Kolorektal Cerrahide ANTĐMĐKROBĐYAL PROFĐLAKSĐ. Cem Terzi

Kolorektal Cerrahide ANTĐMĐKROBĐYAL PROFĐLAKSĐ Cem Terzi

Kolon ve Rektumun Mikrobiyal Florası 120 farklı bakteri anaerobik aerobik 99% 1% Bacteriodes fragilis Fusobacterium E. Coli Enterococci Streptococci A and B Str. pneumoniae

KOLOREKTAL CERRAHĐ ameliyatın tipine göre TEMĐZ-KONTAMĐNE veya KONTAMĐNE olarak sınıflandırılır

KOLOREKTAL CERRAHĐDE YARA ENFEKSĐYONUNU BELĐRLEYEN FAKTÖRLER Kolorektal cerrahi Operasyonun tipi Barsak hazırlığı A.hane disiplini Kontamine olan bakterinin miktarı ve virulansı YARA ENFEKSĐYONU Cerrahi teknik Doğal sistemik direnç Doğal lokal direnç Profilaktik antibiyotikler

YARA ENFEKSĐYONU için RĐSK ĐNDEKSĐ National Nosocomial Infection Surveillance (NNIS) 1. ASA skoru >2 2. Kontamine veya kirli ameliyatlar 3. Ameliyat süresi >T 75%* *T 75% : 3 saat (kolorektal cerrahi için) (Curver DH and et al. Am J Med 91: 152-7, 1991)

KOLOREKTAL CERRAHĐDE NNIS YE Risk indeksi 0 3.2% 1 8.5% 2 16.1% 3 22.2% (Curver DH and et al. Am J Med 91: 152-7, 1991)

OLASI RĐSK FAKTÖRLERĐ Ameliyat süresi Obesite Drenler Sol kolon rezeksiyonu Enflamatuvar barsak hastalığı Cerrahın deneyimi Perioperatif kan transfüzyonu HĐÇ BĐRĐ GÜVENĐLĐR DEĞĐL!

ANTĐMĐKROBĐYAL PROFĐLAKSĐ Profilaksi yapılamazsa enf. oranları Hedef patojenler Antibiyotik(ler) seçimi Yol Zamanlama Süre Yararlara karşı paha ve yan etkiler

ANTĐBĐYOTĐK PROFĐLAKSĐSĐNĐN ETKĐSĐ Incidence Complication With prophylaxis Without prophylaxis p SWI 22% 36% <0.001 Mortality 4.5% 11.2% <0.001 26 RKÇ sonucu (Baum ML and et al. New Eng J Med 305: 795-9, 1981)

123 Kolon Ameliyatında Enfekte Yaralardan Đzole edilen Patojenler Clostridia 14% Bacterioides Pseudomonas 2 Proteus Klebsiella 14 E. Coli Enterococci 13 Streptococci Staphylococci % 10 % 15 % % % 22 % 63 62 % % (Rec Adv Chem Ther 1985)

Antimicrobial prophylaxis in colorectal surgery: a systematic review of randomised controlled trials F Song AM Glenny NHS Centre for Reviews and Dissemination University of York UK Health Technology Assessment 1998; 2(7): 1-120

Antimicrobial prophylaxis in colorectal surgery: a systematic review of randomised controlled trials 147 RKÇ 1984-1995 yılları arasında (12 yıl) toplam 22.927 hasta 70 farklı profilaktik antibiyotik rejimi toplam CYE 11.1% (2540/22.927)

CEFUROXIME + METRANIDAZOLE vs Diğer ANTĐBĐYOTĐKLER Odds ratio (95% c.i.) Reference Year Antibiotic 0-01 0-1 1 10 Proportion with surgical wound infection Karran et al. 1993 Cefuroxime + metronidazole (3) versus imipenem (2-4) 17 of 122 versus 45 of 227 Pacelli et al. 1991 Cefuroxime + metronidazole (3) versus imipenem (1) 6 of 30 versus 5 of 31 Claesson et al. 1986 Cefuroxime + metronidazole (2-6) versus metronidazole (2) 1 of 36 versus 8 of 35 Cunliffe et al. 1985 Cefuroxime + metronidazole (1) versus metronidazole (1) 6 of 40 versus 10 of 40 Haverkorn 1985 Cefuroxime + metronidazole (3) versus metronidazole (3) 0 of 13 versus 3 of 11 Mittermayer et al. 1984 Cefuroxime + metronidazole (1) versus metronidazole (1) 3 of 27 versus 7 of 33 Cann et al. 1988 Cefuroxime + metronidazole (10) versus mezlocillin (7) 6 of 52 versus 13 of 43 Diamond et al. 1988 Cefuroxime + metronidazole (3) versus mezlocillin (3) 10 of 53 versus 15 of 51 Stubbs et al. 1987 Cefuroxime + metronidazole (3) versus mezlocillin (1) 14 of 56 versus 16 of 54 Kingston et al. 1989 Cefuroxime + metronidazole (1) versus latamoxef (1) 27 of 108 versus 32 of 121 Skipper and Karran 1992 Cefuroxime + metronidazole (3) versus cefotetan (2) 5 of 107 versus 26 of 204 Jensen et al. 1990 Cefuroxime + metronidazole (1) versus ampicillin + metronidazole (1-3) 8 of 107 versus 26 of 204 Palmer et al. 1994 Cefuroxime + metronidazole (3) versus co-amoxiclav (3) 2 of 79 versus 8 of 69 Corman et al. 1993 Cefuroxime + metronidazole (1) versus cefoxitin or cefuroxime 0 of 30 versus 5 of 90 Rowe-Jones et al. 1990 Cefuroxime + metronidazole (3) versus cefotaxime + metronidazole (1) 33 of 454 versus 32 of 453 Reynolds et al. 1989 Cefuroxime + metronidazole (4) versus piperacillin (4) 8 of 119 versus 18 of 104 Reynolds et al. 1989 Cefuroxime + metronidazole (4) versus piperacillin + neomycin + metronidazole 8 of 119 versus 9 of 107 Haverkorn 1985 Cefuroxime + metronidazole (3) versus netilmycin + metronidazole (3) 0 of 13 versus 0 of 12 Favours cefuroxime+ metronidazole Favours other antibiotics

GENTAMYCINE + METRANIDAZOLE vs Diğer ANTĐBĐYOTĐK Odds ratio (95% c.i.) Reference Year Antibiotic 0-01 0-1 1 10 100 Proportion with surgical wound infection AhChong et al. 1994 Gentamicin + metronidazole (3) versus ampicillin + sulbactam (3) 7 of 65 versus 6 of 63 Hall et al. 1989 Gentamicin + metronidazole (2) versus co-amoxiclav (2) 18 of 121 versus 16 of 116 Figueras-Felip et al. 1984 Gentamicin + metronidazole (3) versus neomycin + erythromycin (3) 7 of 48 versus 2 of 45 Lau et al. 1988 Gentamicin + metronidazole (1) versus neomycin + erythromycin (3) 5 of 67 versus 14 of 62 McArdle et al. 1995 Gentamicin + metronidazole (3) versus ciprofloxacin (1) + metronidazole (3) 13 of 45 versus 4 of 40 McArdle et al. 1995 Gentamicin + metronidazole (10) versus ciprofloxacin (1) + metronidazole (10) 7 of 42 versus 4 of 42 McCulloch et al. 1986 Gentamicin + metronidazole (3) versus latamoxef (3) 6 of 45 versus 5 of 59 Burdon and Keighley 1987 Gentamicin + metronidazole (1) versus ceftriaxonel (1) 17 of 75 versus 10 of 75 Tudor et al. 1988 Gentamicin + metronidazole (15) versus cefotetan (2) 4 of 21 versus 5 of 20 Weidema et al. 1985 Gentamicin + metronidazole (4) versus metronidazole (4) 18 of 65 versus 15 of 64 Greig et al. 1987 Gentamicin + metronidazole (1) versus gentamicin + metronidazole + cefotetan 1 of 30 versus 3 of 30 Lozano et al. 1985 Gentamicin + metronidazole (10) versus gentamicin + lincomycin (10) 1 of 30 versus 4 of 30 Lozano et al. 1985 Gentamicin + metronidazole (10) versus gentamicin + clindamycin (10) 22 of 209 versus 23 of 219 Moesgaard and Nielsen 1988 Gentamicin + metronidazole (2) versus gentamicin + metronidazole (7) Favours cgentamycine metronidazole Favours other antibiotics

Eski Jenerasyon Sefalosporinler veya Yeni Jenerasyon Sefalosporinler?

ESKĐ JENERASYONA karşı YENĐ JENERASYON Odds ratio (95% c.i.) Reference Year Antibiotic 0-01 0-1 1 10 100 Proportion with surgical wound infection Antonelli et el. 1985 Cephalothin (18) versus cefoxitin (11) 3 of 30 versus 0 of 30 Jones et al. 1987 Cephalothin (4) versus cefoxitin (5) 1 of 35 versus 1 of 36 Jones et al. 1987 Cephalothin (4) versus cefotaxime (1) 1 of 35 versus 4 of 29 Plouffe et al. 1985 Cephalothin (3) versus latamoxef (3) 1 of 24 versus 1 of 26 Thomas et al. 1985 Cephalothin + metronidazole (3) versus latamoxef (3) 5 of 60 versus 3 of 60 Lumley et al. 1992 Cephalothin (1) versus ceftriaxone (1) 7 of 96 versus 7 of 90 Favours cephalothin Favours other antibiotics

YENĐ JENERASYON SEFALOSPORĐNLERĐN ETKĐSĐ Incidence With new-generation cephalosporıns With first-generation cephalosporins SWI 6.0% 6.4% ANLAMLI FARK YOK 6 RKÇ nın sonucu (Song F and et al. Health Technol Assessment 2:39, 1998)

MONOTERAPĐ Veya KOMBĐNASYON

MONOTERAPĐYE karşı KOMBĐNASYON-I Odds ratio (95% c.i.) Reference Year Antibiotic 0-01 0-1 1 10 100 Proportion with surgical wound infection Favre et al. 1984 Cefotaxime alone versus + metronidazole 4 of 74 versus 5 of 72 Hakansson et al. 1993 Cefotaxime alone versus + metronidazole 44 of 280 versus 19 of 287 Raahave et al. 1989 Cefotaxime alone versus + ampicillin 6 of 89 versus 5 of 81 Morton et al. 1989 Cefotetal alone versus + metronidazole 39 of 278 versus 34 of 253 Periti et al. 1993 Cefotetal alone versus + thymostimulin 72 of 434 versus 56 of 425 Coppa and Eng 1988 Cefoxitin alone versus + neomycin + erythromycin 15 of 141 versus 9 of 169 Stellato et al. 1990 Cefoxitin alone versus + neomycin + erythromycin 2 of 51 versus 3 of 51 Peruzzo et al. 1987 Cefoxitin alone versus + tinidazole + neomycin 0 of 39 versus 4 of 41 Hosie et al. 1992 Ceftizoxime alone versus + metronidazole 9 of 85 versus 7 of 89 Lumley et al. 1992 Ceftriaxone alone versus + metronidazole 8 of 94 versus 7 of 90 Corman et al. 1993 Cefuroxime alone versus + metronidazole 3 of 32 versus 0 of 30 Bergman and Solhaug 1987 Doxycycline alone versus + metronidazole 12 of 226 2 of 135 Gerner et al. 1989 Doxycycline alone versus + tinidazole 10 of 107 versus 3 of 116 Greig et al. 1987 Gentamicin + metronidazole alone versus + cefotetan 18 of 65 versus 15 of 64 Lau et al. 1988 Gentamicin + metronidazole alone versus + neomycin + erythromycin 5 of 67 versus 3 of 65 Claesson et al. 1986 Metronidazole alone versus + cefuroxime 8 of 35 versus 1 of 36 Cunliffe et al. 1985 Metronidazole alone versus + cefuroxime 10 of 40 versus 6 of 40 Favours c monotherapy Favours other antibiotics

MONOTERAPĐYE karşı KOMBĐNASYON -II Odds ratio (95% c.i.) Reference Year Antibiotic 0-01 0-1 1 10 100 Proportion with surgical wound infection Mittermayer et al. 1984 Metronidazole alove versus + cefuroxime 7 of 33 versus 3 of 27 Haverkorn 1985 Metronidazole alone versus + cefuroxime 3 of 11 versus 0 of 27 Kling and Burman 1988 Metronidazole alone versus + nalidixic acid 23 of 70 versus 13 of 33 Lindhagen et al. 1984 Metronidazole alone versus + fosfomycin 6 of 23 versus 0 of 26 Gottrup et al. 1985 Metronidazole alone versus + ampicillin 10 of 46 versus 1 of 48 Roland 1986 Metronidazole alone versus + ampicillin /doxycycline 6 of 170 versus 1 of 188 Weidema et al. 1985 Metronidazole alone versus + gentamicin 5 of 20 versus 4 of 21 Morris et al. 1984 Latamoxef alone versus + metronidazole 11 of 53 versus 13 of 56 Jagelman et al. 1985 Neomycin alone versus + metronidazole 8 of 37 versus 0 of 31 Lau et al. 1988 Neomycin + erythromycin alone versus + gentamicin + metronidazole 14 of 62 versus 3 of 65 Petrelli et al. 1987 Neomycin + erythromycin alone versus + cefamandole 1 of 36 versus 0 of 34 Schoetz et al. 1990 Neomycin + erythromycin alone versus + cefoxitin 14 of 96 versus 5 of 101 Stellato et al. 1990 Neomycin + erythromycin alone versus + cefotaxime 3 of 44 versus 3 of 51 Reynolds et al. 1989 Piperacillin alone versus + neomycin + metronidazole 18 of 104 versus 9 of 107 Stewart et al. 1995 Piperacillin alone versus + sulbactam/ciprofloxacin 39 of 168 versus 50 of 317 Norwegian Study Group 1985 Tinidazole alone versus + doxycycline 14 of 135 versus 4 of 132 Desaive 1985 Gentamincin alone versus + ticarcillin 14 of 26 versus 3 of 29 Favours monotherapy Favours other antibiotics

Tek başına Tek başına Neomycine Cefoxitin Gentamycine Cefotetan Doxycycline Ceftriaxone Cefotaxime Ceftizoxime Tinidazole Latomoxef Piperacilline YETERLĐ YETERSĐZ (Song F and et al. Health Technol Assesment 2: 29, 1998)

CERRAHĐ PRATĐKTE ANTĐBĐYOTĐK TERCĐHLERĐ Hollanda Co-amoxiclav + metronidazole 25% Cefuroxime + metronidazole 25% Gentamycine + metronidazole 20% (Janknegt R and et al. Eur J Clin Microbial Infect 13.596-600,1994) ABD Oral neomycin + erythromycin (Page C P and et al. Arch Surg 128: 79-88, 1993) Đngiltere Cefuroxime+ metronidazole (Bloxham CA, MBA Dissertation, 1996) en sık en sık

HANGĐ ANTĐBĐYOTĐK REJĐMĐ? Pek çoğu etkin En etkin olanını belirlemek kolay değil En sık kullanılan: Cef+Met

Uygulama yolu Oral? Parenteral? Topikal?? Kombinasyon?

IV karşı IV+ ORAL / TOPĐKAL R e g i m e n a n d s t u d y I n c i d e n c e o f S W I O d d s r a t i o ( 9 5 % C l f i x e d ) P a r e n t e r a l o n l y n / N P a r e n t e r a l p l u s o r a l /t o p ic a l n / N ( C e f o x i t i n x 3 ) v s. ( c e f o x i t i n x 3 ) + 0 / 3 9 4 /4 1 0.1 1 [ 0.0 1,2.0 3 ] ( t i n i d a z o l e x 1 ) + ( m e t r o n id a z o l e o r a l x 3 ) P e r r u z z o, 1 9 8 7 ( C e f o x i t i n x 3 ) v s. ( c e f o x i t i n x 3 ) + 2 / 5 1 3 /5 1 0.6 5 [ 0.1 0,4.0 8 ] ( n e o m y c i n + e r y th r o m y c i n o r a l ) x 3 S te l la to, 1 9 9 0 ( C e f o x i t i n x 5 ) v s. ( c e f o x i t i n x 5 ) + 1 5 / 1 4 1 9 / 1 6 9 2.1 2 [ 0.9 0,5.0 0 ] ( n e o m y c i n + e r y th r o m y c i n o r a l ) x 3 C o p p a, 1 9 9 8 ( G e n t a m i c i n + m e t r o n i d a z o le ) x 1 v s. 5 / 6 7 3 /6 5 1.6 7 [ 0.3 8,7.2 8 ] ( g e n t a m i c i n + m e t r o n id a z o l e ) x 1 + ( n e o m y c i n + e r y th r o m y c i n o r a l ) x 3 L a u, 1 9 8 8 ( G e n t a m i c i n + m e t r o n i d a z o le ) x 3 v s. 1 3 /4 5 4 /4 0 3.6 6 [ 1.0 8,1 2.3 6 ] ( m e t r o n i d a z o le x 3 ) + ( c i p r o f o l o x a c in o r a l ) M c A r d l e, 1 9 9 5 ( G e n t a m i c i n + m e t r o n i d a z o le ) x 1 0 v s. 7 / 4 2 4 /4 2 1.9 0 [ 0.5 1,7.0 5 ] ( m e t r o n i d a z o le x 1 0 ) + ( c ip r o f l o x a c in o r a l x 1 ) M c A r d l e, 1 9 9 4 ( P i p e r a c i l l in x 1 ) v s. ( p i p e r a c i l l in x 1 ) + 3 9 / 1 6 8 1 8 /1 5 9 2.3 7 [ 1.2 9,4.3 5 ] ( c i p r o f l o x a c i n o r a l x 2 ) T a y lo r 1 9 9 4 ( P i p e r a c i l l in x 4 ) v s. ( p i p e r a c i l l in x 4 ) + 2 6 / 2 2 3 9 / 1 0 7 1.4 4 [ 0.6 5,3.1 8 ] ( m e t r o n i d a z o le x 6 ) + ( n e o m y c i n o r a l x 8 ) R e y n o ld s, 1 9 8 9 ( M e t r o n id a z o l e x 3 ) v s. ( c e p h a z o l in + 1 4 /4 7 4 /5 5 5.4 1 [ 1.6 4,1 7.8 6 ] n e o m y c i n + e r y t h r o m y c in o r a l ) x 3 K h u b c h a n d a n i, 1 9 8 9 ( M e t r o n id a z o l e x 1 ) v s. ( m e t r o n i d a z o le x 1 ) + 1 6 /5 8 9 /6 1 2.2 0 [ 0.8 8,5.4 8 ] ( m e t r o n i d a z o le x 3 ) + ( n e o m y c i n o r a l x 4 ) P l a y f o r th, 1 9 8 8 ( L a t a m o x e f x 3 ) v s. ( m e t r o n i d a z o l e x 3 ) + 5 / 6 4 3 /6 7 1.8 1 [ 0.4 1,7.9 0 ] ( n e o m y c i n o r a l x 3 ) H i n c h e y, 1 9 9 0 ( F o s f o m y c i n + m e t r o n id a z o l e ) x 1 v s. ( a m p i c i l li n x 1 ) + ( m e t r o n i d a z o l e + b a c i t r a c i n + n e o m y c i n ) x 6 N o h r, 1 9 9 0 6 / 7 7 7 /7 2 0.7 8 [ 0.2 5,2.4 6 ] 0.0 1 0.1 1 1 0 1 0 0 ( l o g s c a l e ) F a v o u r s p a r e n t e r a l F a v o u r s p a r e n t e r a l + o r a l / t o p ic a l

Uygulama yolu Oral veya topikal antibiyotiklerin parenteral antibiyotiklere eklenmesi FAZLADAN YARAR GETĐRMĐYOR

Oral neomycin + erythromycin (ABD de en sık kullanılan rejim) IV ceftriaxone + metronidazole IV gentamycine + metronidazole ek IV cefamandole ek IV cefoxitin den daha az etkin (Song F and et al Health Technol Assesment 2:19, 1998)

Zamanlama Bakteriyal kontaminasyon olduğu anda dokuda yeterli antibiyotik konsantrasyonu olmasışarttır Profilaktik antibiyotikler cerrahi insizyondan önce yapılmış olmalıdır (Classen DC and et al. New Eng J Med 366: 281-6, 1992)

TEK DOZ ya da ÇOĞUL DOZLAR?

Tek doza karşı Çoğul dozlar R e g im e n a n d stu d y In c id e n c e o f S W I O d d s r a tio (9 5 % C l fix e d ) S in g le O th e r n /N a n tib io tic s n /N (C e fo x itin x 1 ) v s. (c e fo x itin x 3 ) K o w, 1 9 9 5 (C e fo x itin x 1 ) v s. (c e fo x itin x 4 ) C o rm a n, 1 9 9 3 (C e fo ta x im e x 1 ) v s. (c e fo ta x im e x 3 ) L o h r,1 9 8 4 (C o -a m o x id a v a x 1 ) v s. (c o -a m o x ic la v x 3 ) B a te s, 1 9 9 2 (T ic a rc illin / c la v u la n ic a c id x 1 ) v s. (tic a rc illin / c la v u la n ic a c id x 2 ) C u th b e rtso n, 1 9 9 1 (L a ta m o x e f x 1 ) v s. (la ta m o x e f x 8 ) H a ll, 1 9 8 9 (A m p ic illin + m e tro n id a z o le ) x 1 v s. (a m p ic illin + m e tro n id a z o le ) x 3 Je n se n,,1 9 9 0 (A m p ic illin + m e tro n id a z o le ) x 1 v s. (a m p ic illin + m e tro n id a z o le ) x 3 Je n se n, 1 9 9 0 (A m p ic illin + m e tro n id a z o le ) x 1 v s. (a m p ic illin + m e tro n id a z o le ) x 4 Ju u l, 1 9 8 7 (C e fo ta x im e + m e tro n id a z o le ) x 1 v s. (c e fo ta x im e + m e tro n id a z o le ) x 3 K o w, 1 9 9 5 (M e z lo c illin + m e tro n id a z o le ) x 1 v s. (m e z lo c illin + m e tro n id a z o le ) x 3 G ru n d m a n n, 1 9 8 7 (M e z lo c illin + m e tro n id a z o le ) x 1 v s. (m e z lo c illin + m e tro n id a z o le ) x 7 B ittn e r, 1 9 8 9 (M e z lo c illin + m e tro n id a z o le ) x 1 v s. (m e z lo c illin + m e tro n id a z o le ) x 9 M e n d e l, 1 9 8 7 (C e fu ro x im e + m e tro n id a z o le ) x 1 v s. (c e fu ro x im e + m e tro n id a z o le ) x 3 A b e rg, 1 9 9 1 (M e tro n id a z o le x 1 ) v s. (m e tro n id a z o le x 2-4 ) C a rr, 1 9 8 4 (D o x y c y c lin e x 1 ) v s. (d o x y c y c lin e x 4 ) G o ra n sso n, 1 9 8 4 (G e n ta m ic in + o rn id a z o le ) x 1 v s. (g e n ta m ic in + o rn id a z o le ) x 4 W e n z e l,1 9 8 5 (P ip e ra c illin + tin id a z o le ) x 1 v s. (p ip e ra c illin x 4 ) + tin id a z o le x 3 ) T u c h m a n n, 1 9 8 8 O d d s r a tio (9 5 % C l fix e d ) 1 0 /7 3 8 /8 1 1.4 5 [0.5 4,3.8 9 ] 2 /3 1 0 /2 7 4.6 6 [0.2 1,1 0 1.4 7 ] 4 /3 0 3 /3 0 1.3 8 [0.2 8,6.8 0 ] 2 3 /1 1 3 1 7 /1 1 1 1.4 1 [0.7 1,2.8 2 ] 1 6 /1 4 6 1 7 /1 3 2 0.8 3 [0.4 0,1.7 2 ] 1 2 /1 1 9 1 0 /1 2 6 1.3 0 [0.5 4,3.1 3 ] 6 /1 1 4 /1 2 2.4 0 [0.4 4,1 2.9 8 ] 8 /8 9 8 /9 2 1.0 4 [0.3 7,2.8 9 ] 9 /1 4 9 8 /1 4 5 1.1 0 [0.4 1,2.9 4 ] 7 /8 4 9 /8 1 0.7 3 [0.2 6,2.0 5 ] 4 /7 7 4 /7 7 1.0 0 [0.2 4,4.1 5 ] 6 /4 6 3 /4 4 2.0 5 [0.4 8,8.7 6 ] 2 /5 4 1 /4 6 1.7 3 [0.1 5,1 9.7 3 ] 2 /1 9 1 /2 9 3.2 9 [0.2 8,3 9.1 4 ] 7 /2 2 1 1 /6 8 2.4 2 [0.8 0,7.3 0 ] 1 /5 3 2 /4 9 0.4 5 [0.0 4,5.1 5 ] 6 /3 0 1 0 /3 0 0.5 0 [0.1 5,1.6 2 ] 4 /6 1 5 /6 3 0.8 1 [0.2 1,3.1 9 ] 0.0 1 0.1 1 1 0 1 0 0 (lo g sc a le ) F a v o u rs sin g le F a v o u rs m u ltip le

CYE Tek doz 10.6% Çoğul dozlar 9.7% Anlamlı fark yok 17 RKÇ nın sonucu (Song F and et al. Health Technol Asessment 2:69, 1998)

Süre KISA SÜRELĐ (24 saatten kısa) ya da UZUN SÜRELĐ (bir kaç gün)?

Süre Ameliyatın süresinin tek doz antibiyotik profilaksisinin etkinliğini değiştirdiğini gösteren kanıt yoktur. (Song F and et al. Health Technol Asessment 2:38, 1998)

Süre Öneri: ek olarak ikinci doz antibiyotik(ler) eğer Ameliyat 2 saatten uzun sürerse Ameliyat sırasında aşırı kan kaybı olursa (Waddell TK, CMAJ 151: 925-31, 1994)

Yan etkiler Yıllar içinde yan etkilere dair endişeler ve bildirimler azalmıştır Deri döküntüler Diyare Bulantı en sık karşılaşılan yan etkilerdir.

Rezistan bakteri Aşırı antibiyotik kullanımı resistan bakteri prevelansını artırır Profilaktik antibiyotikler hastanenin antibiyotik rezistan bakteri türü ve prevelansına bağlı olarak seçilmelidir (Office of Technology Assessment USA OTA-H-629, 1995)

Paha etkinliği Yara enfeksiyonlarını olumsuz etkilemeden antibiyotik harcamalarını düşürmek olanaklıdır Tek doz veya 24 saati geçmeyen Daha etkin ancak daha ucuz ilaçlar Monoterapi (Song F. and et al. Health Technol Asessment 2: 40-3, 1998)

UYGULAMA Antibiyotik(ler) aerobik ve anaerobik bakterilere etkin olmalıdır. Antibiyotik(ler) insizyondan önce uygulanmış olmalıdır Đdeal antibiyotik rejimini belirlemeye yönelik çalışmalara devam edilmelidir Uluslararası kabul edilmiş tek bir antibiyotik rejiminden rezistans sorunu nedeniyle kaçınılmalıdır Her merkez kendi sonuçlarına uygun etkin ve ucuz bir antibiyotik rejimi benimsemelidir