A comparison of the prophylactic value of cefotetan and metronidazole appendectomy

Is the efficacy of antibiotic prophylaxis for surgical procedures decreasing? Systematic review and meta-analysis of randomized control trials

OBJECTIVE

Rising antibiotic resistance could reduce the effectiveness of antibiotics in preventing postoperative infections. We investigated trends in the efficacy of antibiotic prophylaxis regimens for 3 commonly performed surgical procedures-appendectomy, cesarean section, and colorectal surgery-and 1 invasive diagnostic procedure, transrectal prostate biopsy (TRPB).

DESIGN

Systematic review and meta-analysis.

METHODS

We searched PubMed and Cochrane databases (through October 31, 2017) for randomized control trials (RCTs) that measured the efficacy of antibiotic prophylaxis for 4 index procedures in preventing postoperative infections (surgical site infections [SSIs] following the 3 surgical procedures and a combination of urinary tract infections [UTIs] and sepsis following TRPB).

RESULTS

Of 399 RCTs, 74 studies (9 appendectomy, 11 cesarean section, 39 colorectal surgery, and 15 TRPB) were included. Multilevel logistic regression models with random intercepts for each study showed no statistically significant increase in SSIs over time for appendectomy (adjusted odds ratio [aOR] per year, 1.03; 95% confidence interval [CI], 0.92-1.16; P=.57), cesarean section (aOR per year, 1.01; 95% CI, 0.96-1.05; P=.80), and TRPB (aOR per year, 0.95; 95% CI, 0.77-1.18; P=.67). However, there was a significant increase in SSIs proportion following colorectal surgery (aOR per year, 1.049; 95% CI, 1.03-1.07; P<.001).

CONCLUSION

The efficacy of antibiotic prophylaxis agents in preventing SSIs following colorectal surgery has declined. Small number of RCTs and low infections rates limited our ability to assess true effect for simple appendectomy, cesarean section, or TRPB.

Diagnosis and management of acute appendicitis. EAES consensus development conference 2015

Unequivocal international guidelines regarding the diagnosis and management of patients with acute appendicitis are lacking. The aim of the consensus meeting 2015 of the EAES was to generate a European guideline based on best available evidence and expert opinions of a panel of EAES members. After a systematic review of the literature by an international group of surgical research fellows, an expert panel with extensive clinical experience in the management of appendicitis discussed statements and recommendations. Statements and recommendations with more than 70 % agreement by the experts were selected for a web survey and the consensus meeting of the EAES in Bucharest in June 2015. EAES members and attendees at the EAES meeting in Bucharest could vote on these statements and recommendations. In the case of more than 70 % agreement, the statement or recommendation was defined as supported by the scientific community. Results from both the web survey and the consensus meeting in Bucharest are presented as percentages. In total, 46 statements and recommendations were selected for the web survey and consensus meeting. More than 232 members and attendees voted on them. In 41 of 46 statements and recommendations, more than 70 % agreement was reached. All 46 statements and recommendations are presented in this paper. They comprise topics regarding the diagnostic work-up, treatment indications, procedural aspects and post-operative care. The consensus meeting produced 46 statements and recommendations on the diagnostic work-up and management of appendicitis. The majority of the EAES members supported these statements. These consensus proceedings provide additional guidance to surgeons and surgical residents providing care to patients with appendicitis.

Formulary conversion of cefoxitin usage to cefotetan: experience at a large teaching hospital

The pharmacy and therapeutics committee at Hartford Hospital recommended replacement of cefoxitin with cefotetan, based on data reported in the literature regarding antimicrobial activity, pharmacokinetic profile, and adverse reactions. Once the recommendation was approved by the medical staff, an intense educational program was instituted, and all orders for cefoxitin were converted to cefotetan with appropriate dosage modifications. A total of 960 patients were treated in the first year; no major patterns of ineffectual therapy or adverse events associated with cefotetan usage have emerged. The mean cost of cefotetan therapy was $180.59, which is $130.26 less per patient than a comparable regimen of cefoxitin (mean cost of therapy $310.85). Based on the data analysis of cefotetan usage for a 12-month period, the actual annual savings due to therapeutic substitution of cefotetan for cefoxitin was $124.961. To further evaluate the clinical efficacy, safety, and savings of this therapeutic interchange, two separate retrospective reviews of patient medical records were performed. The first audit has been previously published in its entirety. In the subsequent audit, 284 additional patient medical charts have been reviewed. These patients received either cefotetan therapy or concomitant therapy of an aminoglycoside combined with either clindamycin or mezlocillin. Clinical outcomes were classified as an empiric cure or improvement for 99.4, 98.5, and 92.9 percent of patients, respectively. In this audit, elevated prothrombin time/partial thromboplastin time values and bleeding episodes were noted infrequently, as were other adverse reactions.(ABSTRACT TRUNCATED AT 250 WORDS)

Preventing wound infection after appendicectomy: a review

An exponential increase in the number of published prospective studies reflects both a continuing interest in, and a lack of consensus on, the optimal prophylaxis of wound sepsis after appendicectomy. Review of the literature over the last 25 years leads us to emphasize both the importance of adequate study size and of stratification of the severity of the sepsis found at operation. For critical comparison of prophylactic regimens the high percentage of wound infections disclosed after discharge from hospital must be taken into account. Antibiotics reduce the frequency of wound sepsis and although low wound sepsis rates have been reported with systemic antibiotics active against only anaerobes, the cumulative evidence favours a spectrum of antibacterial activity against both aerobic and anaerobic organisms. Topical antiseptics have no significant effect but topical antibiotics are beneficial. Wide variations in outcome for similar antibiotic regimens reflect the importance of technical factors in determining the frequency of wound sepsis.