
2 Department of Surgery, Faculty of Medicine, Mansoura University, Mansoura, Egypt

Date of Submission09-Sep-2019
Date of Acceptance24-Sep-2020
Date of Web Publication14-Feb-2020

Correspondence Address:
Abdel M Hussein

Egypt
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ejs.ejs_172_19

Rights and Permissions
  Abstract 


Use of antimicrobials in surgical prophylaxis These consensuses focus on primary perioperative prophylaxis for the prevention of an initial infection, the administration of the first dose of antimicrobial beginning within 60 min before surgical incision is recommended, but administration of vancomycin and fluoroquinolones should begin within 120 min before surgical incision because of the prolonged infusion times required for these drugs. Dosing In general, it is advisable to administer prophylactic agents in a manner that will ensure adequate levels of drug in serum and tissue for the interval during which the surgical site is open, If the duration of the procedure exceeds two half-lives of the antimicrobial or there is excessive blood loss (>1500 ml), the re-dosing interval should be measured from the time of administration of the preoperative dose, not from the beginning of the procedure. The selection of certain antimicrobial in most of the surgeries is shown in Table 2, and the special dosing of antimicrobials in patients with renal impairment is shown in Table 3.
Surgical site infections “SSI” SSIs or wound infections are the most common adverse events affecting hospitalized surgical patients. The most important therapy for an SSI is to open the incision, evacuate the infected material, and continue dressing changes until the wound heals by secondary intention. Before starting an empiric antibiotics course, culture should be done. The antibiotic choice is usually empiric but can be supported by Gram stain, culture of the wound contents, the site of surgery, and the hospital antimicrobial susceptibility test system ‘Hospital Biogram’. The selection of Antibiotics for treatment of incisional surgical site infections is summarized in table 4.
Diabetic foot infections Diabetic Foot infections typically begin in a wound, most often a neuropathic ulceration, while all wounds are colonized with microorganisms, and the presence of infection is defined by greater than or equal to 2 classic findings of inflammation or purulence. Most DFIs are polymicrobial, with aerobic gram-positive cocci, and especially Staphylococci spp., the most common causative organisms. Clinicians should consider the possibility of infection occurring in any foot wound in a patient with diabetes. Clinicians should evaluate a diabetic patient presenting with a foot wound at three levels: the patient as a whole, the affected foot or limb, and the infected wound. The clinically noninfected wounds should not be treated with antibiotic therapy. Prescription of antibiotic therapy for all infected wounds should be done, but with caution, as it is often insufficient unless combined with appropriate wound debridement. The clinicians need to select an empiric antibiotic regimen on the basis of the severity of the infection and the likely etiologic agent(s) (shown in Table 6).


How to cite this article:
Hussein AM, Farid M. Egyptian consensus for the use of antimicrobial therapy in Preoperative prophylaxis, surgical site infections and diabetic foot infections. Egypt J Surg 2020;39:1-10

How to cite this URL:
Hussein AM, Farid M. Egyptian consensus for the use of antimicrobial therapy in Preoperative prophylaxis, surgical site infections and diabetic foot infections. Egypt J Surg [serial online] 2020 [cited 2020 Mar 31];39:1-10. Available from: http://www.ejs.eg.net/text.asp?2020/39/1/1/278319



The recommendations mentioned in this consensus about antibiotic prophylaxis in surgery were taken from the American Society of Health-System Pharmacists, the Infectious Diseases Society of America (IDSA), the Surgical Infection Society (SIS), and the Society for Healthcare Epidemiology of America clinical practice guidelines for antibiotic prophylaxis in surgery in 2013.

The recommendations mentioned in this consensus about surgical site infections (SSIs) were taken from 2014 IDSA guidelines for the management of SSTIs, and the recommendations mentioned in this consensus about antibiotic use in diabetic foot infection (DFI) were taken from IDSA Guidelines 2012 for the management of DFI.

[TAG:2]Use of antimicrobials in surgical prophylaxis [1][/TAG:2]

These consensuses focus on primary perioperative prophylaxis for the prevention of an initial infection.

Timing of initial dose

The antimicrobial agent should be administered at a time to provide serum and tissue concentrations exceeding the minimum inhibitory concentration for the probable organisms associated with the procedure, at the time of incision, and for the duration of the procedure, so administration of the first dose of antimicrobial beginning within 60 min before surgical incision is recommended, but administration of vancomycin and fluoroquinolones should begin within 120 min before surgical incision because of the prolonged infusion times required for these drugs.

Dosing

In general, it is advisable to administer prophylactic agents in a manner that will ensure adequate levels of drug in serum and tissue for the interval during which the surgical site is open.

Weight-based dosing

The dosing of most antimicrobials in pediatric patients is based on body weight, but the dosing of many antimicrobials in adults is not based on body weight, because it is safe, effective, and convenient to use standardized doses for most of the adult patient population.

Such standardized doses avoid the need for calculations and reduce the risk for medication errors; however, in obese patients, especially those who are morbidly obese, serum and tissue concentrations of some drugs may differ from those in normal-weight patients because of pharmacokinetic alterations that depend on the lipophilicity of the drug and other factors.

If weight-based dosing is warranted for obese patients, it has not been determined whether the patient’s ideal body weight or total (i.e. actual) body weight should be used, for dosing a lipophilic drug (e.g. vancomycin) could result in subtherapeutic concentrations in serum and tissue, and the use of actual body weight for dosing a hydrophilic drug (e.g. an aminoglycoside) could result in excessive concentrations in serum and tissue.

Doubling the normal dose of cephalosporins or making fewer adjustments based on renal dysfunction may produce concentrations in obese patients similar to those achieved with standard doses in normal-weight patients.

Re-dosing

Generally intraoperative re-dosing is needed to ensure adequate serum and tissue concentrations of the antimicrobial.

If the duration of the procedure exceeds two half-lives of the antimicrobial or there is excessive blood loss (>1500  ml), the re-dosing interval should be measured from the time of administration of the preoperative dose, not from the beginning of the procedure.

Re-dosing may also be warranted if there are factors that shorten the half-life of the antimicrobial agent (e.g. extensive burns).

Re-dosing may not be warranted in patients in whom the half-life of the antimicrobial agent is prolonged (e.g. patients with renal insufficiency or renal failure) (see [Table 1] for antimicrobial specific re-dosing recommendations).
Table 1 Recommended doses and redosing intervals for commonly used antimicrobials for surgical prophylaxis

Click here to view


Duration

The shortest effective duration of antimicrobial administration for preventing SSI is not known; however, evidence is mounting that postoperative antimicrobial administration is not necessary for most procedure.

The duration of antimicrobial prophylaxis should be less than 24 h for most procedures.

Duration of prophylaxis

The recommendations for a shortened postoperative course of antimicrobials involving a single dose or continuation for less than 24 h are provided.

Selection of antimicrobial(s) in preoperative prophylaxis

Antimicrobial prophylaxis may be beneficial in surgical procedures associated with a high rate of infection (i.e. clean–contaminated or contaminated procedures) and in certain clean procedures where there are severe consequences of infection (e.g. prosthetic implants), even if infection is unlikely.

Prophylactic antimicrobials are not indicated for clean surgical procedures, except for the patients at high risk of infections like diabetic patients, smokers, patients receiving immunosuppressant therapy, and immunocompromised patients and patients who have received an implant as in cardiac and vascular surgeries.

The selection of certain antimicrobial in most of the surgeries is shown in [Table 2], and the special dosing of antimicrobials in patients with renal impairment is shown in [Table 3] [2].
Table 2 Recommendations for surgical antimicrobial prophylaxis

Click here to view
Table 3 Dosing of antibiotics in renal-impairment patients

Click here to view



  Surgical site infections Top


SSIs or wound infections are the most common adverse events affecting hospitalized surgical patients (Brennan, 1991) [3],[4].

SSIs classification

SSIs are divided into the categories of superficial incisional SSI, deep incisional SSI, and organ/space SSI. Superficial incisional SSIs involve only the subcutaneous space (as shown in [Figure 1] of skin layers), occur within 30 days of the surgery, and are documented with at least one of the following:
  1. Purulent incisional drainage.
  2. Positive culture of aseptically obtained fluid or tissue from the superficial wound.
  3. Local signs and symptoms of pain or tenderness, swelling, and erythema after the incision is opened by the surgeon (unless culture negative), or
  4. Diagnosis of SSI by the attending surgeon or physician based on their experience and expert opinion.
Figure 1 Layers of the skin.

Click here to view


A deep incisional infection involves the deeper soft tissue (e.g. fascia and muscle) and occurs within 30 days of the operation or within 90 days if a prosthesis was inserted and has the same findings as described for a superficial incisional SSI.

An organ/space SSI has the same time constraints and evidence for infection as a deep incisional SSI, and it may involve any part of the anatomy (organs or spaces) other than the original surgical incision.

Diagnosis

Local signs of pain, swelling, erythema, and purulent drainage provide the most reliable information in diagnosing an SSI, whereas many patients with a SSI will develop fever. It usually does not occur immediately postoperatively.

After 48 h, SSI is a more common source of fever, and careful inspection of the wound is indicated; by 4 days after surgery, a fever is equally likely to be caused by an SSI or by another infection.

Later infections are less likely, but surveillance standards mandate 30 days of follow-up for operations without placement of prosthetic material and for 90 days for operations where a prosthesis was inserted.

Management

The most important therapy for an SSI is to open the incision, evacuate the infected material, and continue dressing changes until the wound heals by secondary intention.

If there is less than 5 cm of erythema and induration, and if the patient has minimal systemic signs of infection (temperature <38.5°C, WBC count <12 000 cells/µl, and pulse <100 beats/min), antibiotics are unnecessary.

Patients with temperature more than 38.5°C or heart rate more than 110 beats/ min or erythema extending beyond the wound margins for more than 5 cm may require a short course (e.g. 24–48 h) of antibiotics, as well as opening of the suture line.

Principles of antibiotic selection

Before starting an empiric antibiotics course, culture should be done. A brief course of systemic antimicrobial therapy is indicated in patients with SSIs following clean operations on the trunk, head and neck, or extremities that also have systemic signs of infection, whereas for infections following operations on the axilla, gastrointestinal tract, perineum, or female genital tract use, agents active against gram-negative bacteria and anaerobes, such as a cephalosporin or fluoroquinolone in combination with metronidazole, are used.

Infections developing after surgical procedures involving nonsterile areas such as colonic, vaginal, biliary, or respiratory mucosa may be caused by a combination of aerobic and anaerobic bacteria, and these infections can rapidly progress and involve deeper structures than just the skin, such as fascia, fat, or muscle.

The antibiotic choice is usually empiric but can be supported by Gram stain, culture of the wound contents, the site of surgery, and the hospital antimicrobial susceptibility test system ‘Hospital Biogram’ ([Table 4]).
Table 4 Antibiotics for treatment of incisional surgical site infections

Click here to view


[TAG:2]Diabetic foot infections [5][/TAG:2]

Foot infections in persons with diabetes are an increasingly common problem and are associated with potentially serious sequelae. DFIs typically begin in a wound, most often a neuropathic ulceration, while all wounds are colonized with microorganisms, and the presence of infection is defined by greater than or equal to 2 classic findings of inflammation or purulence.

Classification of diabetic foot infections

Infections are then classified into mild (superficial and limited in size and depth), moderate (deeper or more extensive), or severe (accompanied by systemic signs or metabolic perturbations), as shown in [Table 5].
Table 5 Infectious Diseases Society of America and International Working Group on the Diabetic Foot Classifications of Diabetic Foot Infection

Click here to view


Etiology

Most DFIs are polymicrobial, with aerobic gram-positive cocci, and especially Staphylococci spp., the most common causative organisms. Aerobic gram-negative bacilli are frequently copathogens in infections that are chronic or follow antibiotic treatment, and obligate anaerobes may be copathogens in ischemic or necrotic wounds.

These infections can then spread contiguously, including into deeper tissues, often reaching bone.

If the infection progresses, many patients require hospitalization and, all too often, surgical resections or an amputation, diabetic foot complications continue to be the main reason for diabetes-related hospitalization and lower extremity amputations.

Recommendations for a clinician to suspect infection

  1. Clinicians should consider the possibility of infection occurring in any foot wound in a patient with diabetes.
  2. Evidence of infection generally includes classic signs of inflammation (redness, warmth, swelling, tenderness, or pain) or purulent secretions but may also include additional or secondary signs (e.g. nonpurulent secretions, friable or discolored granulation tissue, undermining of wound edges, foul odor).
  3. Clinicians should be aware of factors that increase the risk for DFI and especially consider infection when these factors are present; these include a wound for which the probe-to-bone test is positive, an ulceration present for more than 30 days, a history of recurrent foot ulcers, a traumatic foot wound, the presence of peripheral vascular disease in the affected limb, a previous lower extremity amputation, loss of protective sensation, the presence of renal insufficiency, or a history of walking barefoot.


Assessment of a diabetic patient presenting with a foot infection

  1. Clinicians should evaluate a diabetic patient presenting with a foot wound at three levels: the patient as a whole, the affected foot or limb, and the infected wound.
  2. Clinicians should diagnose infection based on the presence of at least two classic symptoms or signs of inflammation (erythema, warmth, tenderness, pain, or induration) or purulent secretions and the presence of any systemic findings of infection.
  3. Assessing the affected limb and foot for arterial ischemia, venous insufficiency, presence of protective sensation, and biomechanical problems.
  4. Clinicians should debride any wound that has necrotic tissue or surrounding callus; the required procedure may range from minor to extensive.


Obtain specimen(s) for culture

  1. The recommendation is to send a specimen for culture that is from deep tissue, obtained by biopsy or curettage and after the wound has been cleansed and debrided with saline not with antiseptics.


Initiation and modification of an antibiotic regimen for a diabetic foot infection

  1. The clinically noninfected wounds should not be treated with antibiotic therapy.
  2. Prescription of antibiotic therapy for all infected wounds should be done, but with caution, as it is often insufficient unless combined with appropriate wound debridement.
  3. The clinicians need to select an empiric antibiotic regimen on the basis of the severity of the infection and the likely etiologic agent(s) (shown in [Table 6]):
    1. For mild to moderate infections in patients who have not recently received antibiotic treatment, we suggest that therapy just targeting aerobic gram-positive cocci is sufficient.
    2. For most severe infections, we recommend starting broad-spectrum empiric antibiotic therapy, pending culture results and antibiotic susceptibility data.
    3. Empiric therapy directed at Pseudomonas aeruginosa is usually unnecessary except for patients with risk factors for true infection with this organism.
    4. Consider providing empiric therapy directed against MRSA in a patient with a prior history of MRSA infection, when the local prevalence of MRSA colonization or infection is high.
    5. A definitive therapy based on the results of an appropriately obtained culture and sensitivity testing of a wound specimen is recommended as well as the patient’s clinical response to the empiric regime.
    Table 6 Suggested empiric antibiotic regimens based on clinical severity for diabetic foot infectionsa

    Click here to view
  4. Route of administration: parenteral therapy is preferred for all severe, and some moderate, DFIs, at least initially, with a switch to oral agents when the patient is systemically well and culture results are available ([Table 7]).
    Table 7 Suggested route, setting, and duration of antibiotic therapy by clinical syndrome

    Click here to view
  5. Duration of antibiotic therapy:
    1. We suggest continuing antibiotic therapy until, but not beyond, resolution of findings of infection, but not through complete healing of the wound.
    2. We suggest an initial antibiotic course for a soft tissue infection of approximately 1–2 weeks for mild infections and 2–3 weeks for moderate to severe infections ([Table 7], [Figure 2]).
      Figure 2 Algorithm for the management and treatment of surgical site infections. *For patients with type 1 (anaphylaxis or hives) allergy to β-lactam antibiotics. If Gram stain not available, open and debride if purulent drainage is present. Where the rate of infection with methicillin-resistant Staphylococcus aureus infection is high, consider vancomycin, daptomycin, or linezolid, pending results of culture and susceptibility tests. Adapted and modified with permission from Dellinger et al. GI, gastrointestinal; MRSA, methicillin-resistant Staphylococcus aureus; WBC, white blood cell count.

      Click here to view


Financial support and sponsorship

Nil.

Conflicts of interest

None declared.



 
  References Top

1.
Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK et al. American Society of Health-System Pharmacists; Infectious Disease Society of America; Surgical Infection Society; Society for Healthcare Epidemiology of America. Am J Health Syst Pharm 2013; 70:195–283.  Back to cited text no. 1
    
2.
The Nebraska Medical Center. Antimicrobial surgical prophylaxis. Available at. https://www.nebraskamed.com/sites/default/files/documents/for-providers/asp/antimicrobial-surgical-prophylaxis.pdf. [Accessed on 29 August 2019].  Back to cited text no. 2
    
3.
Brennan TA, Leape LL, Laird NM et al. Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study I. N Engl J Med 1991; 324:370–376.  Back to cited text no. 3
    
4.
Stevens DL, Bisno AL, Chambers HF, Dellinger EP, Goldstein EJC, Gorbach SL et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis 2014; 59:e10–e52.  Back to cited text no. 4
    
5.
Lipsky BA, Berendt AR, Cornia PB, Pile JC, Peters EJG, David G. Infectious Diseases Society of America Clinical Practice Guideline for the diagnosis and treatment of diabetic foot infections. Clin Infect Dis 2012; 54:132–173.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Use of antimicro...
Surgical site in...
Diabetic foot in...
References
Article Figures
Article Tables

 Article Access Statistics
    Viewed267    
    Printed24    
    Emailed0    
    PDF Downloaded81    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]