PEMBERIAN ANTIBIOTIK PROFILAKSIS DALAM PEMBEDAHAN OBSTETRI DAN GINEKOLOGI

Dr. Budi Iman Santoso, SpOG K!

Di"isi #ro$o%i R&'onstru'si D&part&m&n O(st&tri dan Gin&'o$o%i Fa'u$tas K&do't&ran #ni"&rsitas Indon&sia Ruma) Sa'it Dr. *ipto Man%un'usumo, +a'arta

MEN*EGAH INFEKSI L#KA OPERASI,

1. Praoperatif a. Persiapan pasien b. Antisepsis tim bedah c. Penaganan personal bedah yang terkena infeksi d. Antibiotik profilaksis 1. Intra operatif a. Ventilasi b. Membersihkan dan desinfeksi lingkungan c. Sampling mikrobiologi d. Sterilisasi instrumen bedah e. Perlindungan tubuh f. Tehnik bedah dan asepsis 2. Pera atan luka pasca bedah !. sur"eilens

PENGG#NAAN ANTIBIOTIK DALAM KLINIK

Pro-i$a'sis, di(&ri'an pada pasi&n s&(&$um 'ontaminasi atau in-&'si t&r.adi Antisipasi, t&rmasu' situasi dimana 'ontaminasi suda) t&r.adi dan p&n%o(atan di(&ri'an untu' m&minima$'an in-&'si pas/a (&da) Empiri' , p&n%o(atan tida' $an%sun% t&r)adap tida' t&rid&nti-i'asin0a pato%&n Lan%sun%, pato%&n t&rid&nti-i'asi

H#B#NGAN PEMBEDAHAN DENGAN INFEKSI

Dip&r'ira'an 123 pasi&n 0an% (&ro(at '& ruma) sa'it m&n.a$ani p&m(&da)an Insid&n , t&r%antun% dari .&nis p&m(&da)an, -a'tor risi'o dan anti mi'ro(a 0an% dipa'ai Dip&r'iran'an $&(i) dari 423 m&rupa'an in-&'si noso'omia$

BERBAGAI FAKTOR 5ANG BERH#B#NGAN DENGAN PENINGKATAN RISIKO INFEKSI BEDAH

Host Fa/tors #lder age #besity Malnutrition $iabetes mellitus Immunocompromising diseases or therapies Presence of other infections Skin diseases Pr&op&rati"& Fa/tors Prolonged pre%op stay Sha"ing the skin Inade&uate antibiotic prophyla'is Sur%i/a$ Fa/tors ( Inade&uate skin antisepsis ( )mergency procedure ( Prosthetic implants ( Prolonged procedure ( *se of drains ( Poor techni&ue ( *ne'pected contamination En"ironm&nta$ Fa/tors ( Staph. or Strep. carrier ( )'cessi"e acti"ity in #+ ( ,ontaminated antiseptics ( Inade&uate "entilation ( Inade&uately sterili-ed e&uipment

PATOGENESIS INFEKSI L#KA BEDAH

In-&'si pada $u'a (&da) t&r.adi (i$a ino'u$um 'uman pada $u'a m&$ampaui m&'anism& p&rta)anan tu(u) s&)in%%a t&r.adi p&rtum(u)an 'uman

KLASIFIKASI KONDISI L#KA OPERASI

B&rsi) B&rsi) t&r'ontaminasi T&r'ontaminasi 'otor

ANGKA INFEKSI LUKA OPERASI SURVEY PREVALENS WHO *ondu/t&d in <4 )ospita$s in 9< /ountri&s durin% 9:;=6;>
.ound ,lass ,lean ,lean%contaminated ,ontaminated All Pre"alence ' 1// post%op patients 1!.! 10.1 22.3 10.0 4range 1.0%!1.15

Ma0on67)it& &t a$. An int&rnationa$ sur"&0 o- t)& pr&"a$&n/& o- )ospita$6a/8uir&d in-&/tion. + Hosp In-&/t 9:;;

Annua$ Sur%i/a$ Sit& In-&/tion Rat& (0 7ound *$ass in a Lar%& #.S. Hospita$
O$son ? L&&. *ontinuous, 9260&ar @ound in-&/tion sur"&i$$an/&. Ar/) Sur% 9::2A9B>,4:<.
9< D SSI p&r 922 pro/&dur&s 9B 92 ; 1 < B 2 C44 C4; C4: C;2 C;9 C;B C;= C;< C;> C;1 A$$ *$&an *$&an6/ontaminat&d *ontaminat&dEDirt06In-&/t&d

ENAM AT#RAN PEMBERIAN ANTIBIOTIK PROFILAKSIS DALAM #PA5A MEN*EGAH INFEKSI L#KA BEDAH

9. Guna'an anti(ioti' (i$a risi'o in-&'si tin%%i atau s&8ua$a& tin%%i 9. +an%an di(&ri'an t&r$a$u /&pat atau $am(at dan 'adarn0a da$am .arin%an m&n/apai pun/a' '&ti'a pisau mu$ai m&n0a0at

PENGAR#H SAAT PEMBERIAN ANTIBIOTIK PROFILAKSIS TERHADAP ANGKA INFEKSI

,lassen $,7 et al89 )ngl : Med 1332
2847 patients undergoing elective clean or cleancontaminated surgical procedures. Patients divided into 4 categories based upon timing of administration of antibiotic Early 2-24 hours before surgery Pre-operatively 0-2 hours before surgery Perioperative 0-3 hours after surgery Post-operative 3-24 hours after surgery

Timing )arly Pre%op Peri%op Post%op

Infection +ate !.26 /.06 1.16 !.!6

9. B&ri'an anti(ioti' 0an% t&pat

Anti(ioti' pro-i$a'sis 0an% m&madai , E-&'ti- m&$a@an 'uman p&n0&(a( in-&'si Tida' p&r$u m&m(unu) s&$uru) 'uman 0an% pot&nsia$ pato%&n M&n/apai 'adar .arin%an $o'a$ 0an% ad&'uat E-&' sampin% 0an% minima$ Mura) Tida' m&n%%an%u '&s&im(an%an -$ora mi'ro(ia$ pada pasi&n maupun ruma) sa'it

YANG TIDAK DIANJURKAN SEBAGAI ANTIBIOTIK PROFILAKSIS

T)ird6%&n&ration /&p)a$osporins *&-otaFim&, *&-triaFon&, *&-op&raGon&, *&-taGidim& or *&-tiGoFim&! Fourt)6%&n&ration /&p)a$osporins, &.%. /&-&pim& 7)0 , EFp&ns& Som& ar& $&ss a/ti"& t)an 9ST %&n&ration a%ainst stap)0$o/o//i Non6optima$ sp&/trum o- a/tion a/ti"it0 a%ainst or%anisms not /ommon$0 &n/ount&r&d in &$&/ti"& sur%&r0! 7id&spr&ad us& -or prop)0$aFis &n/oura%&s &m&r%&n/& or&sistan/&

9. BERIKAN INTRAHENA DAN DOSIS EFEKTIF BERDASARKAN BERAT BADAN *ONTOH *&p)a$osporin /&-aGo$in!
I J 42 '% , 9% K 42 '% ,B%

9. G#NAKAN TAMBAHAN DOSIS INTRA OPERATIF APABILA MEMANG DIB#T#HKAN,

*ONTOH Lama op&rasi $&(i) dari B .am P&rdara)an (an0a'

9. PERTAHANKAN DOSIS PAS*A OPERATIF SEMINIMAL M#NGKIN,

Dosis 2 pada umumn0a m&madai untu' '&(an0a'an pros&dur Dosis sampai <; .am pada pros&dur t&rt&ntu

Endo%&nous Pat)o%&ns *ommon$0 Iso$at&d -rom Postop&rati"& P&$"i/ In-&/tions

A&ro(i/ %ram6positi"& /o//i Viridans and nongroup A, B, and D streptococci Group B streptococci Enterococcus Strept faecalis, Staphylococcus aureus Staphylococcus epidermidis A&ro(i/ %ram6n&%ati"& (a/i$$i Escherichia coli Klebsiella species Proteus mirabilis Gardnerella vaginalis Ana&ro(i/ or%anisms Peptostreptococcus species Bacteroides fragilis group Prevotella bivia Prevotella disiens usobacterium species M0/op$asmas !ycoplasma hominis "reaplasma urealyticum

linical infection in !bst.gyn. " #aclean $% &''(.

O(s&r"ations in O(%0n sur%i/a$ in-&/tions

F&(ri$& mor(idit0 is mor& /ommon a-t&r a(domina$ t)an a-t&r "a%ina$ )0st&r&/tom0 A%& )as in/onsist&nt$0 (&&n s)o@n to (& a ris' -a/tor a-t&r )0st&r&/tom0, @it) pr&m&nopausa$ @om&n s)o@n to (& at in/r&as&d ris' in som& studi&s, &sp&/ia$$0 a-t&r "a%ina$ )0st&r&/tom0

linical infection in !bst.gyn. " #aclean $% &''(.

O(s&r"ations in O(%0n sur%i/a$ in-&/tions

Ba/t&ria$ "a%inosis )as (&&n asso/iat&d @it) an in/r&as&d ris' o- in-&/tion a-t&r a(domina$ )0st&r&/tom0 Pati&nts s/)&du$&d -or &$&/ti"& )0st&r&/tom0 s)ou$d (& s/r&&n&d -or (a/t&ria$ "a%inosisA on& mont) (&-or& t)& p$ann&d pro/&dur&. T)os& -ound to )a"& (a/t&ria$ "a%inosis s)ou$d (& tr&at&d and a$$o@&d s&"&ra$ @&&'s to r&&sta($is) a norma$ $a/to(a/i$$us6 dominant -$ora (&-or& sur%&r0 linical infection in !bst.gyn. " #aclean $% &''(.

Observations in post C.S in e!tion

Duration o- ruptur& m&m(ran& ? post *.S in-&/tion
D SSI p&r 922 /&sar&an s&/tions 9B 92 ; 1 < B 2 No ruptur& I9 )our 96= )ours K= )ours

P&$$& &t a$. 7ound in-&/tion a-t&r /&sar&an s&/tion. In-&/t *ontro$ 9:;1A4,<>1.

ANTIBIOTI* PROPH5LALIS *&sar&an s&/tion

T)&r& ar& su--i/i&nt data to r&/omm&nd routin& anti(ioti/ prop)0$aFis in *S. 9 and Bnd %&n&ration /&p)a$osporins and Au%m&ntin )a"& simi$ar &--i/a/0 in r&du/in% postop&rati"& in-&/tion ? &ndom&tritis. D&spit& t)& t)&or&ti/ n&&d to /o"&r %ram6n&%ati"& and ana&ro(i/ or%anisms, studi&s )a"& not d&monstrat&d a sup&rior r&su$t @it) (road6sp&/trum anti(ioti/s /ompar&d @it) 9st and Bnd %&n&ration /&p)a$osporins. The Cochrane Library, 17 2//1

st

ANTIBIOTI* PROPH5LALIS IN G5NAE*OLOGI*AL S#RGER5

,lean Procedures 8 Antibiotic prophyla'is is

considered optional for most clean procedures7 although it may be indicated for certain patients that fulfill specific risk criteria

+ationale8 ;ikely infecting organism are gram%

positi"e cocci 4S. aureus or S. epidermidis5 and aerobic coliforms 4). coli5.

Agents8

,efa-olin7 cefuro'ime7 augmentin or metronida-ole.

ACOG Practice Bulletin. Antibiotic prophylaxis for gynecologic procedures. Obstet Gynecol 2001;2 !2.

AN"I#IO"IC PROPHYLA$IS IN GYNAECOLOGICAL SURGERY

Ha%ina$Ea(domina$ )0st&r&/tom0 , . Au%m&ntin 9.B % sin%$& dos& . *&-aGo$in 9 6 B % sin%$& dos& M M&tronidaGo$& >22 m% IH sin%$& dos& . *&-uroFim& 9.> % IH sin%$& dos& M M&tronidaGo$& >22 m% IH sin%$& dos& Laparotom0 , In )i%) ris' pati&nts Laparos/op0 , Non& H0st&ros/op0 , Non&

ACOG Practice Bulletin. Antibiotic prophylaxis for gynecologic procedures. Obstet Gynecol 2001;2 !2.

AN"I#IO"IC PROPHYLA$IS IN GYNAECOLOGICAL SURGERY

Infertility promoting surgery 8

. Augmentin 1.2 g single dose . ,efa-olin 1 % 2 g or ,efuro'ime 1.< g IV single dose = Metronida-ole <// mg IV single dose . In salpingostomy for hydrosalpin'> e'tend prophyla'is up to one eek 4do'ycycline ? metronida-ole #+ Augmentin5
ACOG Practice Bulletin. Antibiotic prophylaxis for gynecologic procedures. Obstet Gynecol 2001;2 !2.

AN"I#IO"IC PROPHYLA$IS IN GYNAECOLOGICAL SURGERY

D?*, miss&d a(ortion or indu/&d a(ortion @it) ris'

-a/tors, &.%. )istor0 o- pr&"ious PID, mu$tip$& partn&rs, 0oun%, 'no@n %ono/o//a$ or /)$am0dia in-&/tions! B22 m% DoF0/0/$in& on& )our (&-or&, -o$$o@&d (0 922 m% F B dai$0 F < da0s I#*D ins&rtion and HSG @it) ris' -a/tors , Pro)0$aFis is pro(a($0 indi/at&d 6 DoF0/0/$in& as a(o"&

ACOG Practice Bulletin. Antibiotic prophylaxis for gynecologic procedures. Obstet Gynecol 2001;2 !2.

AN"I#IO"IC PROPHYLA$IS IN O#S"E"RIC AN% GYNAECOLOGICAL SURGERY

Peni!i&&in'Cep(a&osporin a&&er)*
,lindamycin7 IV7 1</ mg 0 hourly for 2@! doses may be used for such patients

ACOG Practice Bulletin. Antibiotic prophylaxis for gynecologic procedures. Obstet Gynecol 2001;2 !2.

Endo/arditis prop)0$aFis
Hi%)6ris' pati&nts
Ampicillin7 2 g IM or IV7 plus gentamicin7 1.< mgA kg 4not to e'ceed 12/ mg5 ithin !/ minutes of starting the procedure> si' hours later7 ampicillin7 1 g IMAIV7 or amo'icillin7 1 g orally

Pati&nts a$$&r%i/ to ampi/$$in E amoFi/i$$in

Vancomycin7 1 g IV o"er 1%2 hours7 plus gentamicin7 1.< mgA kg IVAIM 4not to e'ceed 12/ mg5> inBectionAinfusion ithin !/ minutes of starting the procedure
A#$G Practice Bulletin% Antibiotic prophyla&is for gynecologic procedures% $bstet Gynecol '(()*'+,'%

Ot)&r Important Fa/tors in Pr&"&ntin% Sur%i/a$ In-&/tion

R&mo"& )air (0 /$ippin%, not s)a"in%, imm&diat&$0 (&-or& op&ration Hi%i$an/& -or (r&a's in as&pti/ t&/)ni8u& (0 op&ratin% room t&am Limit sutur&s and $i%atur&s #s& mono-i$am&nt sutur&s Emp$o0 /$os&d su/tion rat)&r t)an op&n draina%&A us& no draina%& i- possi($&

Ot)&r Important Fa/tors in Pr&"&ntin% Sur%i/a$ In-&/tion

EF&r/is& m&ti/u$ous s'in /$osur& Administ&r )i%) intraop&rati"& and postop&rati"& inspir&d oF0%&n Maintain normot)&rmia durin% op&ration #s& sur"&i$$an/& o- @ound in-&/tion @it) r&"i&@ o- pr&"&nti"& m&asur&s

RANGK#MAN
Pemberian antibioti) profila)sis diberi)an pada hampir semua tinda)an pembedahan dengan )ategori bersih ter)ontaminasi *osis tunggal prabedah cu)up memadai pada hampir semua )asus )ecuali pada pembedahan yang lama dan perdarahan banya)

+enerasi pertama atau generasi )edua sefalosporin memberi)an ca)upan yang ade)uat pada )ebanya)an )asus bersih dan bersih ter)ontaminasi Pemilihan antibioti) dipengaruhi oleh )uman penyebab infe)si pada ,enis pembedahan% biaya dan )etersediaan antibioti)a