Principles of antibiotic therapy in surgery
1. The source of infection should always be identified and controlled as soon as possible.
2. Antibiotic empiric therapy should be initiated after a treatable surgical infection has been recognized, since microbiological data (culture and susceptibility results) may not be available for up to 48-72 hours to guide targeted therapy.
3. In critically ill patients empiric broad-spectrum therapy to cover all likely pathogens should be initiated as soon as possible after a surgical infection has been recognized. Empiric antimicrobial therapy should be narrowed once culture and susceptibility results are available and/or adequate clinical improvement is noted
4. Empirical therapy should be chosen on the basis of local epidemiology, individual patient risk factors for MDR bacteria and Candida spp., clinical severity, and infection source.
5. Specimens for microbiological evaluation from the site of infection are always recommended for patients with hospital-acquired or with community-acquired infections at risk for resistant pathogens (e.g. previous antimicrobial therapy, prior infection or colonization with a MDR, XDR and PDR pathogens) and in critically ill patients. Blood cultures should be performed before the administration of antibiotics in critically ill patients.
6. Antibiotics dose should be optimized to ensure that PK-PD targets are achieved. This involves prescribing of an adequate dose, according to the most appropriate and right method and schedule to maximize the probability of target attainment.
7. The appropriateness and need for antimicrobial treatment should be re-assessed daily.
8. Once source control is established, short courses of antibiotic therapy are as effective as longer courses regardless of signs of inflammation.
9. Failure of antibiotic therapy in patients having continued evidence of active infection may require a re-operation for a second source control intervention.
10. Biomarkers such as procalcitonin may be useful to guide duration and/or cessation of antibiotic therapy in critically ill patients.
11. Infection prevention and controlmeasures, combined with antimicrobial stewardship programs should be implemented in surgical departments. These interventions and programs require regular, systematic monitoring to assess compliance and efficacy.
12. Monitoring of antibiotic consumption should be implemented and feedback provided to all ASP team members regularly (e.g. every three-six months) along with resistance surveillance data and outcome measures.