Antibiotics in General Surgical Practice
Authors: Bhat Javid Ahmad , Malik Ajaz Ahmad , Bhat Nadiem Nazir 
Published: March 2019

Introduction: Worldwide antibiotic prescription in surgical practices are inappropriate quite often, reasons being inappropriate indication, inappropriate antibiotic prophylaxis, continuation of empiric therapy despite negative cultures in a stable patient, and a lack of awareness of susceptibility patterns of common pathogens. Extended-spectrum b-lactamase, Carbapenemase resistant and multidrug-resistant strains of organisms causing intrabdominal infections, have developed. The occurrence of MRSA surgical site infection (SSI) has a significant impact on clinical and economic outcomes, notably an increase in postoperative mortality.

Opportunities: There is an array of web of factors which affect the occurrence of SSI and antibiotics should not be answer or replacement to any of those factors. Narrow spectrum antibiotic active against the most probable pathogen to be encountered during operation, for a short period of time in adequate doses should be utilized. Broad-spectrum antimicrobial agents don’t result in lower rates of postoperative SSI compared to narrower spectrum. Elective laparoscopic cholecystectomy, parotidectomy, chest tube insertion and other clean procedures don’t warrant use of prophylaxis. For most patients who have had their wounds opened and adequately drained, antibiotic therapy is unnecessary. Antibiotics should be discontinued at time of incision closure (exceptions include implant-based breast reconstruction, joint arthroplasty, and cardiac procedures and liver transplantation. Hospital-specific antibiograms are important to guide the usage of diverse antibiotic agents to decrease resistance among pathogens. In intrabdominal infections source control is still integral and most important to the treatment of most patients. Routine use of antimicrobial therapy is not appropriate for all patients with intra-abdominal infections e.g. Patients with uncomplicated diverticulitis. In uncomplicated IAIs, when the focus of infection is treated effectively, the administration of antibiotics is unnecessary beyond prophylaxis e.g. Acute unperforated appendicitis removed surgically. In case of intraabdominal infections selection of empirical antimicrobial therapy depends on various factors which include probable contaminating pathogen/s, individual risk assessment and possibility of resistant pathogens. Higher risk patients are those, with severe sepsis/septic shock, elevated APACHE II score (>10), multiple medical comorbidities, problematic or delayed source control. The possibility of resistant pathogens is low in community acquired infections (CAI) in contrast to healthcare or hospital-associated infection (HAI). In Lower risk patients with community-acquired IAI, narrower-spectrum therapy ( coli, Bacteroides) is recommended and there is no need for anti-enterococcal or antifungal therapy. In Higher risk patients with community-acquired IAI, broader-spectrum therapy is recommended with selective use of anti-enterococcal and antifungal therapy. In Patients with healthcare/hospital-associated IAI, broader-spectrum therapy is recommended with additional agents for resistant pathogens. Do not use clindamycin as an anti-anaerobic agent in combination regimens for the empiric treatment in adults and children unless metronidazole cannot be used. Duration of antimicrobial therapy can be significantly shortened to 4-7 days under most of the circumstances. Routine addition of an aminoglycoside to other agents having broad spectrum gram negative coverage provides no additional benefit in intrabdominal infections.

Conclusion: Antibiotics are a treasure but not unlimited. Appropriate use is the need of the hour to save our present and future generations from the menace of antimicrobial resistance. JMS 2018;21(1):54-60