1. Antibioprophylaxis in surgery and MDROs Atelier antibioprophylaxie en chirurgie Workshop Antibiotica profylaxe in de chirurgie Baudouin Byl Hygiène Hospitalière et Gestion de lantibiothérapie Hôpital Erasme – ULB

5. Plan MDR definition Prophylaxis – spectrum - principles Literature – prophylaxis et SSI MDROs Discussion

6. Definition MDR Clinical microb infec 2011: 18(3), 268-281

7. Definition MDR

9. 20139 Antibioprophylaxis common principles Limited to well proven indications Targeted to organisms involved in SSI Timing of administration Perop administration if needed Duration < 24 hrs

10. 201310 Antibioprophylaxis new recommendations Bratzler DW et al Am J Health-Sys Pharm Vol 70, feb1, 2013 previous: Clin Infect Dis, 1994; 18: 422-427 ASHP IDSA SHEA SIS

11. Spectrum The narrowest Resistance patterns from organisms causing SSI should take precedence over hospitalwide antibiograms In some cases, procedure-specific resistance patterns! Consensus 2013

12. 201312 Spectrum Skin incision: SSI: ~ 80% Gram positive ~ 20% Gram négative First choice: anti-staph (oxa-S) + anti bgn cef 1 (cef2)

14. 201314 From 1994 to 2013 … Dramatic decrease in sensitivity to cef1 (cef2) MDR ….

15. 201315 R rate cef1 cef2, enterobacterial species Erasme 1993-2011

16. 201316 Rec 2013 - Quid des MDR? MRSA MDR Enterobacteriacae Pseudomonas aeruginosa VRE …

17. 201317 Rec 2013 - Quid des MDR? Consensus 2013

18. 201318 2013/ MRSA Glycopeptides en prophylaxie –Consensus 2013 Cluster of MRSA or MRSE known MRSA colonisation (or at high risk) AND who will have a skin incision !!! vanco less effective on MSSA !!! –czol+vanco! (Specific setting: community MRSA)

19. 201319 2013/ MR(S)SA From controverse to growing evidence… S aureus carriage eradication recommended –Cardiac surgery –Orthopedic surgery –Spinal procedures ! Surveillance of R to mupi ! ? Timing? Duration? ! operational considerations ! (BB) Consensus 2013

20. 201320 MRSA Screening vs high risk conditions –Pts/units Eradication + Vancomycine

21. 201321 VRE Enteroccoccus uncovered by conventional prophylaxis (rare exceptions) VRE to be considered in special settings (Li TX, …)

22. 201322 Enterobacteriaceae

23. 201323 Gram neg / PUBMED MDR / prophylaxis / surgery : 0 Carbapenemase / SSI / prophylaxis: 0 Carbapenemase / prophylaxis: 0 ESBL / prophylaxis: 47 –Surgery 12 - 7 urology - 4 transplantation - 1 obesity (pharmaco ertapenem)

24. 201324 MDR carriage / exposition to antibiotics Abundant literature – overlaps between: –ESBL –UTI –Neutropenic patients –Quinolone use

25. 201325 Urology / ciproR Urology Transrectal prostate biopsy E coli : first causative (75- 90%) Haute prévalence esbl et ciproR E coli ciproR 17%!!! Quid proph quinolones? Qi et al J Urol 2013: 2026 Williamson et al, CID, 2013:267

26. 201326 Urology / customized prophylaxis FQ vs [ctri or genta or sxt or cefpodox] Reduction infection / ctrl histor by screening and adapted prophylaxis Reduction infection Taylor J Urol 2012: 1275 Duplessis et al Urology 2012: 556-563

27. 201327 Urology / cipro + amikacin Kehinde J Urol 2013; 189: 911 Historic contrl : cipro Intervention: cipro+amika

28. 201328 ESBL / epidemiology / liver Tx Independant risk factors – fecal carriage ESBL –Previous infection with ESBL –Previous Blactam –Previous SBP (quinolones!) Need for targeted prophylaxis Bert, Transplant infect disease, 2013:0: 1-6

29. 201329 ESBL / epidemiology / liver Tx Bert, Transplant infect disease, 2013: 1-6 %pts

30. 201330 Colonisation / Clinical impact ICU ~7 % infections caused by ESBL+ –Among carriers 10% first infection and 27% second infection caused by ESBL+ Razazi Int Care Med 2012; 38:1769-1778

31. 201331 ESBL / prophylaxis

32. 201332 Antibioprophylaxis new recommendations Bratzler DW et al Am J Health-Sys Pharm Vol 70, feb1, 2013 previous: Clin Infect Dis, 1994; 18: 422-427

33. 201333 Rec 2013 Transplanted pts (liver, lungs): –Include coverage for any potential pathogen (isolated < donor / receiver) Colo-rectal –czol+ metro –Or ctri+metro (if high R cef1/2) [or ertapenem!!] Consensus 2013

34. Quid Gram neg MDRO?

35. 201335 Quid Gram neg/MDR? Consider customising –Urology (trans rectal biopsy) –Local SSI epidemiology Screening!(rectal) Screening high risk Customize to screening results Customize to high risk (ex uro!)

36. 201336 Operational considerations Preoperative clinical path Customize vs systematic screening (lab costs!)

37. 201337 Operational considerations

38. Your opinion?