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Indian Association of Surgical Gastroenterology - Antibiotic Guidelines 2013

Background:

The Indian Association of Surgical Gastroenterology (IASG) decided to formulate a ‘set of recommendations for antibiotic usage’ in intra-abdominal infections, encountered by its members. Three working groups with defined areas to address were set up and are mentioned below:

Group A: Antibiotic use for established/suspected intra-abdominal infections

Members: Dr Adarsh Chaudhary, Past President, IASG (Group Leader), Dr V. Sitaram, Dr Puneet Dhar, Dr Sudeep Shah, Dr Rajneesh Singh

Group B: Antibiotic recommendations related to surgical prophylaxis

Members: Dr H. Ramesh, President Elect, IASG (Group Leader), Dr Ramesh Ardhanari, Dr Anil Agarwal, Dr Pradeep R., Dr Sudeep Naidu

Group C: Other important issues in Intra-abdominal infections

Members: Dr R. A. Sastry, Past President, IASG (Group Leader), Dr Sadiq Sikora, Dr Sanjay Nagral, Dr Sanjay Debakshi, Dr Sujoy Pal

 

An attempt was made to provide representations to both public and private sector institutions in all the groups.

These groups prepared detailed guidelines which were discussed among some members of the groups in mid-2012 and it was suggested that the detailed reports needed to be summarized. There was debate over the actual use of these guidelines and it was suggested that IASG should make an effort to collect data so that India-specific guidelines related to the antibiotic of choice in our clinical scenario may be prepared. Hence, one of the members was requested to prepare a questionnaire to gather appropriate data for this purpose. The questionnaire is available as a separate PDF.

 

A summary of the guidelines prepared by the three groups is provided below 

 

Guidelines - 2013

Prophylactic antimicrobial therapy

  1. A single preoperative dose of antibiotic is sufficient; there is no evidence for postoperative prophylactic antibiotic.
  2. Antibiotics are repeated if the duration of operation is >4 hours or if blood loss is >1 litre (except vancomycin, aminoglycoside, fluoroquinolone).
  3. Prophylactic antibiotics should be administered within 1 hour prior to incision.

 

1. Clean operation with or without use of prosthetic implant (hepatectomy, hydatid cyst liver without biliary communication, splenectomy, porto-systemic shunt operation)

Recommendation: Inj Cefazolin 1 g i.v. or Cefuroxime 1.5 g i.v.

 

2a. Clean contaminated operation (cholecystectomy laparoscopic and open, gastrojejunostomy, gastrectomy, jejunal resection anastomosis, distal pancreatectomy, pseudocyst gastrostomy, pseudocyst jejunostomy, low risk perforated peptic ulcer)

Recommendation: Inj Cefazolin 1 g i.v. or Cefuroxime 1.5 g i.v. (evidence for prophylactic antibiotic in low risk laparoscopic cholecystectomy is thin)

2b. Clean contaminated operation (operation where upper aerodigestive tract is open, including oesophageal operations or gastric outlet obstruction)

Recommendation: Inj Cefazolin 1 g i.v. + Inj Metronidazole 500 mg i.v.

 

3. Contaminated operation (colectomy, obstructed biliary tract, choledocholithiasis) Recommendation: Inj Cefazolin 1 g i.v. or Cefuroxime 1.5 g i.v. + Inj Metronidazole 500 mg i.v.

+ Inj Gentamicin at 4-5 mg/kg body weight i.v. OR Amikacin 15 mg/ kg ideal body weight i.v. (alternative: clindamycin + metronidazole)

Appendicectomy (laparoscopic or open) for non-perforated acute appendicitis

Recommendation: Cefazolin 1 g i.v. or Cefuroxime 1.5 g i.v. + Inj Metronidazole 500 mg i.v.

 

4. Dirty (faecal peritonitis, anastomotic leakage)

Antibiotics are not ‘prophylactic’ here. The wound may be left open. Choice of antibiotics will depend on whether organ dysfunction is present or not. Specimens for culture and sensitivity should be taken at operation. If organ dysfunction is present ‘high end’ antibiotics will be chosen initially and ‘scaled down’ once culture/sensitivity results are available (see therapeutic antibiotics).

 

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