Is it time to refine? An exploration and simulation of optimal antibiotic timing in general surgery

[Influence of anesthesia on surgical site infections]

Surgical site infections (SSI) are the most frequent cause of impaired perioperative wound healing, lead to increased postoperative morbidity, mortality and length of hospital stay and are therefore a relevant perioperative complication. In addition to numerous measures taken by the surgical departments, there are anesthesiological options that can help to reduce the risk of SSI. In addition to heat, volume and transfusion management these include, for example, the use of antibiotics and the choice of the anesthesia procedure. This article is intended to provide fundamental knowledge on SSI, shows various options for reducing them in the context of anesthesia and evaluates their effectiveness and evidence based on the current state of knowledge.

Timing of prophylactic antibiotics administration and suspected systemic infection after percutaneous biliary intervention

BACKGROUND/PURPOSE

Prophylactic antibiotics administration before percutaneous biliary intervention (PBI) is currently recommended, but the underlying evidence is mostly extrapolated from prophylactic antibiotics before surgery. The aim of this study was to evaluate the impact of prophylactic antibiotics administration timing on the incidence of suspected systemic infection after PBI.

METHODS

The incidence of suspected systemic infection after PBI was compared in patients who received prophylactic antibiotics at four different time intervals between antibiotics administration and skin puncture for PBI. Suspected post-intervention systemic infection was assessed according to predetermined clinical criteria.

RESULTS

There were 98 (21.6%) suspected systemic infections after 454 PBIs in 404 patients. There were significant differences among the four groups in the incidence of suspected systemic infection after the intervention (p = .020). Fever was the most common sign of suspected systemic infection. Administration of prophylactic antibiotics more than an hour before PBI was identified as an independent risk factor of suspected systemic infection after adjusting for other relevant factors (adjusted odds ratio = 10.54; 95% confidence interval, 1.40-78.86).

CONCLUSIONS

The incidence of suspected systemic infection after the PBI was significantly lower when prophylactic antibiotics were administered within an hour before the intervention.

Effective Antimicrobial Prophylaxis in Surgery: The Relevance and Role of Pharmacokinetics-Pharmacodynamics

Appropriate surgical antimicrobial prophylaxis (SAP) is an important measure in preventing surgical site infections (SSIs). Although antimicrobial pharmacokinetics-pharmacodynamics (PKPD) is integral to optimizing antibiotic dosing for the treatment of infections, there is less research on preventing infections postsurgery. Whereas clinical studies of SAP dose, preincision timing, and redosing are informative, it is difficult to isolate their effect on SSI outcomes. Antimicrobial PKPD aims to explain the complex relationship between antibiotic exposure during surgery and the subsequent development of SSI. It accounts for the many factors that influence the PKs and antibiotic concentrations in patients and considers the susceptibilities of bacteria most likely to contaminate the surgical site. This narrative review examines the relevance and role of PKPD in providing effective SAP. The dose-response relationship i.e., association between lower dose and SSI in cefazolin prophylaxis is discussed. A comprehensive review of the evidence for an antibiotic concentration-response (SSI) relationship in SAP is also presented. Finally, PKPD considerations for improving SAP are explored with a focus on cefazolin prophylaxis in adults and outstanding questions regarding its dose, preincision timing, and redosing during surgery.

Antibiotic use in gastrointestinal surgery patients at a Vietnamese national hospital

BACKGROUND

Invasive gastrointestinal surgery may be performed as an open or endoscopic procedure, such as laparoscopic semi-colon surgery, laparoscopic appendectomy, laparoscopic gastrectomy, and anal surgery, among other such operations. Regardless of the approach, the operative procedure interferes with the patient's gastrointestinal tract, necessitating the rational use of prophylactic antibiotics to improve treatment outcomes and minimize postoperative infections.

OBJECTIVE

To investigate the prophylactic and postoperative antibiotic usage in patients who underwent invasive gastrointestinal surgery, and to identify factors associated with postoperative infection.

DESIGN

This descriptive, cross-sectional study included 112 patients who underwent invasive gastrointestinal surgery at the Department of Gastroenterology, Thong Nhat Hospital. We conducted a cross-sectional study in all inpatients aged 18 years and older, who underwent invasive gastrointestinal surgery between January 2020 and December 2020. We recorded patient characteristics, the administration and appropriateness of antibiotics, as well as treatment outcomes. The appropriateness of prophylactic and postoperative antibiotic usage was assessed based on 2015 Vietnamese national guideline for antibiotic use. Multivariable logistic regression analysis was used to determine the factors associated with postoperative infection.

RESULTS

Patients' mean age was 59.7 ± 17.2 years. Most surgeries (89.3%) were clean-contaminated procedures. The rates of appropriate types of antibiotics selected, doses, and overall rates of appropriateness of antibiotic prophylaxis were 68.0%, 76.4% and 54.7%, respectively. Of the patients investigated, 34.8% had at least one sign of postoperative infection; the overall appropriate rate of postoperative antibiotic was 38.5%. Old age was associated with postoperative infection and longer length of hospitalization.

CONCLUSION

Implementation of the guidelines recommended for the prophylactic and therapeutic use of antibiotics is essential to improve treatment outcomes.

A Danish study on emergency or urgent surgery for small bowel obstruction in adults: Incidence, causes, administration of antibiotics, and infectious complications

Background

Small bowel obstruction is potentially life-threatening; however, the incidence of surgery for small bowel obstruction is unknown, the patient characteristics are poorly described, and the triggers for giving antibiotics with possible influence on complications are unclear. The aims of this study were to fill these gaps to describe the incidence and the characteristics of patients undergoing surgery for small bowel obstruction and to identify triggers for giving antibiotics and the association with postoperative infections.

Methods

From July 1, 2014, to July 31, 2015, we included adult patients undergoing surgery for small bowel obstruction at 3 hospitals representing one Danish region. We collected information on patient characteristics, diagnosis, antibiotics, and infectious complications until postoperative day 90 and survival until 1 year.

Results

The 3 hospitals serve a population of 656,353 adults, and treatment is free of charge. A total of 192 patients underwent emergency surgery for small bowel obstruction in the period (incidence: 27/100,000 citizens or 1,200 operations in Denmark annually). The patients with small bowel obstruction had adhesive obstruction (62%), neoplasms (11%), or hernias (7%). A total of 83% received antibiotic prophylaxis, and triggers were preoperative elevated C-reactive protein [odds ratio (95% confidence intervals): 2.49 (1.04-5.98), P = .041] or resection of the bowel [3.10 (1.22-7.89), P = .017]. The incidence of postoperative infections was not reduced among patients receiving antibiotics.

Conclusion

We found that 27/100,000 patients undergo surgery for small bowel obstruction in Denmark each year. Adhesive obstruction was the primary reason (62%). A total of 83% received prophylactic antibiotics triggered by elevated C-reactive protein or bowel resection. We found no association between antibiotic use and infectious complications.

The Japan Society for Surgical Infection: guidelines for the prevention, detection, and management of gastroenterological surgical site infection, 2018

BACKGROUND

The guidelines for the prevention, detection, and management of gastroenterological surgical site infections (SSIs) were published in Japanese by the Japan Society for Surgical Infection in 2018. This is a summary of these guidelines for medical professionals worldwide.

METHODS

We conducted a systematic review and comprehensive evaluation of the evidence for diagnosis and treatment of gastroenterological SSIs, based on the concepts of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. The strength of recommendations was graded and voted using the Delphi method and the nominal group technique. Modifications were made to the guidelines in response to feedback from the general public and relevant medical societies.

RESULTS

There were 44 questions prepared in seven subject areas, for which 51 recommendations were made. The seven subject areas were: definition and etiology, diagnosis, preoperative management, prophylactic antibiotics, intraoperative management, perioperative management, and wound management. According to the GRADE system, we evaluated the body of evidence for each clinical question. Based on the results of the meta-analysis, recommendations were graded using the Delphi method to generate useful information. The final version of the recommendations was published in 2018, in Japanese.

CONCLUSIONS

The Japanese Guidelines for the prevention, detection, and management of gastroenterological SSI were published in 2018 to provide useful information for clinicians and improve the clinical outcome of patients.

Evaluation of Surgical Antimicrobial Prophylaxis and Incidence of Surgical Site Infection at Borumeda Hospital, Northeast Ethiopia: Retrospective Cross-Sectional Study

BACKGROUND

Surgical site infections are global healthcare problems. Although surgical site infections are preventable, they still cause significant morbidity, high death rates, and financial stress on national budgets and individual patients. Inappropriate uses of surgical antimicrobial prophylaxis are increasing and worsening patients' quality of life. This study determined the incidence and risk factors of surgical site infections.

METHODS

Institution-based retrospective cross-sectional study was conducted using a structured data abstraction format on patients who were attending at the surgical ward of Borumeda hospital from April 1, 2017, to March 31, 2019. The data were collected during July 15-30, 2019. A systematic random sampling technique was employed to select 227 surgical cases. Multivariate logistic regression was computed using the statistical package for social sciences version 23.

RESULTS

The incidence of surgical site infections was 46.7%. Prophylaxis was administered to 188 (82.8%) surgical cases. Prophylaxis was recommended for 151 (66.5%). Out of these, only 143 (94.7%) received prophylaxis. One hundred seventy-four (78.4%) of the procedures had appropriate indication. The compliance of surgical antimicrobial prophylaxis use was 13.7%. The predictors of surgical site infections were receiving prophylaxis more than 24 h after surgery (AOR=3.53, 95% CI: 1.22-10.17), clean-contaminated wounds (AOR=4.54, 95% CI: 1.33-15.53), surgical procedure of thyroidectomy (AOR=5.2, 95% CI: 0.9-21.4), appendectomy (AOR = 29, 95% CI: 6.2-141.7), cholecystectomy (AOR = 21, 95% CI: 3.5 -126.7), hernia (AOR= 8.8, 95% CI: 1.2-62.2), skin and deep tissue (AOR = 125, 95% CI: 7.8-196.7), and orthopedic (AOR=57, 95% CI: 1.6-209.5).

CONCLUSION

There was high inconsistency between surgical antimicrobial prophylaxis practice and international surgical site infections prevention guideline. Wrong selection of antimicrobial agents was the most noncompliant to the guidelines. The incidence of surgical antimicrobial prophylaxis was high and requires due attention. The duration of postoperative prophylaxis should be kept to less than 24 h.

Questionnaire Survey Regarding Prevention of Surgical Site Infection after Neurosurgery in Japan: Focus on Perioperative Management and Administration of Surgical Antibiotic Prophylaxis

Various guidelines regarding surgical site infection (SSI) have recently been established. However, perioperative management of the wound and use of antibiotics have never been standardized completely in departments of neurosurgery in Japan. This survey investigated current perioperative management and administration of surgical antibiotic prophylaxis (SAP) and compared with guidelines intended to reduce SSI associated with neurosurgery in Japan. Questionnaires were distributed to members of the conference on Neurosurgical Techniques and Tools and the Japan Society of Aesthetic Neurosurgery via internet. The questionnaires asked about methods of perioperative management. A total of 255 members returned answers to the questionnaires. The questionnaires revealed that partial or no removal of the hair and hair shampooing at the day before surgery were performed in 96.1% and 88.1% of each institute following the World Health Organization (WHO) guidelines. Use of SAP at just before, during, and after surgery were 65.0%, 86.2%, and 63.0%, respectively. The postoperative period of use of intravenous SAP prolonged beyond 24 h in 80.0% against the recommendation of WHO. Perioperative management of wounds and use of SAP varies in institutes in Japan and some procedures were far different from the WHO guidelines. Japanese neurosurgeons should notice the prolonged SAP and comply with the WHO guidelines.

Optimal timing of surgical antimicrobial prophylaxis in laparoscopic surgery: a before-after study

Background

The optimal timing of preoperative surgical antimicrobial prophylaxis (SAP) remains uncertain. This study aimed to evaluate the impact of changing the timing of SAP on the incidence of surgical site infection (SSI) in laparoscopic surgery.

Methods

We performed a before-after study from August 2014 through June 2017 to assess the impact of changes in the timing of SAP on the incidence of SSI at a 790-bed tertiary care center in Japan. The intervention was the administration of SAP immediately after the study patients entered the operating room for laparoscopic surgery.

Results

In total, 1397 patients who met the inclusion criteria were analyzed. After the intervention, the median time between the time of SAP completion and the time of surgical incision changed from 8 min to 26 min (p <  0.001), and the number of cases without SAP completion prior to surgical incision decreased (16.8% vs. 1.8%; p <  0.001). However, changes in the overall incidence of SSI did not significantly differ between the pre-intervention and the intervention groups (13.8% vs. 13.2%; p = 0.80).

Conclusions

Although the timing of preoperative SAP improved, the intervention did not have a significant impact on reducing the incidence of SSI in the current study. Besides preoperative SAP, multidisciplinary approaches should be incorporated into projects aimed at comprehensively improving surgical quality to reduce SSI.

Timing of preoperative antibiotic prophylaxis in 54,552 patients and the risk of surgical site infection: A systematic review and meta-analysis

The aim of the study was to assess the effect of timing of preoperative surgical antibiotic prophylaxis (SAP) on surgical site infection (SSI) and compare the different timing intervals.The benefit of routine use of SAP prior to surgery has long been recognized. However, the optimal timing has not been defined. For the purpose of developing recommendations for the World Health Organization guideline for SSI prevention, a systematic review and meta-analysis of all relevant evidence was conducted.Major medical databases were searched from 1990 to 2016. The primary outcome was SSI after preoperative-SAP comparing different timing intervals. Adjusted odds ratios (OR) with 95% confidence intervals (CI) were extracted and pooled for each comparison with a random effects model.Fourteen papers with 54,552 patients were included in this review. In a quantitative analysis, there was no significant difference when SAP was administered 120-60 minutes prior to incision compared to administration 60-0 minutes prior to incision. Studies investigating different timing intervals within the last 60 minutes time frame reported contradictive results. The risk of SSI almost doubled when SAP was administered after first incision (OR:1.89; 95%CI:[1.05-3.40]) and was 5 times higher when administered more than 120 minutes prior to incision (OR5.26; 95%CI:[3.29-8.39]).Administration of antibiotic prophylaxis more than 120 minutes before incision or after incision is associated a higher risk of surgical site infections than administration less than 120 minutes before incision. Within this 120-minute time frame prior to incision, no differential effects could be identified. The broadly accepted recommendation to administer prophylaxis within a 60-minute time frame prior to incision could not be substantiated.

New WHO recommendations on preoperative measures for surgical site infection prevention: an evidence-based global perspective

Surgical site infections (SSIs) are among the most preventable health-care-associated infections and are a substantial burden to health-care systems and service payers worldwide in terms of patient morbidity, mortality, and additional costs. SSI prevention is complex and requires the integration of a range of measures before, during, and after surgery. No international guidelines are available and inconsistencies in the interpretation of evidence and recommendations of national guidelines have been identified. Given the burden of SSIs worldwide, the numerous gaps in evidence-based guidance, and the need for standardisation and a global approach, WHO decided to prioritise the development of evidence-based recommendations for the prevention of SSIs. The guidelines take into account the balance between benefits and harms, the evidence quality, cost and resource use implications, and patient values and preferences. On the basis of systematic literature reviews and expert consensus, we present 13 recommendations on preoperative preventive measures.

Efficacy of antibiotic prophylaxis prior to tympanoplasty for contaminated cholesteatoma

OBJECTIVES

To evaluate the efficacy of combined antistaphylococcal and antipseudomonal preoperative antibiotics for preventing surgical site infections following tympanoplasty and mastoidectomy with contaminated cholesteatoma.

STUDY DESIGN

Retrospective chart review.

METHODS

Medical records of patients who underwent tympanoplasty ± mastoidectomy for cholesteatoma were reviewed. Only cases considered to have contaminated or dirty surgical fields were included. The primary outcome measure was occurrence of postoperative surgical site infections, perichondritis, pinna abscess, periotic cellulitis, or periotic abscess requiring systemic antibiotic therapy or surgical intervention.

RESULTS

The charts of 326 patients who underwent tympanoplasty ± mastoidectomy were reviewed. Of those, 195 met inclusion criteria. Preoperative antibiotics included clindamycin and ceftazidime or gentamicin. Patients treated with no perioperative antibiotics had a surgical site infection rate of 11%, and those treated with perioperative antibiotics had a rate of 1% (P = 0.02).

CONCLUSION

Administration of preoperative antibiotics to cover staphylococcal and pseudomonal species may prevent surgical site infections with tympanoplasty ± mastoidectomy for contaminated cholesteatoma.

LEVEL OF EVIDENCE

4. Laryngoscope, 126:2363-2366, 2016.

Propionibacterium acnes in shoulder surgery: is loss of hair protective for infection?

BACKGROUND

Propionibacterium acnes (P acnes) has been linked to chronic infections in shoulder surgery. It was recently observed during first-time shoulder surgery in healthy patients at a rate between 36% and 56%. Male gender and the anterolateral approach were reported risk factors. Because the skin biology greatly differs, we aimed to correlate skin complaints with P acnes-positive intraoperative cultures from different tissue layer samples in patients undergoing shoulder surgery for the first time.

METHODS

Intraoperative samples (1 skin, 1 superficial, 1 deep tissue, and 1 control sample) from 112 patients (70 men, 42 women; aged 59.2 years) were cultured. The association between the presence of P acnes in the deep or superficial tissue, or both, and 10 items of a validated preoperative questionnaire for skin pathology was explored.

RESULTS

The cultures were positive for P acnes in 38.4% (n = 43) of the cases. Skin samples were positive for P acnes in 8% (n = 9), superficial samples were positive in 23% (n = 26), and deep samples were positive in 30% (n = 34). Self-reported "loss of hair" was significantly negatively associated with the presence of P acnes in the superficial or deep tissue sample (P = .00028).

DISCUSSION

Patients who report having "loss of hair" show fewer P acnes-positive cultures in intraoperative tissue samples taken during open shoulder surgery. Whether this subgroup is at a lesser risk for P acnes infections remains to be substantiated.

LEVEL OF EVIDENCE

Basic Science Study; Microbiology.

Perioperative use of antibiotics in otologic procedures

PURPOSE OF REVIEW

Surgical site infections (SSIs) have garnered tremendous attention in recent years. Surgeons tend to administer antimicrobial agents liberally, partly over fears of being sued or not paid to care for the SSI. As a result, microbial resistance to conventional agents continues to increase.

RECENT FINDINGS

Few new studies have been published in the otologic literature. The use of perioperative 'bundles' has been shown to be effective in reducing SSIs in procedures such as craniotomy. A single dose of antistaphylococcal and antipseudomonal prophylaxis appears to be highly efficacious prior to contaminated tympanomastoid surgery. Overuse of antimicrobial therapy can paradoxically increase SSIs.

SUMMARY

Otologic surgeons should adhere to established best practices when prescribing antimicrobial therapy perioperatively. Clinical trials of perioperative bundles are needed for otologic procedures.

Perioperative risk factors for surgical site infection in tibial tuberosity advancement: 224 stifles

OBJECTIVE

To examine perioperative factors affecting surgical site infection (SSI) rate following tibial tuberosity advancement (TTA).

STUDY DESIGN

Retrospective case series.

SAMPLE POPULATION

224 stifles in 186 dogs.

METHODS

Medical records of dogs that underwent TTA in a single institution were reviewed. Information on signalment, anaesthetic and surgical parameters, as well as occurrence of SSI was recorded. Dogs were followed for a minimum of three months postoperatively. The association between perioperative factors and SSI was assessed using Chi-squared tests and binary logistic regression.

RESULTS

The prevalence of SSI was 5.3% (12/224 TTA). Surgical time (p = 0.02) and anaesthesia time (p = 0.03) were significantly associated with SSI. For every minute increase in surgical time and anaesthesia time, the likelihood of developing SSI increased by seven percent and four percent respectively. The use of postoperative antimicrobial therapy was not significantly associated with lower SSI (p = 0.719). Implants were removed in 1.3% of cases (3/224 TTA).

CONCLUSIONS

The findings of this study suggest that increased surgical and anaesthesia times are significant risk factors for SSI in TTA, and that there is no evidence that postoperative prophylactic antimicrobial therapy is associated with SSI rate.

Prophylactic antibiotics in dermatological surgery

This is a review of the common pathogens of surgical site infections, antibiotic coverage for particular anatomical sites, mechanisms by which surgical site infections occur and the latest data and recommendations for prophylactic antibiotics in the prevention of surgical site infections, infective endocarditis and haematogenous joint infections. Recent evidence-based guidelines on surgical prophylaxis is for restricted indications and a shorter duration of antibiotic prophylaxis in situations where no clinical benefit of prolonged therapy has been proven, in order to minimise the potential adverse ecological and clinical effects associated with antibiotic therapy. This review recommends the cautious use of prophylactic antibiotics in dermatological surgery to help prevent the growing problem of bacterial resistance as well as other morbidity and health-care costs.

Prevention of infectious complications after elective colorectal surgery in children: an American Pediatric Surgical Association Outcomes and Clinical Trials Committee comprehensive review

OBJECTIVE

This goal of this review was to examine the clinical evidence in support of commonly utilized measures intended to reduce complications following elective colorectal surgery.

DATA SOURCE

Literature searches were performed to identify relevant studies from Medline, PubMed, and Cochrane databases.

STUDY SELECTION

The American Pediatric Surgery Association Outcomes and Clinical Trials Committee selected eight questions to address this topic systematically in the context of three management areas: 1) appropriate utilization of systemic antibiotics for colorectal procedures, 2) reduction of stool burden through mechanical bowel preparation, and 3) intraluminal gut decontamination through use of enteral nonabsorbable antibiotics. Primary outcomes of interest included the occurrence of infectious and mechanical complications related to stool burden and intraluminal bacterial concentration (incisional surgical site infection, anastomotic leakage, and intraabdominal abscess).

RESULTS

The evidence in support of each management category was systematically reviewed, graded, and summarized in the context of the review's primary outcomes. Practice recommendations were made as deemed appropriate by the committee.

CONCLUSIONS

Clinical evidence in support of interventions to reduce infectious complications following colorectal surgery is derived almost exclusively from the adult literature. High-quality evidence to guide clinical practice in children is sorely needed, as the available data may have only limited relevance to pediatric colorectal diseases.

Propionibacterium acnes in shoulder surgery: true infection, contamination, or commensal of the deep tissue?

BACKGROUND

Propionibacterium acnes has been linked to chronic infections in shoulder surgery. Whether the bacterium is a contaminant or commensal of the deep tissue is unclear. We aimed to assess P. acnes in intraoperative samples of different tissue layers in patients undergoing first-time shoulder surgery.

METHODS

In 118 consecutive patients (mean age, 59.2 years; 75 men, 43 women), intraoperative samples were correlated to preoperative subacromial injection, the type of surgical approach, and gender. One skin, one superficial, one deep tissue, and one test sample were cultured for each patient.

RESULTS

The cultures were positive for P. acnes in 36.4% (n = 43) of cases. Subacromial injection was not associated with bacterial growth rates (P = .88 for P. acnes; P = .20 for bacteria other than P. acnes; P = .85 for the anterolateral approach; P = .92 for the deltopectoral approach; P = .56 for men; P = .51 for women). Skin samples were positive for P. acnes in 8.5% (n = 10), superficial samples were positive in 7.6% (n = 9), deep samples were positive in 13.6% (n = 16), and both samples (superficial and deep) were positive in 15.3% (n = 18) of cases (P < .0001). P. acnes was detected in the anterolateral approach in 27.1% (n = 32) of cases and in the deltopectoral approach in 9.3% (n = 11) of cases (P = .01; relative risk, 1.93; 95% confidence interval, 1.08-3.43). Thirty-five of the P. acnes-positive patients were men (81.4%), and 8 patients were women (18.6%; P = .001; relative risk, 2.51; 95% confidence interval, 1.28-4.90).

DISCUSSION

P. acnes was detected in more than one third of patients undergoing first-time shoulder surgery. Preoperative subacromial injection was not associated with bacterial growth. P. acnes was observed more frequently in the deep tissues than in the superficial tissues. The relative risk for obtaining a positive P. acnes culture was 2-fold greater for the anterolateral approach than for the deltopectoral approach, and the risk was 2.5-fold greater for men.