Infection control in colon surgery

Colon Injuries and Infectious Complications in Concurrent Gunshot-Related Fractures

INTRODUCTION

Concurrent colonic injury among patients with gunshot-related fractures presents a potential risk for infectious complications. We hypothesized that colon injuries are associated with more infectious orthopedic complications among gunshot victims with concurrent fractures.

MATERIALS AND METHODS

We reviewed trauma patients arriving at our level 1 trauma center from January 1, 2019 to May 31, 2022 who suffered any gunshot-related fracture and also underwent an exploratory laparotomy. Of these patients, those with colon injuries were compared to those without colon injuries. Baseline characteristics, including antibiotic regimens, were collected in addition to outcomes of length of stay, intensive care unit admission, ventilator requirement, and development of infectious orthopedic complications.

RESULTS

Overall, 56 of the 107 included patients had colon injuries. Age, sex, race/ethnicity, and Injury Severity Score were similar between groups. Of patients with colonic injuries, 16.1% received early, repeat dosing of broad-spectrum antibiotics, while only 3.9% of patients without colonic injuries received this antibiotic dosing (P = 0.04). Interestingly, only patients with colon injuries developed infectious orthopedic complications and none of the patients without colon injuries developed such complications (10.7% versus 0.0%, P = 0.03). All patients with orthopedic infections had infected pelvic fractures. Length of stay was 3 d longer in the colon injury group (P = 0.04). There was no difference in intensive care unit admission, ventilator requirement, or death.

CONCLUSIONS

Concurrent colon injuries among patients with gunshot-related fractures are associated with higher risk of infectious orthopedic complications, likely from direct spread of fecal contaminant. Early, broad-spectrum antibiotics may be associated with reduced infectious orthopedic complications.

Oral Antibiotic Prophylaxis Lowers Surgical Site Infection in Elective Colorectal Surgery: Results of a Pragmatic Cohort Study in Catalonia

BACKGROUND

The role of oral antibiotic prophylaxis (OAP) and mechanical bowel preparation (MBP) in the prevention of surgical site infection (SSI) after colorectal surgery is still controversial. The aim of this study was to analyze the effect of a bundle including both measures in a National Infection Surveillance Network in Catalonia.

METHODS

Pragmatic cohort study to assess the effect of OAP and MBP in reducing SSI rate in 65 hospitals, comparing baseline phase (BP: 2007-2015) with implementation phase (IP: 2016-2019). To compare the results, a logistic regression model was established.

RESULTS

Out of 34,421 colorectal operations, 5180 had SSIs (15.05%). Overall SSI rate decreased from 18.81% to 11.10% in BP and IP, respectively (OR 0.539, CI95 0.507-0.573, p < 0.0001). Information about bundle implementation was complete in 61.7% of cases. In a univariate analysis, OAP and MBP were independent factors in decreasing overall SSI, with OR 0.555, CI95 0.483-0.638, and OR 0.686, CI95 0.589-0.798, respectively; and similarly, organ/space SSI (O/S-SSI) (OR 0.592, CI95 0.494-0.710, and OR 0.771, CI95 0.630-0.944, respectively). However, only OAP retained its protective effect at both levels at multivariate analyses.

CONCLUSIONS

oral antibiotic prophylaxis decreased the rates of SSI and O/S-SSI in a large series of elective colorectal surgery.

Preoperative oral antibiotics with versus without mechanical bowel preparation to reduce surgical site infections following colonic resection: Protocol for an international randomized controlled trial (ORALEV2)

AIM

Surgical site infections (SSIs) are common after colonic surgery. SSIs can cause relevant morbidity and increase costs of care. Preoperative oral antibiotics can reduce the incidence of SSIs after resection of the colon, but the role of mechanical bowel preparation (MBP) is debated. This study aims to assess the impact of a combined regimen of oral antibiotics and MBP on SSIs after colonic surgery.

METHODS

An international, multicentre, pragmatic, adaptive, parallel-group, randomized controlled trial will be conducted across Europe. Adult patients scheduled to undergo elective colonic resection will be assessed for inclusion. Patients will be randomized into one of two treatment arms: (1) preoperative oral antibiotics without MBP (control); (2) preoperative oral antibiotics with MBP (experimental). All patients will receive intravenous antibiotics at anaesthetic induction. The primary aim will be 30-day SSI, assessed by a blinded nurse. Additional end-points include safety, morbidity and mortality, satisfaction with the preparation, time to return of bowel function, time to complete recovery and time to discharge, long-term results. Analyses will be performed with a modified intention-to-treat approach. Interim analyses are planned.

DISCUSSION

This will be the first randomized clinical trial to assess the efficacy and safety of preoperative oral antibiotics plus MBP versus preoperative oral antibiotics only, before colonic surgery. The knowledge obtained could help to establish the ideal preparation for patients scheduled to undergo resection of the colon. Full protocol NCT04161599.

Surgical site infection in elective colonic and rectal resections: effect of oral antibiotics and mechanical bowel preparation compared with mechanical bowel preparation only

AIM

Surgical site infections are disproportionately common after colorectal surgery and may be largely preventable. The objective of this retrospective cohort study was to determine the effect of oral antibiotics and mechanical bowel preparation on surgical site infections.

METHOD

A retrospective study of a consecutive series of elective colonic and rectal resections following an Enhanced Recovery After Surgery pathway, which also included mechanical bowel preparation, from 1 September 2014 to 30 September 2017. The addition of oral antibiotics (neomycin and metronidazole) to the mechanical bowel preparation procedure was assessed. Development of surgical site infections within 30 days was the main outcome measured. The secondary outcome was assessment of possible surgical site infection predictors.

RESULTS

Seven-hundred thirty-two patients were included: 313 (43%) preintervention (mechanical bowel preparation only); and 419 (57%) postintervention (mechanical bowel preparation plus oral antibiotics). Surgical site infection rates preintervention and. postintervention were: overall, 20.8% vs 10.5%, P < 0.001; superficial, 10.9% vs 4.3%, P < 0.001; and organ space, 9.9% vs 6.2%, P = 0.03. Subgroup analysis of colonic resections revealed a significant reduction in overall (17.1% vs 6.8%), superficial (10.7% vs 4.3%) and organ space (6.4% vs. 2.6%) infections. Rectal resections had significant reduction in overall (26.2% vs 15.3%) and superficial (11.1% vs 4.4%) infection rates but not in organ space infections (15.1% vs 10.9%). Multivariate regression analysis revealed open vs minimally invasive surgery (P < 0.001) and omission of oral antibiotics (P = 0.004) as independent predictors of surgical site infections.

CONCLUSION

Administration of oral antibiotics resulted in significant reduction of superficial and organ space infections after colonic resection; after rectal resection, significant reduction only of superficial infections was found.

Preoperative Oral Antibiotic Prophylaxis Reduces Surgical Site Infections After Elective Colorectal Surgery: Results From a Before-After Study

BACKGROUND

Surgical site infections (SSIs) are common complications after colorectal procedures and remain an important source of morbidity and costs. Preoperative oral antibiotic prophylaxis is a potential infection control strategy, but its effectiveness without simultaneous use of mechanical bowel preparation (MBP) is unclear. In this study, we aimed to determine whether preoperative oral antibiotics reduce the risk of deep SSIs in elective colorectal surgery.

METHODS

We performed a before-after analysis in a teaching hospital in the Netherlands. Patients who underwent surgery between January 2012 and December 2015 were included. On 1 January 2013, oral antibiotic prophylaxis with tobramycin and colistin was implemented as standard of care prior to colorectal surgery. The year before implementation was used as the control period. The primary outcome was a composite of deep SSI and/or mortality within 30 days after surgery.

RESULTS

Of the 1410 patients, 352 underwent colorectal surgery in the control period and 1058 in the period after implementation of the antibiotic prophylaxis. We observed a decrease in incidence of the primary endpoint of 6.2% after prophylaxis implementation. When adjusted for confounders, the risk ratio for development of the primary outcome was 0.58 (95% confidence interval, 0.40-0.79). Other findings included a decreased risk of anastomotic leakage and a reduction in the length of postoperative stay.

CONCLUSIONS

Preoperative oral antibiotic prophylaxis prior to colorectal surgery is associated with a significant decrease in SSI and/or mortality in a setting without MBP. Preoperative oral antibiotics can therefore be considered without MBP for patients who undergo colorectal surgery.

Microorganisms associated with incisional infections after gastrointestinal surgery in dogs and cats

OBJECTIVE

To determine the rate of incisional infections after gastrointestinal surgery in dogs and cats and describe the aerobic bacteria isolated from these infections.

STUDY DESIGN

Retrospective study.

ANIMALS

Client-owned dogs (n = 210) and cats (n = 66).

METHODS

Records of dogs and cats that underwent gastrointestinal surgery at the Matthew J. Ryan Veterinary Hospital at the University of Pennsylvania were reviewed for surgical procedures, presence of an infection, bacterial species isolated, perioperative antimicrobials administered, and outcome.

RESULTS

The median duration of follow-up was 14 days (4-35). Incisional infections were recorded in 7% (20/276) of cases. Among those 20 cases, culture results were available in 12 of 20 cases. The most common bacterial isolate cultured was Escherichia coli. The most common perioperative antimicrobials administered to treat incisional infection were cefazolin and cefoxitin. Only two of the bacterial isolates were susceptible to these antimicrobials. Bacteria isolated from incisional infections were most often susceptible to chloramphenicol, imipenem, and gentamicin.

CONCLUSION

Bacterial isolates from incisional infections in this population consisted of native gastrointestinal flora, which was often resistant to the most commonly used perioperative antimicrobials.

CLINICAL SIGNIFICANCE

Contamination at time of surgery is the most likely source of incisional infection after gastrointestinal surgery. This rate of infection justifies more rigorous intraoperative hygiene protocols and evaluation of the antimicrobials' susceptibility of causative bacteria to guide antimicrobial treatment.

Mechanical bowel preparation and oral antibiotic prophylaxis in colorectal surgery: Analysis of evidence and narrative review

The role of oral antibiotic prophylaxis and mechanical bowel preparation in colorectal surgery remains controversial. The lack of efficacy of mechanical preparation to improve infection rates, its adverse effects, and multimodal rehabilitation programs have led to a decline in its use. This review aims to evaluate current evidence on antegrade colonic cleansing combined with oral antibiotics for the prevention of surgical site infections. In experimental studies, oral antibiotics decrease the bacterial inoculum, both in the bowel lumen and surgical field. Clinical studies have shown a reduction in infection rates when oral antibiotic prophylaxis is combined with mechanical preparation. Oral antibiotics alone seem to be effective in reducing infection in observational studies, but their effect is inferior to the combined preparation. In conclusion, the combination of oral antibiotics and mechanical preparation should be considered the gold standard for the prophylaxis of postoperative infections in colorectal surgery.

Prevention of severe infectious complications after colorectal surgery using preoperative orally administered antibiotic prophylaxis (PreCaution): study protocol for a randomized controlled trial

BACKGROUND

Colorectal surgery is frequently complicated by surgical site infections (SSIs). The most important consequences of SSIs are prolonged hospitalization, an increased risk of surgical reintervention and an increase in mortality. Perioperative intravenously administered antibiotic prophylaxis is the standard of care to reduce the risk of SSIs. In the last few decades, preoperative orally administered antibiotics have been suggested as additional prophylaxis to further reduce the risk of infection, but are currently not part of routine practice in most hospitals. The objective of this study is to evaluate the efficacy of a preoperative orally administered antibiotic prophylaxis (Pre-OP) in addition to intravenously administered perioperative antibiotic prophylaxis to reduce the incidence of deep SSIs and/or mortality after elective colorectal surgery.

METHODS/DESIGN

The PreCaution trial is designed as a multicenter, double-blind, randomized, placebo-controlled clinical trial that will be carried out in The Netherlands. Adult patients who are scheduled for elective colorectal surgery are eligible to participate. In total, 966 patients will be randomized to receive the study medication. This will either be Pre-OP, a solution that consists of tobramycin and colistin sulphate, or a placebo solution. The study medication will be administered four times daily during the 3 days prior to surgery. Perioperative intravenously administered antibiotic prophylaxis will be administered to all patients in accordance with national infection control guidelines. The primary endpoint of the study is the cumulative incidence of deep SSIs and/or mortality within 30 days after surgery. Secondary endpoints include both infectious and non-infectious complications of colorectal surgery, and will be evaluated 30 days and/or 6 months after surgery.

DISCUSSION

To date, conclusive evidence on the added value of preoperative orally administered antibiotic prophylaxis in colorectal surgery is lacking. The PreCaution trial should determine the effects of orally administered antibiotics in preventing infectious complications in elective colorectal surgery.

TRIAL REGISTRATION

Netherlands Trial Register, ID: NTR6113 . Registered on 11 October 2016; EudraCT 2015-005736-17.