mengapa perlu profilaksis??? -...
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Dr. Eko Setijanto, M.Med., MSi., Sp.AN., KICKomite Pengendalian Resistensi Antimikroba RSUD Dr. MOEWARDI SURAKARTA
MENGAPA PERLU PROFILAKSIS???
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DULU
penggunaan antibiotiksaat operasi
suntikan oralPre op (+) (-)
Post op Sampai flatus 5-7 hari
Jenis
Amoksisilin clavAmpisilin,
SulbenisilinSefotaksim, SeftriaksonSeftasidim
Gentamisin,Nitromisin,Tobramisin
Amoksisilin ClavErythromisin SefadroksilClindamicin
Masalah • Antibiotik Profilaksis diberikankurang tepat (jenis, dosis, kombinasi, dan lamanya)
• Pemahaman Profilaksis dan Terapirancu
• Bakteri Resisten semakin banyak• Multi resisten antimikroba• Penemuan Antibiotik lamban• Pedoman /pemakaian antibiotik
tidak terkendali• Penjualan antibiotik tidak terkendali
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Bakteri resisten
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Impact of Prolonged Antibiotic
Prophylaxis • 2,641 op by past art. Coronarius jantung– Group 1 <48 jam of antibiotics– Group 2 >48 jam of antibiotics
• SSI rates– Group 1 9% (131/1,502)– Group 2 9% (100/1,139)– Odds ratio 1.0 (95% CI: 0.8–1.3)
• Peningkakatan resitensi pada group 2:– Odds ratio 1.6 (95% CI: 1.1–2.6)
CABG = coronary artery bypass grafting; CI = confidence interval.Harbarth S et al. Circulation. 2000;101:2916–2921.
Treating > 48hrs:• More resistant bugs• Higher cost
Definitions :antibiotik yang diberikan pre-saat-setelah operasi pada kasus yang secara klinis tidak terdapat tanda infeksi. Tujuannya untuk mencegah terjadinya ILO / SSI
Delayed healing
HerniaPossible evisceration
AbscessFistula
Other procedures needed
Infection here may cause:
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Antibiotika profilaksis
Kolonisasi
Persiapan operasi
(Mayhall) • Bersih – Operasi tidak melibatkan
saluran cerna, urinarius, vagina
• Bersih terkontaminasi– Operasi melibatkan saluran
cerna, urinarius, vagina– Tidak terdapat tanda klinis
infeksi
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IndikasiAntibiotik Profilaksis
• Kasus operasi bersih dan bersih kontaminasi
• Pada operasi bersih Diberikan apabila berisiko komplikasi lebih merugikan infertilitas, operasi jantung
• Pemasangan implant/benda asing
Persiapan pasien operasi
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Elective Surgical
Procedures Prevention of Hyperglycemia
Volume 345:1359-1367 November 8, 2001 Number 19
Intensive Insulin Therapy in Critically Ill PatientsGreet Van den Berghe, M.D., Ph.D., Pieter Wouters, M.Sc., Frank Weekers, M.D., Charles Verwaest, M.D., Frans Bruyninckx, M.D., Miet Schetz, M.D., Ph.D., Dirk Vlasselaers, M.D., Patrick Ferdinande, M.D., Ph.D., Peter Lauwers, M.D., and Roger Bouillon, M.D., Ph.D.
80 mg/dl> Gluc. Darah <110mg/dl akan menurunkan: ICU mortality (8%-4.6%) Sepsis (46%) ARF requiring HD (41%) RBC transfusion (50%) Polyneuropathy (44%)
Independent variable with conventional care
SSIs and Glucose Levels CTS pts
012345
678
100–150 150–200 200–250 250–300Day 1 Blood Glucose (mg/dL)
Deep
Infe
ctio
n Ra
te, %
Zerr KJ et al. Glucose control lowers the risk of wound infection in diabetics after open heart operations, page 360. Reprinted from The Annals of Thoracic Surgeons, Vol. 63.
1.3% 1.6%2.5%
6.7%
P=0.002
Glucose control (200 mg/dl)decreases infection rate
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Elective Surgical
ProceduresPerioperative
Normothermia
• 200 CRS patients– Control: Routine intraoperative
thermal care (mean temperature 34.7°C)
– Treatment: Active warming (mean temperature 36.6°C)
• Incidence of SSI– Control 19% (18/96)
– Treatment 6% (6/104); P=0.009
Kurz A et al. N Engl J Med. 1996;334:1209–1215.
Warm Patient Strategies:•Start with warm room•Use Bair Hugger•Cool room for procedure•Use 40o irrigation•Warm room on closingGOAL : >36oC (98.6oF)
cold patientshad 3x infection
rate
Elective Surgical
Procedures Supplemental
Oxygen
• 500 CRS patients– 80% or 30% inspired oxygen during
operation and for 2 hours post surgery– All patients received prophylactic antibiotics
• Results– Arterial and subcutaneous PO2
higher in 80% oxygen group
– Lower incidence of SSIs with higher supplemental oxygen (5.2% vs 11.2%; P=0.01)
Greif et al. N Engl J Med. 2000;342:161–167.
Oxygen Strategy:•Supplemental O2 for 2hrs in RR low O2 2x infection rate
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Pencegahaninfeksi
terkendali
Menjelang Operasi
• Tidak gelisah• Tidur cukup
– R/ Sleep inducer
• Pasien mandi bersih dengan sabun
Elective Surgical
ProceduresHair Removal Clipping hair just before case is best
Hair Removal Method
Infection Rate
sore / kerok/shaving 5.2 - 8.8%
pagi / kerok 6.4 - 10%
sore / cukur 4 - 7.5%
pagi / cukur 1.8 - 3.2%
Alexander JW, et al. Arch Surg 1983; 118:347-352
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Pencegahaninfeksi
terkendali
• Syarat masuk kamar operasi– Cap– Masker– Celemek– Hand scrubing– Gaun– Sarung tangan /glove
• Antisepsis lapangan operasi iodophore /chlorheksidine
PemberianAntibiotikprofilaksis
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DONTSDONTSDONTSDONTSDONTS
Harbarth et al, Circulation 2000
Timing Insisi
Classen et al. N Engl J Med 1992
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• 30 menit sebelum operasi• Intravenous – drip
(dilarutkan dalam 100 ml NS)
• Diberikan dalam 15-30 menit• Dosis tunggal• Tidak memerlukan “skin
test”
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Fakta laporan
Cefuroxim Dosistunggal 3 Dosis p
Sepsis 11 (0.8) 6 (0.5) 0.17
Posible sepsis 7 (0.5) 9 (0.7) 0.37
Superfisial ILO 25 (1.9) 31 (2.3) 0.50
Total hip implant surgery
Wymenga et al, 1992
FaktaStudy
AMRIN Operasi Angka ILO
Histerektomi Sub Total 0/46
Histerektomi Total 1/277
Penggunaan antibiotika profilaksisdi Dep/SMF. Obstetri Ginekologi RSU. Dr. Soetomo. (AMRIN
2003- 2004)
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Antibiotik Proflaksis