At - Antibiotic Prophylaxis Prevent Infection in Obstetric and Gynecologic

PENGGUNAAN ANTIBIOTIK PROFILAKSIS
UNTUK MENCEGAH
INFEKSI DAERAH OPERASI
Nuswil Bernolian
DIVISI FETOMATERNAL DEPARTEMEN OBSTETRIK DAN GINEKOLOGI

FK UNSRI/RSUP. DR MOHAMMAD HOESIN PALEMBANG
Manajemen Update Infeksi dalam Kehamilan dan Rasionalisasi Penggunaan Antimikroba bagi Anggota POGI Sumsel
Hotel Harper Palembang, 24 Februari 2019
WHO
•Antimicrobial resistance (AMR) is the ability

of a microorganism (like bacteria, viruses,
and some parasites) to stop an antimicrobial
(such as antibiotics, antivirals and
antimalarials) from working against it.
DID YOU KNOW?
WHAT IS ANTIBIOTIC
PROPHYLAXIS ?
Antibiotic prophylaxis
Prevent outcome infection !!
Suggest to obese women El-Nashar SA et al. Extended antibiotic prophylaxis for prevention of
surgical-site infections in morbidly obese women who undergo
combined hysterectomy and medically indicated panniculectomy: a
cohort study. Am J Obstet Gynecol 2010;202:306.e1-9
El-Nashar SA et al. Extended antibiotic prophylaxis for prevention of
Antibiotik Profilaksis
(American Journal of Obstetrics & Gynecology AUGUST 2017)
Microbiology findings for patient with infection
El-Nashar SA et al.
Am J Obstet Gynecol
2010;202:306.e1-9
Antibiotic prophylaxis in obstetric procedures
SOGC Guidelines
J Obstet Gynaecol Can 2017;39(9):p293-299
Antibiotic prophylaxis in obstetric procedures
SOGC Guidelines
HOW to administered ???
SOGC Guidelines
ANTIBIOTIC PROPHYLAXIS ON INTRAPARTUM
Approximately 30% of women in the antepartum period are
colonized with group B Streptococcus (GBS)
After the implementation of intrapartum antibiotic
prophylaxis, the estimated rates of early GBS infection were
reduced by 83%
Recently, 4 or more hours of intrapartum antibiotic prophylaxis
prior to delivery has been shown to be the most effective
treatment for preventing early-onset GBS disease
Turrentine M. Intrapartum antibiotic
prophylaxis for group B Streptococcus:
has the time come to wait more than 4
hours? AJOG, 2014
THE PREVENTION OF EARLY-ONSET NEONATAL
GROUP B STREPTOCOCCAL DISEASE
THE PREVENTION OF EARLY-ONSET NEONATAL
GROUP B STREPTOCOCCAL DISEASE
Recommendations.....
Recommended antibiotic regimens for intrapartum
prophylaxis
• 1. Penicillin G 5 million units IV, then 2.5 to 3.0 million every 4 hours until
delivery or
• 2. If the woman is allergic to penicillin but has a low risk of anaphylaxis:
cefazolin 2 g IV then 1 g every 8 hours until delivery or
• 3. If the woman is allergic to penicillin and at risk of anaphylaxis:
clindamycin 900 mg IV every 8 hours until delivery (if isolate is susceptible
to clindamycin with no inducible resistance) or vancomycin 1 g IV every 12
hours until delivery
ANTIBIOTIC PROPHYLAXIS FOR TERM OR NEAR-
TERM PREMATURE RUPTURE OF MEMBRANES
In women with latency longer than 12 hours,

prophylactic antibiotics are associated with
significantly lower rates of chorioamnionitis by
51% and endometritis by 88%
Saccone G, Berghella V. Antibiotic prophylaxis for term or

near-term premature rupture of membranes: metaanalysis
randomized trials. Am J Obstet Gynecol 2015;212:627.e1-9
Antibiotic prophylaxis in prelabor spontaneous
rupture of fetal membranes at or beyond 36 weeks of
pregnancy
The routine use of prophylactic antibiotics in women with

prelabor spontaneous rupture of fetal membranes at or beyond
36 weeks of pregnancy does not reduce the risk of neonatal and
maternal infection-related morbidity
A.F. Nabhan et al. International Journal of Gynecology and

Obstetrics 124 (2014) 59–62
Antibiotic prophylaxis for cesarean delivery
Always before
skin incision
Camann W et al. International Journal of Obstetric

Anesthesia (2011) 20, 1–2
In obese women.....
• Higher adipose concentrations of cefazolin were observed after

the administration of an increased prophylactic dose
• This concentration-based pharmacology study supports the use
of 3 g of cefazolin at the time of cesarean delivery in obese
women
• Normal and overweight women (BMI <30 kg/m2) reach
adequate cefazolin concentrations with the standard 2-g dosing
Swank ML, Wing DA, Nicolau DP, et al. Increased 3-gram
cefazolin dosing for cesarean delivery prophylaxis in
obese women. Am J Obstet Gynecol 2015;213:415.e1-8
Antibiotic choices for cesarean prophylaxis
ACOG practice bulletin No.120. Use of prophylactic antibiotics

in labor and delivery. Obstet Gynecol 2011;117(6):1472–83.
• Single dose within 60 minutes of incision:

• Cephalosporin (preferably first-generation because of cost and
equivalent efficacy with later generations) or
• Ampicillin (shorter half-life than cefazolin)
• If penicillin allergic:
• Clindamycin / aminoglycoside
• Consider adding vancomycin if known MRSA carrier.
• Addition of azithromycin for adjunctive therapy is under
investigation.
ANTIBIOTIC PROPHYLAXIS ON POST
CAESAREAN
• Increasing the use of extended-spectrum antibiotic

prophylaxis over 3 time periods was associated with a
decreasing trend in postcesarean incisional wound infection
Tita ATN et al. Impact of extended-spectrum antibiotic

prophylaxis on incidence of postcesarean surgical wound
infection. Am J Obstet Gynecol 2008;199:303.e1-303.e3
Antibiotic prophylaxis on hysterectomy
Prophylactic antibiotic
use is associated with decreased
Surgical Site Infection rates after
hysterectomy
El-Nashar SA et al. Extended antibiotic prophylaxis for prevention of

• Cefazolin plus metronidazole appears to reduce the risk
for surgical site infection after hysterectomy compared
with cefazolin or second generation cephalosporin alone
Antibiotic prophylaxis on abdominal
hysterectomy
There was no difference between the use of single-dose

preoperative ceftriaxone and cefazolin in preventing infectious
morbidity among patients undergoing hysterectomy
N. Phoolcharoen et al. A randomized controlled trial comparing

ceftriaxone with cefazolin for antibiotic prophylaxis in
abdominal hysterectomy. International Journal of Gynecology
and Obstetrics 119 (2012) 11–13
Antibiotic Prophylaxis in Gynecologic Procedures
SOGC Guidelines
ANTIBIOTIC PROPHYLAXIS IN GYNECOLOGIC
PROCEDURES
SOGC Guidelines
ANTIBIOTIC PROPHYLAXIS IN GYNECOLOGIC
PROCEDURES
SOGC Guidelines
Antibiotic prophylaxis for hysteroscopy evaluation
of uterine cavity
• Diagnostic office hysteroscopy should not be recommended antibiotic prophylaxis
Kasius JC et al. Fertility and

Sterility.95(2): 2011
ANTIBIOTIC PROPHYLAXIS FOR SELECTED
GYNECOLOGIC SURGERY
Antibiotic prophylaxis may be beneficial in first-trimester suction

curettage and laparotomy
No advantage was found for loop electrosurgical excision,

hysteroscopy, or laparoscopic gynecologic surgery
M.Y. Morrill et al. Antibiotic prophylaxis for selected

gynecologic surgeries. International Journal of Gynecology and
Obstetrics 120 (2013) 10–15
(American Journal of Obstetrics & Gynecology AUGUST 2017)
• 6 perioperative measures that were independently associated with SSI
risk:
• Appropriate selection of prophylactic antibiotics;
• Postoperative normothermia (temperature > 98.6F);
Oral antibiotics with mechanical bowel prep;
• Postoperative day #1 glucose 140 mg/dL;
• Minimally invasive approach; and
• Short operative time < 100 minutes
Impact of Treating > 48hrs:
• More resistant bugs
Prolonged • Higher cost
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)
• Peningkatan 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.
Glucose control
• Implement perioperative glycemic control and
use blood glucose target levels < 200 mg/dL in
diabetic and non-diabetic surgical patients
(Category 1A)
– No recommendation can be made regarding the
safety and effectiveness of lower or narrower
blood glucose target levels and SSI. (No
Recommendation/unresolved issue)
– No recommendation can be made regarding
hemoglobin A1C target levels and the risk of
surgical site infection in diabetic and non-diabetic
patients. (No recommendation/unresolved issue)
Disclaimer: The findings and conclusions are draft and have been presented at HICPAC but have not been
formally disseminated by the CDC and should not be construed to represent any agency determination or
policy.
Postoperative Hyperglycemia
and SSI in General Surgery
Patients
Relative SSI Rate
14
10,5
3,5
0
< 110 111-140 141-180 181-220 >220
Glucose Value in first 48 hr
Ata A, et al. Arch Surg 2010; 145: 858-64.
Elective
Surgical
Procedures  80 mg/dl> Gluc. Darah <110mg/dl akan
Prevention of menurunkan:
Hyperglycemia  ICU mortality (8%-4.6%)
 Sepsis (46%)
 ARF requiring HD (41%)
 RBC transfusion (50%)
 Polyneuropathy (44%)
 Independent variable with conventional care
Volume 345:1359-1367 November 8, 2001 Number 19
Intensive Insulin Therapy in Critically Ill Patients
Greet 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.
Glucose control (200 mg/dl)
decreases infection rate
SSIs and Glucose Levels CTS pts

8
6.7%
Deep Infection Rate, %

7
6
P=0.002
5
4
2.5%
3
1.3% 1.6%
2
1
0
100–150 150–200 200–250 250–300
Day 1 Blood Glucose (mg/dL)
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.
Perioperative
hyperglycemia
was associated
with adverse
outcomes in
general surgery
patients with and
without diabetes.
Ann Surg 2013; 257:8–14.
Normothermia
• Maintain perioperative normothermia
(Category 1A)
– No recommendation can be made regarding
the safety or effectiveness of strategies to
achieve and maintain normothermia, the
lower limit of normothermia, or the optimal
timing and duration of normothermia.
policy.
Elective • 200 CRS patients
Surgical • Control: Routine intraoperative
thermal care
Procedures (mean temperature 34.7°C)
Perioperative
• Treatment: Active warming
Normothermia (mean temperature 36.6°C)
• Incidence of SSI
• Control 19% (18/96)
Warm Patient Strategies: • Treatment 6% (6/104); P=0.009
•Start with warm room cold patients
•Use Bair Hugger
•Cool room for procedure had 3x infection
•Use 40o irrigation rate
•Warm room on closing
GOAL : >36oC (98.6oF)
Kurz A et al. N Engl J Med. 1996;334:1209–1215.
Oxygenation
• For patients with normal pulmonary function
undergoing surgery with general anesthesia
with endotracheal intubation, administer
increased fraction of inspired oxygen (FiO2)
intraoperatively and post-extubation in the
immediate postoperative period in
combination with strategies to optimize
tissue oxygen delivery through maintenance
of perioperative normothermia and adequate
volume replacement. (Category 1A)
policy.
J Eval Clin Pract. 2009; 15:360-5.
Oxygenation
• No recommendation for
– Those without endotracheal intubation
– Mechanism (facemask, cannula)
postoperatively
– Optimal FiO2 target, duration, and delivery
method
policy.
Elective
Surgical • 500 CRS patients
Procedures • 80% or 30% inspired oxygen during
Supplemental operation and for 2 hours post surgery
Oxygen • All patients received prophylactic antibiotics
• Results
• Arterial and subcutaneous PO higher in 2
80% oxygen group

• Lower incidence of SSIs with higher
supplemental oxygen (5.2% vs 11.2%;
Oxygen Strategy: P=0.01)
•Supplemental O2 for
low O2 2x infection rate
2hrs in RR
Greif et al. N Engl J Med. 2000;342:161–167.
Skin Preparation
• Require patients to shower or bathe (full body)
with an antimicrobial or non-antimicrobial
soap or antiseptic agent on at least the night
before the operative day. (Category 1B)
– No recommendation can be made regarding the
optimal timing of the preoperative shower or bath
or the total number of soap or antiseptic agent
applications for the prevention of surgical site
infection. (No recommendation/ unresolved
issue)
policy.
Skin Preparation
• Perform intraoperative skin preparation with
an alcohol-based antiseptic agent, unless
contraindicated. (Category 1A)
• Do not use an antimicrobial sealant following
intraoperative skin preparation and prior to
skin incision for the prevention of surgical
site infection. (Category IA)
• Use of plastic adhesive drapes with or
without antimicrobial properties, is not
necessary for the sole purpose of the
prevention of surgical site infection.
(Category II)
policy.
TAKE HOME
MESSAGES
TAKE HOME MESSAGES
• An accurate antibiotic prophylaxis decrease infection after

procedural on obstetric and gynecologic
• For obese women, antibiotic prophylaxis should be increased of
doses
Centers for Disease Control and Prevention’s National Healthcare Safety Network classification for surgical site infection (SSI)
Thank
You

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PENGGUNAAN ANTIBIOTIK PROFILAKSIS

DIVISI FETOMATERNAL DEPARTEMEN OBSTETRIK DAN GINEKOLOGI

•Antimicrobial resistance (AMR) is the ability

Prevent outcome infection !!

In women with latency longer than 12 hours,

Saccone G, Berghella V. Antibiotic prophylaxis for term or

The routine use of prophylactic antibiotics in women with

A.F. Nabhan et al. International Journal of Gynecology and

Camann W et al. International Journal of Obstetric

• Higher adipose concentrations of cefazolin were observed after

ACOG practice bulletin No.120. Use of prophylactic antibiotics

• Single dose within 60 minutes of incision:

• Increasing the use of extended-spectrum antibiotic

Tita ATN et al. Impact of extended-spectrum antibiotic

El-Nashar SA et al. Extended antibiotic prophylaxis for prevention of

There was no difference between the use of single-dose

N. Phoolcharoen et al. A randomized controlled trial comparing

Kasius JC et al. Fertility and

Antibiotic prophylaxis may be beneficial in first-trimester suction

No advantage was found for loop electrosurgical excision,

M.Y. Morrill et al. Antibiotic prophylaxis for selected

CABG = coronary artery bypass grafting; CI = confidence interval.

SSIs and Glucose Levels CTS pts

Deep Infection Rate, %

80% oxygen group

• An accurate antibiotic prophylaxis decrease infection after

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