Antimicrobial Prophylaxis (2023-2024) - Cairo University PDF

Antimicrobial Prophylaxis Department of Medical Pharmacology Faculty of Medicine (Kasr Al-Ainy), Cairo University 2023 -2024 Outline Revision of antibacterial chemotherapy important notes Surgical versus medical prophylaxis The three rules of surgical prophylaxis...

Antimicrobial Prophylaxis Department of Medical Pharmacology Faculty of Medicine (Kasr Al-Ainy), Cairo University 2023 -2024 Outline Revision of antibacterial chemotherapy important notes Surgical versus medical prophylaxis The three rules of surgical prophylaxis Indication Choice Duration Examples of surgical prophylaxis Examples of medical prophylaxis  Objective of this Stewardship Program practical session Healthcare system that promotes and monitors judicious ‫تعقل‬ use of antimicrobials, to optimize clinical effectiveness and minimize misuse and overuse, which confer resistance to their effect. By 2050, if pattern of antimicrobial use continues the same way, deaths attributed to antimicrobial resistance will exceed those caused by vehicle accidents and cancer. Antimicrobial Prophylaxis 3 Antimicrobials ▪ Overview Antimicrobial Prophylaxis 4  Antibiotic READING A SUBSTANCE PRODUCED BY A LIVING MICROORGANISM TO KILL OR INHIBIT THE GROWTH OF OTHER LIVING MICROORGANISMS. Aerobic Anaerobic Obligate: TB Obligate: C. perfringens Microaerophilic: Facultative: H. pylori E. coli Aerotolerant: Streptococci Gram +ve = Bluish Gram –ve = Reddish  Gentle Reminder CLASSIFICATION OF ANTIMICROBIALS Narrow- spectrum Broad- spectrum ▪ Inhibition of normal flora > Intestine Pseudomembranous o Vancomycin colitis + Vagina Candidiasis o Erythromycin, o Broad- spectrum & ▪ Inhibition of vitamin B synthesis clarithromycin & antipseudomonal ▪ Inhibition of vitamin K synthesis azithromycin penicillins o Aminoglycosides o Tetracyclines o Sulfonamides o Chloramphenicols o Trimethoprim o Clindamycin Antimicrobial Prophylaxis 6  Gentle Reminder CLASSIFICATION OF ANTIMICROBIALS Bactericidal Bacteriostatic Bacteriostatic (low conc.) & Bactericidal (high conc.) o Inhibitors of cell wall synthesis o Tetracyclines o Erythromycin o Aminoglycosides o Macrolides o Chloramphenicol o Co-trimoxazole o Clindamycin o Quinolones o Sulfonamides o Rifampicin o Trimethoprim o Metronidazole Antimicrobial Prophylaxis 7 AVOID THE FOLLOWING COMBINATIONS ! A bactericidal antimicrobial is effective Bactericidal Bacteriostatic in presence of actively growing bacteria Penicillin Aminoglycoside NOT IN SAME syringe Nephrotoxic antimicrobials Nephrotoxic drugs Penicillins Thiazide diuretics Cephalosporins NSAIDs Vancomycin Aminoglycosides Antimicrobial Prophylaxis 8 Better to Avoid THE FOLLOWING COMBINATIONS ! Ototoxic antimicrobials Vancomycin Aminoglycosides Sulfonamides Sulfur- containing drugs Cross- allergy Thiazide diuretics Loop diuretics Diazoxide Sulfonylureas (antidiabetics) Aminoglycosides Neuromuscular blockers Curare- like effect Antimicrobial Prophylaxis 9 Beware! Sulfonamides Drink plenty of fluids + Urinary alkalinization HME inhibitors Chloramphenicol Quinolones Metronidazole HME inducer Rifampicin Outdated tetracyclines Fanconi syndrome Antimicrobial Prophylaxis 10 Beware! Chloramphenicol IN Premature babies Gray baby syndrome Metronidazole Disulfiram- like effect Cross- allergy & Penicillins Cross- resistance Cephalosporins Carbapenems No systemic effect if Acid- labile penicillins administered orally Vancomycin Some oral sulfonamides (sulfasalazine) Aminoglycosides Antimicrobial Prophylaxis 11 Beware! Cefoperazone, ceftriaxone (3rd generation cephalosporins) Doxycycline Biliary excretion Moxifloxacin Some aminoglycosides (streptomycin, kanamycin, amikacin) Resistant TB Some fluoroquinolones (ciprofloxacin, levofloxacin, gatifloxacin, (2nd line) moxifloxacin) Damage of growing cartilage Fluoroquinolones QT prolongation Fluoroquinolones Fatal aplastic anemia Chloramphenicol Antimicrobial Prophylaxis 12 Antimicrobial Prophylaxis ▪ Surgical Prophylaxis Antimicrobial Prophylaxis 13 Surgical Prophylaxis ▪ Types of Wounds READING Clean Clean- contaminated = Elective, Closed procedure = Urgent, Open procedure Contaminated (expected infection 20%) = Open wound, inflammation (no pus), spill from hollow organ, penetrating trauma < 4 hours Dirty (expected infection 40%) = Purulence, abscess, perforated organ, penetrating trauma > 4 hours Antimicrobial Prophylaxis 14 Surgical ProphylaxisINDICATIONS READING ▪ Surgical Procedures 1 Contaminated & clean-contaminated OR 2 Operations lasting more than 2 hours OR 3 Unclean wound 4 At least three medical diagnoses OR (Diabetic + Hypertensive + Cardiac) Antimicrobial Prophylaxis 15 Surgical Prophylaxis Egyptian Drug Authority (EDA) 2022 Up to ▪ Duration 24- 48 hours According to suspected micro-organisms, depending on ▪ Selection site of operation Antimicrobial Prophylaxis 16  Is it clean wound? No yes Antimicrobial prophylaxis For 24-48 hrs According to suspected micro-organisms, No justification of antibiotic prophylaxis if there is no depending on site of operation and type of other indication for wound prophylaxis If gram –ve or anaerobes If gram +ve is suspected suspected High risk 1-Neurosurgical operation Type III gastrointestinal 2-Coronary catherterization 1-Coronary artery ortrhopedic bypass(G+ve staph) fracture with soft Surgery 3-Tonsillectomy and head and 2-orthopedric surgery tissue damage Staphylococci,G neck surgery without prosthesis type I and II (G+ve staph) –ve, Anaerobes) (Staphylococci,Gr 4- Elective low risk am –ve, cephazoline+ Cephazoline IV gastrointestinal surgery Anaerobes) metronidazole Or 5- Clean wound of orthopedic Alternative: Cefuroxime IV Ceftriaxone surgery involving knee, hand or Alternative: Clindamycin+ foot + No prosthesis Alternative: Clindamycin+ gentamicin Clindamycin Levofloxacin Antimicrobial Prophylaxis 17 Antimicrobial Prophylaxis ▪ Non- surgical Prophylaxis Antimicrobial Prophylaxis 18 Non-surgical Prophylaxis Egyptian Drug Authority (EDA) 2023 Antimicrobial Prophylaxis No justification of antibiotic prophylaxis ▪ Urinary catheter Diagnostic laparoscopy Intra-uterine device ▪ Gynecological Endometrial biopsy Antimicrobial Prophylaxis 19 Non-surgical Prophylaxis Egyptian Drug Authority (EDA) 2023 Antimicrobial Prophylaxis 1- Rheumatic fever 2- Infective endocarditits 3-Meningitis 4-Post splenectomy 5-Spontaneous bacterial peritoinitis Antimicrobial Prophylaxis 20 Rheumatic Fever Gentle Reminder Secondary prophylaxis Antibacterials: A. Penicillins: 1. Benzathine penicillin G (IM 0.6-1.2 million – every 3-4 weeks) B. For patients allergic to penicillin: 1. Azithromycin Or 2. Clarithromycin Or Rheumatic Fever Gentle Reminder Secondary prophylaxis >>> Duration SBE Gentle Reminder Prophylaxis against SBE Antibacterials: A. Beta lactams: 1. Amoxicillin (oral - one hour before surgery) Or 2. Ampicillin (injection - 30 min before surgery) Or 3. Cephalexin (oral - one hour before surgery) Or 4. Cephazoline (injection - 30 min before surgery) B. For patients allergic to penicillin: 1. Azithromycin (oral or injection) Or 2. Clarithromycin (oral) Or 3. Clindamycin (oral or injection) Non-surgical Prophylaxis Egyptian Drug Authority (EDA) 2023 ▪ Meningitis Bacteria Antimicrobial Hemophilus Rifampicin influenza Neisseria Rifampicin meningitidis OR Ciprofloxacin OR Ceftriaxone Antimicrobial Prophylaxis 24 Non- surgical Prophylaxis Staphylococci Egyptian Drug Authority (EDA) 2022 Streptococci ▪ Post- splenectomy (gram +ve) Antimicrobial Alternatives Duration Penicillin allergy Amoxicillin Erythromycin 1st 2 years post- (250 mg once (500 mg twice operative + daily) daily) vaccination Gram –ve ▪ Spontaneous bacterial peritonitis (SBP) Anaerobes Antimicrobial Duration Norfloxacin Until liver compensation + OR Resolution of ascites Ciprofloxacin OR Co-trimoxazole Antimicrobial Prophylaxis 25 Let’s test our knowledge In surgical prophylaxis before an emergency operation of perforated appendix, the regimen is to: - a. Give an antimicrobial which spectrum covers gram-ve organisms. b. Combine bactericidal to bacteriostatic antimicrobials. c. Give more than one antimicrobial to broaden the spectrum of activity. d. Administer oral combined to parenteral antimicrobials. Antimicrobial Prophylaxis 26 Let’s test our knowledge In surgical prophylaxis before an emergency operation of perforated appendix, the regimen is to: - a. Give an antimicrobial which spectrum covers gram-ve organisms. b. Combine bactericidal to bacteriostatic antimicrobials. c. Give more than one antimicrobial to broaden the spectrum of activity of antimicrobials. d. Administer oral combined to parenteral antimicrobials. c Antimicrobial Prophylaxis 27 Let’s test our knowledge A young female had a previous attack of rheumatic fever. She is scheduled to receive monthly injection of IM benzathine penicillin G. Which of the following information would be the least relevant when planning her future injections? a. Her age and weight. b. History of previous allergy to penicillins. c. Whether she had previous rheumatic carditis or not. d. Her marital status. Antimicrobial Prophylaxis 28 Let’s test our knowledge A young female had a previous attack of rheumatic fever. She is scheduled to receive monthly injection of IM benzathine penicillin G. Which of the following information would be the least relevant when planning her future injections? a. Her age and weight. b. History of previous allergy to penicillins. c. Whether she had previous rheumatic carditis or not. d. Her marital status. d Antimicrobial Prophylaxis 29 Let’s test our knowledge In a dental clinic, a male patient will undergo tooth extraction. Knowing he had a previous cardiac valve replacement, is alcoholic and allergic to penicillins, which of the following antimicrobials would be the best choice as a prophylaxis of bacterial endocarditis? a. Ampicillin. b. Azithromycin. c. Metronidazole. d. Cephalexin. Antimicrobial Prophylaxis 30 Let’s test our knowledge In a dental clinic, a male patient will undergo tooth extraction. Knowing he had a previous cardiac valve replacement, alcoholic and allergic to penicillins, which of the following antimicrobials would be the best choice as a prophylaxis of bacterial endocarditis? a. Ampicillin. b. Azithromycin. c. Metronidazole. d. Cephalexin. b Antimicrobial Prophylaxis 31  Please don’t forget to fill this evaluation questionnaire at the end of the session. Evaluation questionnaire 32  Director General of the World Health Organization (2007-2017)