Prophylactic antibiotics in elective colorectal surgery

The Role of Bowel Preparation in Open, Minimally Invasive, and Converted-to-Open Colectomy

BACKGROUND

Bowel preparation before colectomy is considered an effective strategy to decrease postoperative complications. However, data regarding the effect of bowel preparation in patients undergoing minimally invasive colectomy are limited. The aim of this study was to investigate the role of different bowel preparation strategies in patients undergoing open, minimally invasive, and converted-to-open elective colectomies.

METHODS

We identified 39,355 patients who underwent elective colectomy from the American College of Surgeons National Surgical Quality Improvement Program colectomy-targeted database (2012-2016). Multivariate logistic regression models were used to assess the impact of different bowel preparation strategies on postoperative complications and mortality in three subapproach groups: open (n = 12,141), minimally invasive (n = 23,057), and converted to open (n = 4157).

RESULTS

Overall, a total of 10,066 (25.6%) patients received no preparation (NP), 11,646 (29.5%) mechanical bowel preparation (MBP) alone, 1664 (4.2%) antibiotic bowel preparation (ABP) alone, and 15,979 (40.6%) MBP + ABP. Compared with NP, MBP + ABP showed the strongest protective effects. MBP + ABP was associated with reduced risk of major complications (odds ratio [OR] = 0.60, 95% confidence interval [CI]: 0.55-0.66), infectious complications (OR = 0.50, 95% CI: 0.46-0.54), any complications (OR = 0.55, 95% CI: 0.51-0.60), 30-d mortality (OR = 0.68, 95% CI: 0.48-0.96), anastomotic leak (OR = 0.50, 95% CI: 0.43-0.58), and length of stay ≥ 4 d (OR = 0.64, 95% CI: 0.61-0.67) in overall population. These protective effects, except for 30-d mortality, were observed in open, minimally invasive, and converted-to-open groups. When the analysis was limited to robotic surgery only, MBP + ABP was only associated with reduced risk of major complications (OR = 0.61, 95% CI: 0.38-0.97) compared with NP. The protective effects remained similar over the study time period.

CONCLUSIONS

MBP + ABP is a preferred preoperative strategy in open, minimally invasive, and converted-to-open colectomy.

Perioperative Management of Patients Undergoing Elective Colorectal Surgery in Israel: A National Survey

BACKGROUND

The approach to perioperative antibiotic prophylaxis, bowel preparation, and postoperative routines in elective colorectal resections has changed over the last two decades. The aim of this national survey was to document the current methods of perioperative management of those patients scheduled for elective colorectal resections in surgical departments in Israel.

METHODS

A mail and telephone survey of surgical departments was conducted in 2001 in order to evaluate the routines of perioperative management of elective colorectal resections. Re-evaluation was performed in 2004.

RESULTS

In 2001, all but one of the responders used low-residue diet preoperatively and combined oral and parenteral antibiotic prophylaxis. Polyethylene glycol or sodium phosphate bowel preparation was used by 69% of the responders. The most common oral regimens were a combination of neomycin plus metronidazole (43.5%) or neomycin plus erythromycin (47.8%). The most common parenteral regimens used were gentamicin plus metronidazole or gentamicin plus metronidazole plus ampicillin (56.5% and 17% of the responders, respectively). Cephalosporins alone or in combination were used in three departments. In 17 departments (74%), parenteral prophylactic antibiotics were continued for 24 h or longer (up to 72 h). All but one of the departments left a nasogastric tube for 1-5 days after surgery. There were substantial changes over the last three years-that is, less use of preoperative restriction diets, shorter duration of perioperative antibiotic coverage, more common use of cephalosporins, switch to sodium dihydrogen and sodium hydrogen phosphate bowel preparation, shorter use of postoperative nasogastric drainage, and faster resumption of peroral fluids.

CONCLUSIONS

In 2001, the majority of surgical departments in Israel used a conservative approach to perioperative management of patients undergoing elective colorectal resections. Significant changes occurred during the last three years. The perioperative routines used today in most general surgery departments in Israel comply with current recommendations.

Bowel preparation for colorectal surgery

PURPOSE

The aim of this study was to assess recent literature regarding bowel preparation for colonoscopy and surgery.

METHODS

The study was conducted by an Index Medicus English-language search of articles relevant to both oral mechanical and parenteral and oral antibiotic preparation for elective colorectal surgery and mechanical bowel preparation for colonoscopy. The study period was from 1975 to 2000. In addition, studies of elective colorectal surgery without mechanical bowel preparation were also considered.

RESULTS

Although several recent prospective, randomized trials have suggested that elective colorectal surgery can be safely performed without any mechanical bowel preparation, mechanical bowel preparation remains the standard of care, at least in North America at the present time. A recent survey of the members of The American Society of Colon and Rectal Surgeons revealed that the majority currently use sodium phosphate for bowel preparation and use a dual oral antibiotic regimen before elective colorectal surgery, combined with two doses of parenteral antibiotics. Although some of the use patterns are based on prospective, randomized study, others seem founded strictly on habit and theory.

CONCLUSIONS

The current methods of bowel cleansing for both colonoscopy and surgery include sodium phosphate and polyethylene glycol; colorectal surgeons practicing in North America currently prefer sodium phosphate. Additional preparation for colorectal surgery includes perioperative parenteral antibiotics and, to a slightly lesser degree, preoperative oral antibiotic preparation. Although some recent prospective, randomized studies have suggested that omission of mechanical bowel preparation for elective colorectal surgery is not only feasible but potentially preferable, caution is recommended before routinely omitting these widely practiced measures, because data to support such routine omission are limited.

Comparison of cefotaxime plus metronidazole versus cefoxitin for prevention of wound infection after abdominal surgery

In a randomized prospective stratified trial consisting of 1010 patients undergoing abdominal surgery involving the viscera, the efficacy of cefotaxime plus metronidazole was compared to cefoxitin for preventing wound infection. The efficacy of a single dose of antibiotics versus three doses over 24 hours was also evaluated. This study demonstrated that a single-dose antibiotic regimen was as effective as a multiple-dose regimen in the prophylaxis of wound infections following abdominal surgery. In addition it demonstrated that the cefotaxime plus metronidazole regimen is comparable to that of cefoxitin and is more cost-effective. It is concluded that a single dose of cefotaxime plus metronidazole provides effective prophylaxis against postoperative wound infections following abdominal surgery.

Prophylaxis against sepsis in patients undergoing major surgery

Postoperative infection in general surgical patients is discussed according to operation types. A selection of the huge literature on each group is reviewed, and details from the author's own work and ideas are presented. By discussing these points attempts are made to determine the best regimens for a given set of clinical circumstances. There is a small literature indicating that postoperative chest infection can be prevented by some antibacterial drug regimens, and this question has been addressed; it seems that in the past it has been largely ignored. Some nonantibacterial methods of reducing postoperative infection are also briefly discussed.

Preoperative bowel preparation. A survey of colon and rectal surgeons

A survey of 500 clinically active, board-certified colon and rectal surgeons in the United States and Canada was conducted to obtain data regarding current methods of bowel preparation for elective colorectal surgery. A review of recent publications on preoperative bowel preparation was used to compare the current literature recommendations with the actual practice among the group surveyed. Responses were received from 352 of 500 colorectal surgeons to whom questionnaires were sent (70 percent response rate). All respondents used a mechanical preparation and some form of antibiotics. The favorite antibiotic regimen was oral antimicrobials combined with systemic antibiotics (88 percent). Concomitant administration of oral neomycin-erythromycin base and a systemic second generation cephalosporin active against both anaerobic and aerobic colonic bacteria, together with oral polyethelene glycol electrolyte mechanical colonic cleansing, was the most popular method of preoperative bowel preparation (58 percent). The second most frequent method of mechanical bowel cleansing consisted of conventional enemas, dietary restrictions, and cathartic preparations (36 percent). Mannitol solution (5 percent), and whole-gut irrigation per nasogastric tube (1 percent) were the least popular methods of mechanical bowel cleansing. The literature supports the current methods of preoperative bowel preparation used by the vast majority of surgeons surveyed.

Containing costs of antimicrobials in the hospital: a critical evaluation

Because reimbursement of hospitals from patient sources for the cost of antimicrobial agents varies considerably according to the nature of the patient population, the actual savings potential of cost-containment efforts is proportional to the extent that costs are not reimbursed. Meaningful cost estimations include calculations for drug preparation, administration, necessary laboratory tests, toxicity, and acquisition. Savings in surgical antimicrobial prophylaxis may be estimated according to the type and volume of operations, history of usage excesses, and anticipated degree of cooperation of surgeons. In therapy, savings generally derive from restricting use of costly drugs. Studies that demonstrate similar outcomes of patient care in restricted and unrestricted settings are presently lacking. Such studies are essential for programs that promote change from parenteral to oral antimicrobials, because they may shorten the length of hospitalization. The outcome of antimicrobial cost-containment efforts in patient care should be monitored as a surveillance activity to be conducted by infection control practitioners involved with quality assessment.

Fundamentals in the prophylaxis of septic surgical complications

An operation in which the colonic/rectal wall is opened represents a destruction of a complicated balance between the patient and his intestinal micro-flora, giving way for infective micro-organisms to become established. The surgeon should try to minimize the number of organisms reaching the operation field and reduce their possibilities of establishment. Some strategical and tactical guide-lines for achieving these goals are given.