Antibiotic prophylaxis in "clean" surgical procedures

Selecting antibacterial agents for the control of surgical infection: mini-review

An analysis of the recent literature on the control of surgical infections confirms the role of antimicrobial agents which guarantee valid perioperative antisepsis in both clean and clean-contaminated surgery. Current chemotherapy is able to check serious postoperative infectious complications by reducing the risk of septic shock with use of a glycopeptide-aminoglycoside-betalactam combination together with anti-inflammatory drugs.

Complications of flaps

Flaps are susceptible to the same complications as side-to-side closures. However, as the blood supply to a flap is more precarious, the complication may have a more dire effect. This article catalogues the various acute complications with an emphasis on early recognition and management.

Sterile technique and the prevention of wound infection in office surgery--Part II

Surgical infection and associated complications are minimized by a combination of appropriate sterile technique and careful surgical technique. This review covers the essential elements of infection control for the office-based surgical practice. Recommendations are made concerning operating room facilities, instrument sterilization, and tray set-up (Part I, J Dermatol Surg Oncol 14:1364-1371, 1988). Part II addresses surgical prepping, surgical technique, and prophylactic antibiotics.

Zero infection rate: an achievable irreducible minimum in clean surgery?

For clean elective surgery, the goal of nosocomial infection control is nothing less than an infection rate of zero. Although infection rates of less than 1% are being posted regularly in selected surgical operations today, infection rates of 2% to 6% persist in many procedures such as coronary artery bypass surgery and vascular surgery. Predictable achievement of a zero infection rate in all of clean surgery will require new directions in both basic and clinical research.

Research into the prevention of infection in clean surgery has, to date, focused upon 1) identifying and controllingthe routes of wound contamination, 2)decontamination of a contaminated woundthrough the prophylactic use of antimicrobials, and 3)modifying the host immune system. The latter is a fascinating area of new research which will not be discussed in detail here.

Routes of contaminationare often categorized as endogenous or exogenous. “Endogenous” generally refers to bacterial seeding of the wound from the flora of the patient's own skin, nose, perineum, and GI tract. “Exogenous” contamination has come to mean bacteria originating from the operating room environment or operating room personnel which reach the wound by direct inoculation (eg, improperly sterilized instruments, hands of the surgeon via torn gloves) or by the airborne route. These categories may not be broad enough to satisfy the complexities of the hospital environment, however. The addition of the category “acquired endogenous” may be of help in describing contamination which occurs when patients become colonized with resistant hospital flora and subsequently carry this newly acquired flora into the operating theater.

Prophylactic mezlocillin for transurethral prostatectomy

In a randomised clinical trial of 100 consecutive patients treated by transurethral prostatectomy, half were given prophylactic intravenous mezlocillin. Blood cultures were obtained, the urine examined and the post-operative progress of each patient was carefully followed. The results were analysed and a high incidence of bacteraemia and septicaemia was found. Single-dose prophylactic mezlocillin was highly effective in preventing this complication. The presentation of septicaemia in mild and severe form is described and the aetiology discussed. Probable risk factors are identified and prophylactic and therapeutic measures described.

Surgical antiseptics

The skin cannot be sterilized because approximately 20% of the resident flora are beyond the reach of surgical scrubs and antiseptics. The goal of surgical preparation of the skin with antiseptics is to remove transient and pathogenic microorganisms on the skin surface and to reduce the resident flora to a low level. Four antiseptics which have been popular over the past two decades are discussed. Benzalkonium chloride is somewhat unstable on the skin and is too prone to contamination to be in general use. Hexachlorophene is not recommended due to narrow spectrum and risks secondary to percutaneous absorption. The iodophors are excellent antiseptics, but recent studies raise questions about effectiveness and contamination. Chlorhexidine is a very safe and effective antiseptic. Comparison studies with chlorhexidine, hexachlorophene, and iodophors show chlorhexidine to be the most effective agent. Chlorhexidine can be toxic to the middle ear and irritating to the eyes with direct contact. Caution should be used in these areas with chlorhexidine and other antiseptics.