PEMBERIAN ANTIBIOTIK

PROFILAKSIS DALAM PEMBEDAHAN

OBSTETRI DAN GINEKOLOGI

Dr. Budi Iman Santoso, SpOG(K)

Divisi Urologi Rekonstruksi

Departemen Obstetri dan Ginekologi
Fakultas Kedokteran Universitas Indonesia
Rumah Sakit Dr. Cipto Mangunkusumo, Jakarta

MENCEGAH INFEKSI LUKA 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. Perawatan luka pasca bedah
3. surveilens

PENGGUNAAN ANTIBIOTIK DALAM

KLINIK
Profilaksis:
diberikan pada pasien sebelum kontaminasi atau
infeksi terjadi
Antisipasi:
termasuk situasi dimana kontaminasi sudah terjadi
dan pengobatan diberikan untuk meminimalkan
infeksi pasca bedah
Empirik : pengobatan tidak langsung terhadap
tidak teridentifikasinya patogen
Langsung: patogen teridentifikasi

HUBUNGAN PEMBEDAHAN
DENGAN INFEKSI
Diperkirakan 60% pasien yang berobat ke
rumah sakit menjalani pembedahan
Insiden : tergantung dari jenis
pembedahan, faktor risiko dan anti
mikroba yang dipakai
Diperkirankan lebih dari 70% merupakan
infeksi nosokomial

BERBAGAI FAKTOR YANG BERHUBUNGAN

DENGAN PENINGKATAN RISIKO INFEKSI BEDAH
Host Factors
Older age
Obesity
Malnutrition
Diabetes mellitus
Immunocompromising
diseases or therapies
Presence of other
infections
Skin diseases
Preoperative Factors
Prolonged pre-op stay
Shaving the skin
Inadequate antibiotic prophylaxis

Surgical Factors
Inadequate skin antisepsis
Emergency procedure
Prosthetic implants
Prolonged procedure
Use of drains
Poor technique
Unexpected contamination
Environmental Factors
Staph. or Strep. carrier
Excessive activity in OR
Contaminated antiseptics
Inadequate ventilation
Inadequately sterilized equipment

PATOGENESIS INFEKSI LUKA BEDAH

Infeksi pada luka bedah terjadi bila
inokulum kuman pada luka melampaui
mekanisme pertahanan tubuh sehingga
terjadi pertumbuhan kuman

KLASIFIKASI KONDISI LUKA OPERASI

Bersih
Bersih terkontaminasi
Terkontaminasi
kotor

ANGKA INFEKSI LUKA OPERASI

SURVEY PREVALENS WHO
Conducted in 47 hospitals in 14
countries during 1983-85
Wound Class

Prevalence
x 100 post-op patients

Clean

13.3

Clean-contaminated

16.4

Contaminated

28.9

All

16.6
(range 4.6-34.4)

Mayon-White et al. An international survey of the prevalence

of hospital-acquired infection. J Hosp Infect 1988

Annual Surgical Site Infection Rate by Wound

Class in a Large U.S. Hospital

# SSI per 100 procedures

Olson & Lee. Continuous, 10-year wound

infection surveillance. Arch Surg 1990;125:794.
14

All

12

Clean
Clean-contaminated

10

Contaminated/Dirty-Infected

8
6
4
2
0
'77

'78

'79

'80

'81

'82

'83

'84

'85

'86

ENAM ATURAN PEMBERIAN ANTIBIOTIK

PROFILAKSIS DALAM UPAYA MENCEGAH
INFEKSI LUKA BEDAH

1. Gunakan antibiotik bila risiko infeksi

tinggi atau sequalae tinggi
1. Jangan diberikan terlalu cepat atau
lambat dan kadarnya dalam jaringan
mencapai puncak ketika pisau mulai
menyayat

PENGARUH SAAT PEMBERIAN ANTIBIOTIK

PROFILAKSIS TERHADAP ANGKA INFEKSI
Classen DC, et al:N Engl J Med 1992
2847 patients undergoing elective clean or cleancontaminated surgical procedures.
Patients divided into 4 categories based upon timing
of administration of antibiotic

Timing

Infection
Rate

Early

3.8%

Pre-op

0.6%

Peri-op

1.4%

Post-op

3.3%

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

1. Berikan antibiotik yang tepat

Antibiotik profilaksis yang memadai :

Efektif melawan kuman penyebab infeksi
Tidak perlu membunuh seluruh kuman yang
potensial patogen
Mencapai kadar jaringan lokal yang adekuat
Efek samping yang minimal
Murah
Tidak menggangu keseimbangan flora mikrobial
pada pasien maupun rumah sakit

YANG TIDAK DIANJURKAN SEBAGAI

ANTIBIOTIK PROFILAKSIS
Third-generation cephalosporins (Cefotaxime, Ceftriaxone,
Cefoperazone, Ceftazidime or Ceftizoxime)
Fourth-generation cephalosporins: e.g. cefepime
Why :
Expense
Some are less active than 1ST generation against
staphylococci
Non-optimal spectrum of action (activity against organisms
not commonly encountered in elective surgery)
Widespread use for prophylaxis encourages emergence of
resistance

1. BERIKAN INTRAVENA DAN DOSIS

EFEKTIF BERDASARKAN BERAT BADAN
CONTOH
Cephalosporin (cefazolin)
< = 70 kg : 1g
> 70 kg

:2g

1. GUNAKAN TAMBAHAN DOSIS INTRA OPERATIF

APABILA MEMANG DIBUTUHKAN:

CONTOH
Lama operasi lebih dari 2 jam
Perdarahan banyak

1. PERTAHANKAN DOSIS PASCA OPERATIF

SEMINIMAL MUNGKIN:

Dosis 0 pada umumnya memadai untuk

kebanyakan prosedur
Dosis sampai 48 jam pada prosedur
tertentu

Endogenous Pathogens Commonly Isolated

from Postoperative Pelvic Infections
Aerobic gram-positive cocci
Viridans and nongroup A, B,
and D streptococci
Group B streptococci
Enterococcus
Strept faecalis,
Staphylococcus aureus
Staphylococcus epidermidis
Aerobic gram-negative bacilli
Escherichia coli
Klebsiella species
Proteus mirabilis
Gardnerella vaginalis

Anaerobic organisms
Peptostreptococcus
species
Bacteroides fragilis group
Prevotella bivia
Prevotella disiens
Fusobacterium species
Mycoplasmas
Mycoplasma hominis
Ureaplasma urealyticum

Clinical infection in Obst.gyn. : Maclean A, 1995.

Observations in Obgyn
surgical infections
Febrile morbidity is more common after
abdominal than after vaginal hysterectomy
Age has inconsistently been shown to be a risk
factor after hysterectomy, with premenopausal
women shown to be at increased risk in some
studies, especially after vaginal hysterectomy

Clinical infection in Obst.gyn. : Maclean A, 1995.

Observations in Obgyn surgical

infections
Bacterial vaginosis has been associated with an
increased risk of infection after abdominal
hysterectomy
Patients scheduled for elective hysterectomy should
be screened for bacterial vaginosis; one month
before the planned procedure. Those found to have
bacterial vaginosis should be treated and allowed
several weeks to reestablish a normal lactobacillusdominant flora before surgery
Clinical infection in Obst.gyn. : Maclean A, 1995.

Observations in post
C.S infection

# SSI per 100 cesarean sections

Duration of rupture membrane & post

C.S infection
12
10
8
6
4
2
0
No rupture

<1 hour

1-3 hours

>3 hours

Pelle et al. Wound infection after cesarean

section. Infect Control 1986;7:456.

ANTIBIOTIC PROPHYLAXIS
Cesarean section

There are sufficient data to recommend routine

antibiotic prophylaxis in CS.

1 and 2nd generation cephalosporins and Augmentin

have similar efficacy in reducing postoperative
infection & endometritis.

st

Despite the theoretic need to cover gram-negative

and anaerobic organisms, studies have not
demonstrated a superior result with broad-spectrum
antibiotics compared with 1st and 2nd generation
cephalosporins.
The Cochrane Library, 1, 2004

ANTIBIOTIC PROPHYLAXIS IN
GYNAECOLOGICAL SURGERY

Clean Procedures : Antibiotic prophylaxis is

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

Rationale: Likely infecting organism are grampositive cocci (S. aureus or S. epidermidis) and
aerobic coliforms (E. coli).

Agents:

Cefazolin, cefuroxime, augmentin or

metronidazole.
ACOG Practice Bulletin. Antibiotic prophylaxis for gynecologic
procedures. Obstet Gynecol 2001;23:2.

ANTIBIOTIC PROPHYLAXIS IN
GYNAECOLOGICAL
SURGERY

Vaginal/abdominal hysterectomy :
. Augmentin 1.2 g single dose
. Cefazolin 1 - 2 g single dose Metronidazole 500 mg IV single
dose
. Cefuroxime 1.5 g IV single dose Metronidazole 500 mg IV single
dose
Laparotomy : In high risk patients
Laparoscopy : None
Hysteroscopy : None

ACOG Practice Bulletin. Antibiotic prophylaxis for gynecologic

procedures. Obstet Gynecol 2001;23:2.

ANTIBIOTIC PROPHYLAXIS IN
GYNAECOLOGICAL
SURGERY

Infertility promoting surgery :

. Augmentin 1.2 g single dose
. Cefazolin 1 - 2 g or Cefuroxime 1.5 g IV single dose
Metronidazole 500 mg IV single dose
. In salpingostomy for hydrosalpinx; extend prophylaxis
up to one week (doxycycline + metronidazole OR
Augmentin)
ACOG Practice Bulletin. Antibiotic prophylaxis for gynecologic
procedures. Obstet Gynecol 2001;23:2.

ANTIBIOTIC PROPHYLAXIS IN
GYNAECOLOGICAL
SURGERY

D&C: missed abortion or induced abortion with risk

factors, (e.g. history of previous PID, multiple partners,
young, known gonococcal or chlamydia infections)
200 mg Doxycycline one hour before, followed by 100 mg
x 2 daily x 4 days
IUCD insertion and HSG with risk factors :
Prohylaxis is probably indicated - Doxycycline as above

ACOG Practice Bulletin. Antibiotic prophylaxis for gynecologic

procedures. Obstet Gynecol 2001;23:2.

ANTIBIOTIC PROPHYLAXIS IN
OBSTETRIC AND GYNAECOLOGICAL
SURGERY

Penicillin/Cephalosporin
allergy
Clindamycin, IV, 150 mg 6 hourly for
23 doses may be used for such patients

ACOG Practice Bulletin. Antibiotic prophylaxis for gynecologic

procedures. Obstet Gynecol 2001;23:2.

Endocarditis prophylaxis
High-risk patients
Ampicillin, 2 g IM or IV, plus gentamicin, 1.5 mg/ kg
(not to exceed 120 mg) within 30 minutes of starting
the procedure; six hours later, ampicillin, 1 g IM/IV,
or amoxicillin, 1 g orally

Patients allergic to ampicllin / amoxicillin

Vancomycin, 1 g IV over 1-2 hours, plus gentamicin,
1.5 mg/ kg IV/IM (not to exceed 120 mg);
injection/infusion within 30 minutes of starting the
procedure
ACOG Practice Bulletin. Antibiotic prophylaxis for
gynecologic procedures. Obstet Gynecol 2001;23:2.

Other Important Factors in Preventing

Surgical Infection

Remove hair by clipping, not shaving,

immediately before operation
Vigilance for breaks in aseptic technique by
operating room team
Limit sutures and ligatures
Use monofilament sutures
Employ closed suction rather than open
drainage; use no drainage if possible

Other Important Factors in

Preventing Surgical Infection
Exercise meticulous skin closure
Administer high intraoperative and
postoperative inspired oxygen
Maintain normothermia during operation
Use surveillance of wound infection with
review of preventive measures

RANGKUMAN
Pemberian antibiotik profilaksis diberikan pada
hampir semua tindakan pembedahan dengan kategori
bersih terkontaminasi
Dosis tunggal prabedah cukup memadai pada hampir
semua kasus kecuali pada pembedahan yang lama
dan perdarahan banyak

Generasi pertama atau generasi kedua

sefalosporin memberikan cakupan yang adekuat
pada kebanyakan kasus bersih dan bersih
terkontaminasi
Pemilihan antibiotik dipengaruhi oleh kuman
penyebab infeksi pada jenis pembedahan, biaya
dan ketersediaan antibiotika