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 Damage micro-organisms without harming the

host tissue cells. They are either
 Cidal or
 Static
 They fall into two groups:
 Synthetic e.g. sulphonamides, nitrofurantoin
 Anti-biotics ʹ natural products of one micro-
organisms affecting other micro-organisms ʹ
penicillin
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 Antagonistic ʹ effect less than each drug used

alone
 Agonistic ʹ effect more than each drug used
alone
 Additive ʹ effect equal to the algebraic sum of
the effects of both drugs
 Synergistic ʹ effect more than the algebraic
sum of the individual effects
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 mixed bacterial infections in which the organisms are not

susceptible to a common agent e.g.
 Intra-abdominal sepsis secondary to GIT perforation (anaerobes & aerobes,
combination is synergistic)
 Polymicrobial bacteria in a febrile, nectropenic patient
 Endometritis and post-hysterectomy infections caused by aerobic and
anaerobic vagino-cervical flora
 To achieve synergistic anti-microbial activity against a single
organism
 To overcome bacterial tolerance
 To prevent the development of bacterial antibiotic resistance
 To decrease the toxicity of the most effective agent
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  ! "#$
 Yecessary only in high risk cases of bacterial contamination
 Yot a substitute or alternative to aseptic practice and good
surgical technique
 Timing is vital ʹ aim at a saturated tissue concentration at the
time of surgical manipulation and throughout the operation
 Route of administration should be intravenous
 Should be employed only when evidence shows that it has
advantages
 Choice of agent (preferably bactericidal) should be made on the
basis of activity against the pathogens most commonly
encountered
 % !&' $&' (&!' &#"")*#&+ $,
 Endogenous contamination
 GIT surgery
 Biliary tract surgery
 Colorectal
 Appendicectomy
 Vaginal/abdominal hysterectomy
 Urinary tract surgery
 Exogenous contamination
 Lower limbs (vascular disease)
 Prosthetic joint replacement
 Prosthetic heart surgery
 Yeurological shunts
 Extensive trauma and burns
 Surgical procedures & instrumentation in rheumatic &
vasvular heart disease
 mesh repair for hernia
 Host immune suppression
 Diabetes mellitus, chronic renal failure, malignancy,
aplastic anaemia, malnutrition, obstructive jaundice,
steroid therapy, cytotoxic therapy
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 Combination of bacterial numbers and
virulence overcome local host defences.
 Bacterial factors:-
 Type of bacterial
 Yumbers of inoculums ш105.
 Toxins produced by pathopen
 Organism ability to resist phagocytosis and intra-
cellular destruction
 Local wound factors:-
 Inhibition of local defence mechanisms
 Use of foreign bodies
 Lack of accurate approximation of tissues
 Strangulation of tissues
 Presence of dead tissue, haematomas or seromas
 Patient Factors:
 Very young and very old
 Reduced blood flow to wound ʹ vascular disease
 Local decrease in oxygen tissue tension
 Reduced vascular reactivity ʹ anaemia, old age, steroids
 Inhibition of cellular function ʹ malignancy states,
trauma
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 Avoidance of bacterial contamination
 Environmental factors: theatre design to limit airborne
contamination. Use of ultraviolet light for
decontamination of theatre, lamina flow of ventilation
systems, limiting of traffic within operating room
 Sterilization techniques
 Pre-operative preparation of patient
 On admission one acquires resident organisms on the ward
 Shower, use of antibacterial soap, treat all cutaneous
infections and any other before elective procedures
 Hair removal ʹ extensive hair removal should not be done.
If needed, it should be done on the operating table
 Skin preparation ʹ adequate preparation and draping are
vital
 Operating room team discipline
 Dressing
 Scrubbing
 minimizing endogenous contamination when
transecting of GIT, etc
 Good surgical techniques
 minimize damage
 Remove all devitalized tissue
 Remove foreign material
 Choice of sutures ʹ monofilament in areas of
contamination
 Avoidance of dead space, seromas, haematomas
 Avoid closure of infected wounds/contaminated. Delayed
primary closure can be considered if wound must be
closed
 Improving Host Resistance
 Correction or control of co-morbidities that
interfere with body resistance
 Immunotherapy
 Active and passive immunization e.g. tetanus
 Prophylaxis chemotherapy
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 Clean
 Yon traumatic, no break in technique, no entry into respiratory,
alimentary and genitor-urinary tracts
 Clean ʹ contaminated
 GIT, R/S entered without significant spillage. Oropharyx, vagina
or non infected genito-urinary or biliary tract entered
 minor breaks in techniques
 Contaminated
 major break in technique
 Traumatic wounds
 Gross spillage from GIT
 Entrance into infected genitor-urinary and biliary tracts. 5%
infection rate
 Dirty
 Operating in regions already infected with gross
contamination e.g. perforated GIT. 50% infection
rate.
 Clean wounds do not require antibiotics.
Contaminated require prophylactic while dirty
require therapeutic doses.

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 Super-infection
 Selective pressure on endogenous flora and
exogenous bacteria that colonize sites at risk
 Resistant (fungal) organisms hence emerge to
become pathogens causing super infection
 Prevention: Limit the dose and duration of
antibiotics

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 Clean wounds do not require antibiotics
 Clean contaminated wounds require
prophylactic antibiotics
 Contaminated and dirty wounds require
therapeutic antibiotics