A randomized prospective study of cefoxitin versus piperacillin in appendicectomy

Optimizing antibiotic management for patients with acute appendicitis: A quality improvement study

BACKGROUND

To decrease surgical site infections after appendectomy for acute appendicitis, preoperative broad-spectrum antibiotics are often used in clinical practice. However, this treatment strategy has come under scrutiny because of increasing rates of antibiotic-resistant infections.

METHODS

The aim of this multisite quality improvement project was to decrease the treatment of uncomplicated acute appendicitis with piperacillin-tazobactam without increasing the rate of surgical site infections. Our quality improvement intervention had 2 distinct components: (1) updating electronic health record orders to encourage preoperative administration of narrow-spectrum antibiotics and (2) educating surgeons and emergency department clinicians about selecting appropriate antibiotic therapy for acute appendicitis. Patient demographics, clinical characteristics, and outcomes were compared 6 months before and after implementation of the quality improvement intervention.

RESULTS

A total of 352 laparoscopic appendectomies were performed during the 6-month preintervention period, and 369 were performed during the 6-month postintervention period. The preintervention period and postintervention period groups had similar baseline demographics, vital signs, and laboratory test values. The rate of preoperative piperacillin-tazobactam administration significantly decreased after the intervention (51.4% preintervention period vs 20.1% postintervention period, P < .001). The rate of surgical site infections was similar in both groups (superficial surgical site infections = 1.4% preintervention period vs 0.8% postintervention period, P = .50; deep surgical site infections = 1.1% preintervention period vs 0.0% postintervention period, P = .06; and organ space surgical site infections = 3.1% preintervention period vs 3.0% postintervention period, P > .99). Rates of 30-day readmission, reoperation, and Clostridioides difficile infection also did not differ between groups.

CONCLUSION

Our quality improvement intervention successfully decreased piperacillin-tazobactam administration without increasing the rate of surgical site infections in patients with acute appendicitis.

Surgical Antimicrobial Prophylaxis in Abdominal Surgery for Neonates and Paediatrics: A RAND/UCLA Appropriateness Method Consensus Study

Surgical site infections (SSIs), i.e., surgery-related infections that occur within 30 days after surgery without an implant and within one year if an implant is placed, complicate surgical procedures in up to 10% of cases, but an underestimation of the data is possible since about 50% of SSIs occur after the hospital discharge. Gastrointestinal surgical procedures are among the surgical procedures with the highest risk of SSIs, especially when colon surgery is considered. Data that were collected from children seem to indicate that the risk of SSIs can be higher than in adults. This consensus document describes the use of preoperative antibiotic prophylaxis in neonates and children that are undergoing abdominal surgery and has the purpose of providing guidance to healthcare professionals who take care of children to avoid unnecessary and dangerous use of antibiotics in these patients. The following surgical procedures were analyzed: (1) gastrointestinal endoscopy; (2) abdominal surgery with a laparoscopic or laparotomy approach; (3) small bowel surgery; (4) appendectomy; (5) abdominal wall defect correction interventions; (6) ileo-colic perforation; (7) colorectal procedures; (8) biliary tract procedures; and (9) surgery on the liver or pancreas. Thanks to the multidisciplinary contribution of experts belonging to the most important Italian scientific societies that take care of neonates and children, this document presents an invaluable reference tool for perioperative antibiotic prophylaxis in the paediatric and neonatal populations.

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&lt;.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.

Effect of Optimized Antibiotic Prophylaxis on the Incidence of Surgical Site Infection

Objective.

To compare the rate of surgical site infection (SSI) before and after an intervention period in which an optimized policy for antibiotic prophylaxis was implemented. To demonstrate that a more prudent, restrictive policy would not have a detrimental effect on patient outcomes.

Design.

Before-after trial with prospective SSI surveillance in the Dutch nosocomial surveillance network (Preventie Ziekenhuisinfecties door Surveillance [PREZIES]), using the criteria of the Centers for Disease Control, including postdischarge surveillance for up to 1 year.

Methods.

During a preintervention period and a postintervention period (both 6-13 months), 12 Dutch hospitals collected data on antimicrobial prophylaxis and SSI rates. The study was limited to commonly performed surgical procedures in 4 specialties: vascular, intestinal, gynecological and orthopedic surgery. Selected risk factors for analysis were sex, age, American Society of Anesthesiologists classification, wound contamination class, duration of surgery, length of hospital stay before surgery, and urgency of surgery (elective or acute).

Results.

A total of 3,621 procedures were included in the study, of which 1,668 were performed before the intervention and 1,953 after. The overall SSI rate decreased from 5.4% to 4.5% (P = .22). Among the procedures included in the study, the largest proportion (55%) were total hip arthroplasty, and the smallest proportion (2%) were replacement of the head of the femur. SSI rates varied from 0% for vaginal hysterectomy to 21.1% for femoropopliteal or femorotibial bypass surgery. Crude and adjusted odds ratios showed that there were no significant changes in procedure-specific SSI rates after the intervention (P>.1).

Conclusions.

An optimized and restrictive antibiotic prophylaxis policy had no detrimental effect on the outcome of clean and clean contaminated surgery, as measured by SSI rate.

Effect of Optimized Antibiotic Prophylaxis on the Incidence of Surgical Site Infection

Objective.

To compare the rate of surgical site infection (SSI) before and after an intervention period in which an optimized policy for antibiotic prophylaxis was implemented. To demonstrate that a more prudent, restrictive policy would not have a detrimental effect on patient outcomes.

Design.

Before-after trial with prospective SSI surveillance in the Dutch nosocomial surveillance network (Preventie Ziekenhuisinfecties door Surveillance [PREZIES]), using the criteria of the Centers for Disease Control, including postdischarge surveillance for up to 1 year.

Methods.

During a preintervention period and a postintervention period (both 6-13 months), 12 Dutch hospitals collected data on antimicrobial prophylaxis and SSI rates. The study was limited to commonly performed surgical procedures in 4 specialties: vascular, intestinal, gynecological and orthopedic surgery. Selected risk factors for analysis were sex, age, American Society of Anesthesiologists classification, wound contamination class, duration of surgery, length of hospital stay before surgery, and urgency of surgery (elective or acute).

Results.

A total of 3,621 procedures were included in the study, of which 1,668 were performed before the intervention and 1,953 after. The overall SSI rate decreased from 5.4% to 4.5% (P = .22). Among the procedures included in the study, the largest proportion (55%) were total hip arthroplasty, and the smallest proportion (2%) were replacement of the head of the femur. SSI rates varied from 0% for vaginal hysterectomy to 21.1% for femoropopliteal or femorotibial bypass surgery. Crude and adjusted odds ratios showed that there were no significant changes in procedure-specific SSI rates after the intervention (P>.1).

Conclusions.

An optimized and restrictive antibiotic prophylaxis policy had no detrimental effect on the outcome of clean and clean contaminated surgery, as measured by SSI rate.

The use of pre- or postoperative antibiotics in surgery for appendicitis: a systematic review

BACKGROUND AND AIM

The aim of this study was to review the literature regarding the use of pre- and/or postoperative antibiotics in the management of appendicitis, using data obtained from PubMed and the Cochrane Library.

MATERIAL AND METHODS

A literature search was conducted using the terms "appendicitis" combined with "antibiotics." Studies were selected based on relevance for the evidence on prophylactic and postoperative treatment with regard to the route and duration of drug administration and the findings of surgery.

RESULTS

Patients with acute appendicitis should receive preoperative, broad-spectrum antibiotics. The use of postoperative antibiotics is only recommended in cases of perforation, and treatment should then be given intravenously, for a minimum period of 3-5 days for adult patients, until clinical signs such as fever resolve and laboratory parameters such as C-reactive protein curve and white blood cell (WBC) start to decline.

CONCLUSION

Preoperative antibiotic prophylaxis is recommended in all patients with acute appendicitis, whereas postoperative antibiotics only in cases of perforation.