THE CURRENT ROLE OF ANTIBIOTICS IN COLON AND RECTAL SURGERY IS PRESENTED IN A BRIEF AND CONCISE MANNER- ON AN EVIDENCE BASED APPROACH.

1. DR SANOOP K ZACHARIAH Consultant Surgeon & Assistant Professor MOSC Medical College Kolenchery Kerala, India

4. ONE DROP OF FEACES = 400 SPECIES OF BACTERIA 10 12 BACTERIA PER GRAM OF WET FEACES 40-50% OF SOLID FEACES=BACTERIA

5. COLORECTAL SURGERY= LOT OF BACTERIA

8. SUPERFICIAL SSI DEEP SSI ORGAN SPACE SSI SKIN SUBCUTANEOUS DEEP SOFT TISSUE FASCIA&MUSCLE INTRAPERITONEAL 1)HORAN ET AL,INFECT CONTROL HOSP EPIDEMOL 1992;13(10);606-8 2)AMJ INFECT CONTROL,2008:36:309-32

9. NUMBER OF RISK FACTORS PROCEDURE 0 1 2 3 GASTRIC SURGERY 1.84 2.64 4.86 APPENDICECTOMY 1.49 2.68 3.49 SMALL BOWEL SURGERY 2.62 6.31 COLON SURGERY 4.18 6.07 8.01 10.86 BREAST SURGERY .80 2.74 HERNIA SURGERY 1.02 2.47 4.36

13. MICROBIOLOGICAL COMPOSITION AND DISTRIBUTION OF THE GUT 10 3 10 8 10 12 Aerobes To Predominantly Anaerobes

16. LYMPHATICS,BLOOD BOWEL EXTRA INTESTINAL SITES

17. >10 5 =INFECTION

22. NATIONAL RESEARCH COUNCIL GROUP 1964(NRC) TAXONOMY OF SURGICAL WOUNDS WOUND TYPE DESCRIPTION 1 CLEAN ELECTIVE,NON TRAUMATIC,NOBREAK IN TECNIQUE,RESPIRATORY,GI,GENITOURINARY TRACT NOT ENTERED 2 CLEAN CONTAMINATED ELECTIVE OPENING OF RS,GI,GENITURINARY TRACT WITHOUT SIGNIFICANT SPILLAGE 3 CONTAMINATED TRAUMATIC WOUND,GROSS SPILLAGE FROM GI TRACT,ENCOUNTERING INFECTED URINE/BILE. 4 DIRTY SUPPORATIVE-INFLAMMATION,PRE-OP PERFORATION OF RS,GI,GTU ,TRACTS

23. ABSENCE OF ANTIMICROBIAL PROPHYLAXIS- WOUND INFECTION-32-58% INFECTIOUS COMPLICATIONS-UPTO 75% CATEGORY WITHOUT PROHYLATIC ANTIBIOTICS PROHYLATIC ANTIBIOTICS 1 CLEAN 1-2% 1-2% 2 CLEAN CONTAMINATED 6-11% 3.3% 3 CONTAMINATED 13-20% 6.4% 4 DIRTY 27-40% 7.1%

24. ??PENICILLIN AMINOGLYCOSIDE CEPHALOSPORINS METRONIDAZOLE,…….?????????

26. CHOOSE ONE FROM EACH EMPIRICALLY AEROBIC COVERAGE GENTAMICIN TOBRAMYCIN AMIKACIN CEFOTAXIM CEFTIZOXIME CRFTRIAXONE AZTREONAM CIPROFLOXACIN ANEROBIC COVERAGE CLINDAYCIN METRONIDAZOLE CHLORAMPHENICOL

28. HALF-LIVES OF SELECTED ANTIBIOTICS COMMONLY USED FOR PROPHYLAXIS Antibiotic Half-life (hours) Cefazolin Vancomycin Cefoxitin Cefotetan Aminoglycosides Metronidazole Clindamycin Ciprofloxacin 1.8 6 0.6 to 1 3 to 4.6 2 8 2.4 to 3 3 to 5

30. ONLY CONDITIONS APPLICABLE TO COLORECTAL SURGERY ARE INCLUDED CONTAMINATION- NO POSTOPERATIVE ANTIBIOTICS Traumatic enteric perforations-12 hrs Peritoneal contamination with bowel contents in elective/emg surgery Appendectomy – early/phlegmonous RESECTABLE INFECTION- UPTO 24 HRS Gangrenous (appendicitis) Resection of ischemic/strangulated necrotic bowel without perforation MILD INFECTION-UPTO 48HRS Intra abdominal infection with localized pus formation Late(>12 hrs)perforation without established infection MODERATE INFECTION-UPTO 5 DAYS Diffuse established intra abdominal infection from any source SEVERE INFECTION->5 DAYS Intra abdominal infection with a source not easily controllable Post op intraabdominal infection

36. IN ANORECTAL ABCESS, FISTULA, PILONIDAL ABCESS COMMONEST ORGANISMS ISOLATED WERE GUT SPECIFIC ORGANISMS & STAP.AUREUS Whitehead et al 1982 BJS

38. HA-MRSA, CA-MRSA VRSA,VISA ESBL

39. Suppression of normal gut flora Overgrowth of toxigenic strains of C.Difficile Effects- toxin a-mildly cytopathic toxin b-highly cytopathic Strain-bi/na1/027-new highly toxigenic strain-a,b toxins- Common antibiotics- penicillin, clindamycin, cephalosporin

40. YEAR AUTHORS RESULT 1985 Lozaro et al Iv metronidazole to be highly effective against anaerobes 1991 Tsimyianu et al Ornidazole 1g+cetrioxone =metronidazole+amikacin 1993 Rohwedher et al Ciprofloxacin 750mg single dose +met > gentamicin 8omg+met 1995 Nyam et al Amoxicllin-clavulanic acid > ceftrioxone+metronidazole 1996 Akuell Single dose ceftotam2gm+met > multiple doses(3) 2000 Zanella et al Single dose cefipime/ceftrioxone +met =other alternative regimens 2000 Zelenitsky et al Single high dose gentamicin+met>multiple standard doses 2005 Epsin et al Oral antibiotics have no additional benefits when added to paraenteral prophylatics

41. DNA mRNA DNA GYRASE PENICILLIN CEPHALOSPORIN VANCOMYCIN AMPHOTERICIN BACITRACIN GENTAMICIN METRONIDAZOLE CIPROFLOXACIN t-RNA LINEZOLID

42. MECHANICAL PREP REMOVES FEACAL BULK NOT BACTERIA RISK OF INFECTION WITH MEC.PREP ALONE=25-30% ROUTINE USE OF MECHANICAL PREP HAS BEEN QUESTIONED