Prospective randomized trial of single dose cefuroxime against mezlocillin in elective gastric surgery

Antimicrobial Prophylaxis Reduces the Rate of Surgical Site Infection in Upper Gastrointestinal Surgery: A Systematic Review

Surgical site infection occurs with high frequency in gastrointestinal surgery, contributing to the high incidence of morbidity and mortality. The accepted practice worldwide for the prevention of surgical site infection is providing single- or multiple-dose antimicrobial prophylaxis. However, most suitable antibiotic and optimal duration of prophylaxis are still debated. The aim of the systematic review is to assess the efficacy of antimicrobial prophylaxis in controlling surgical site infection rate following esophagogastric surgery. PubMed and Cochrane databases were systematically searched until 31 October 2021, for randomized controlled trials comparing different antimicrobial regimens in prevention surgical site infections. Risk of bias of studies was assessed with standard methods. Overall, eight studies concerning gastric surgery and one study about esophageal surgery met inclusion criteria. No significant differences were detected between single- and multiple-dose antibiotic prophylaxis. Most trials assessed the performance of cephalosporins or inhibitor of bacterial beta-lactamase. Antimicrobial prophylaxis (AMP) is effective in reducing the incidence of surgical site infection. Multiple-dose antimicrobial prophylaxis is not recommended for patients undergoing gastric surgery. Further randomized controlled trials are needed to determine the efficacy and safety of antimicrobial prophylaxis in esophageal cancer patients.

[Antibiotic prophylaxis in gastroduodenal surgery]

The incidence of postoperative wound infections is increased up to 35% after gastroduodenal surgery, when gastric motility and acidity are decreased, as in case of gastric ulcer or cancer, obstruction, bleeding, antacid therapy. The endogenous flora contaminating the operative-site consists of organisms of the oropharynx and the jejunum and includes anaerobes like bacteroides, aerobes like streptococci, staphylococci, E. coli. Antimicrobial prophylaxis is therefore indicated in these high risk patients. All groups of antibiotics have been used, however 1st and 2nd generation cephalosporins are the most effective. A single dose given intravenously just before anaesthesia is recommended, a second dose is advisable intraoperatively when surgery is prolonged or massive blood loss occurs. Antibiotic prophylaxis is also recommended in gastric bypass surgery for obesity, but remains controversial for percutaneous endoscopic gastrotomy.

Prophylactic parenteral cefuroxime: subcutaneous concentrations in laparotomy wounds

Plasma and subcutaneous adipose tissue cefuroxime concentrations were measured in laparotomy wounds, by means of high-pressure liquid chromatography, in 12 patients undergoing elective abdominal operations. After intravenous administration of 1.5 g cefuroxime at induction of anaesthesia, the measured concentrations in serum and wound tissue during a 2 h period were above the MIC 90 of most micro-organisms derived from the alimentary tract. Tissue peak levels were reached within 15 min and the tissue half life was 1.5 h.

A prospective randomized trial to compare triple dose mezlocillin with triple dose cefuroxime plus metronidazole as prophylaxis in colorectal surgery

The results of a prospective randomized clinical trial to compare three dose regimens of mezlocillin with cefuroxime plus metronidazole for prophylaxis in emergency and elective colorectal surgery are reported. Severe wound infection occurred in five patients (10%) receiving mezlocillin and in four patients (7%) receiving cefuroxime and metronidazole. There were two episodes of septicaemia, each in the mezlocillin group. The total number of surgically related infections was less with cefuroxime plus metronidazole (n = 10) compared with mezlocillin (n = 17), but this was not statistically significant (P greater than 0.1).

Single dose systemic antibiotic prophylaxis of surgical wound infections

The proper duration of antimicrobial use for the prevention of postoperative surgical infection has been a subject of controversy. Currently, more than 40 published clinical trials are available in which the efficacy of single dose surgical prophylaxis with parenteral antimicrobials has been studied. These studies have compared single doses versus multiple doses of the same agent, single doses of antimicrobial versus placebo, single doses of various antimicrobials, and a single dose of one agent versus multiple doses of another agent. In all trials in which single dose regimens were compared with multidose regimens, the single dose regimens resulted in a similar frequency of postoperative wound infections. Single antimicrobial doses, usually cephalosporins given immediately before operation, are effective in preventing wound infections in gastric, biliary, and transurethral operations, hysterectomies and cesarean sections. For colorectal operations, the value of single parenteral doses of various agents has been established; however, it is not clear if there is an added benefit when oral antimicrobials are also used. For open heart operations or those in which prosthetic materials are implanted, the value of single dose regimens has not been established.