Antimicrobial prophylaxis in colorectal surgery: a systematic review of randomized controlled trials

Best practices in wound care for gastrointestinal stoma and colorectal cancer patients from a nursing perspective: A meta-analysis

Colorectal cancer, a type of colon or bowel cancer, poses a major challenge in the treatment of colorectal lesions. Colorectal endoscopic mucosal resection (EMR) is a minimally invasive technique, but the risk of wound infections remains a significant concern. These infections can impede the healing process, affecting daily activities and patient satisfaction. To mitigate the risk of wound infections, various prophylactic measures have been explored, including medication, vaccines, lifestyle adjustments and hygiene practices. This study aims to investigate the prevention of wound infections through prophylactic measures in colorectal EMR. A comprehensive literature review was conducted to identify prophylactic measures that can prevent wound infections. A systematic literature search was conducted using both free words and search terms. The data extraction was performed after a comprehensive literature screening. The meta-analysis was performed using the metabin function of the meta library in R to evaluate the infection incidences in intervention and control groups. A total of 599 infection incidences were considered, with 267 in intervention and 332 in the control group. The results of meta analysis demonstrated significant reduction of wound incidences following the prophylactic measures (risk ratio [RR] = 0.77, 95% confidence interval [CI]: 0.6747; 0.9016, I2 = 78.5%, p < 0.01). The wound infection ratio analysis also exhibited an approximate 6.6% less infection rate in the intervention group, demonstrating significantly less wound infection following the implementation of prophylactic measures. This study highlights the crucial significance of prevention of wound infections by prophylactic measures in colorectal EMR.

Gastrointestinal functions after laparoscopic right colectomy with intracorporeal anastomosis: a pilot randomized clinical trial on effects of abdominal drain, prolonged antibiotic prophylaxis, and D3 lymphadenectomy with complete mesocolic excision

PURPOSE

Routine use of abdominal drain or prolonged antibiotic prophylaxis is no longer part of current clinical practice in colorectal surgery. Nevertheless, in patients undergoing laparoscopic right hemicolectomy with intracorporeal anastomosis (ICA), it may reduce perioperative abdominal contamination. Furthermore, in cancer patients, prolonged surgery with extensive dissection such as central vascular ligation and complete mesocolon excision with D3 lymphadenectomy (altogether radical right colectomy RRC) is called responsible for affecting postoperative ileus. The aim was to evaluate postoperative resumption of gastrointestinal functions in patients undergoing right hemicolectomy for cancer with ICA and standard D2 dissection or RRC, with or without abdominal drain and prolonged antibiotic prophylaxis.

METHODS

Monocentric factorial parallel arm randomized pilot trial including all consecutive patients undergoing laparoscopic right hemicolectomy and ICA for cancer, in 20 months. Patients were randomized on a 1:1:1 ratio to receive abdominal drain, prolonged antibiotic prophylaxis or neither (I level), and 1:1 to receive RRC or D2 colectomy (II level). Patients were not blinded. The primary aim was the resumption of gastrointestinal functions (time to first gas and stool, time to tolerated fluids and food). Secondary aims were length of stay and complications' rate.

CLINICALTRIALS

gov no. NCT04977882.

RESULTS

Fifty-seven patients were screened; according to sample size, 36 were randomized, 12 for each arm for postoperative management, and 18 for each arm according to surgical techniques. A difference in time to solid diet favored the group without drain or antibiotic independently from standard or RRC. Furthermore, when patients were divided with respect to surgical technique and into matched cohorts, no differences were seen for primary and secondary outcomes.

CONCLUSION

Abdominal drainage and prolonged antibiotic prophylaxis in patients undergoing right hemicolectomy for cancer with ICA seem to negatively affect the resumption of a solid diet after laparoscopic right hemicolectomy with ICA for cancer. RRC does not seem to influence gastrointestinal function recovery.

Tailored Pre-Operative Antibiotic Prophylaxis to Prevent Post-Operative Surgical Site Infections in General Surgery

The average American today undergoes three inpatient and two outpatient surgical procedures during one's life, each of which carries with it a risk of post-operative infection. It has long been known that post-operative infections cause significant morbidity in the immediate peri-operative period, but recent evidence suggests that they can have long-term consequences as well, increasing a patient's risk of infectious complications in unrelated surgeries performed months or even years later. While there are several theories on the origin of this association, including bacterial colonization of a post-operative infectious wound site, antimicrobial resistance from curative courses of antibiotics, subclinical immunosuppression, or the creation of an inflammatory "pathobiome" following an infectious insult, it is ultimately still unclear why patients who experience a single post-operative infection seem to be at a significantly higher risk of experiencing subsequent ones. Regardless, this association has significant implications for the routine use of pre-operative antibiotic prophylaxis. Indeed, while the prescription of antibiotics pre-operatively has dramatically reduced the rate of post-operative infections, the chosen prophylaxis regimens are typically standardized according to national guidelines, are facing increasing antimicrobial resistance patterns, and have been unable to reduce the risk of post-operative infection to acceptably low levels for certain surgeries. As a result, some clinicians have speculated that tailoring pre-operative antibiotic prophylaxis according to a patient's prior infectious and operative history could improve efficacy and further reduce the rate of post-operative infections. The purpose of this review is to describe the evidence for the link between multiple post-operative infections and explore the efficacy of individualized pre-operative prophylaxis.

Preoperative oral antibiotic administration in patients undergoing curative resection with stoma creation for colorectal cancer: effectiveness in preventing surgical site infection and the possibility of peristomal candidiasis induced by enterobacterial alteration

AIM

There are many reports that preoperative oral antibiotics (OAs) are effective in preventing surgical site infections (SSIs) in colorectal surgery. However, there is no consensus on the optimal dose of OAs. In this study, we investigated the efficacy of OAs in preventing SSIs and the possibility that OAs induce enterobacterial alteration in the intestinal tract.

METHOD

We performed a retrospective cross-sectional analysis of 389 patients who underwent R0 resection and stoma creation for colorectal cancer in our department between 2009 and 2020. We focused on the incidence of peristomal candidiasis (PSC) as an indicator of enterobacterial alteration and used kanamycin (KM) and metronidazole (MNZ) as the OAs. A low-dose group received 1000 mg/day of both KM and MNZ, and a high-dose group received 2000 mg/day of both KM and MNZ.

RESULTS

SSI occurred in 60 of the 389 cases (15.4%). Regardless of stoma type, SSI was significantly more common in the non-OA group, while PSC was significantly less common. When examined by OA dose, the incidence of SSI was not significantly different between the low-dose and high-dose groups. However, PSC was significantly more common in the high-dose group than in the non-OA and low-dose groups. Analysis of bacterial and fungal levels in stool samples showed that bacterial levels after OAs were significantly lower than before OAs, while fungal levels increased.

CONCLUSION

OAs significantly reduce SSI in colorectal cancer surgery. However, excess OAs were significantly associated with the occurrence of PSC without contributing to further reduction in SSI.

A Spanish Survey on the Perioperative Use of Antimicrobials in Small Animals

Appropriate use of perioperative antimicrobials can significantly reduce the risk of post-operative infections. However, inappropriate antimicrobial use can result in the creation of multidrug-resistant bacteria, increased costs, host flora disruption, side effects and increased risk of hospital-acquired infections. This survey evaluated the current perioperative use of antimicrobials in small animals by Spanish veterinarians using a web-based questionnaire. Responses were represented using descriptive statistics and a statistical analysis of the association between demographic data and perioperative antimicrobial use was performed. Pre-operative antimicrobials were administered in clean surgery by up to 68.3% of participants, 81.0% in clean-contaminated surgery and 71.3% in dirty surgery, while in the post-operative period, antimicrobials were administered by up to 86.3% of participants in clean surgery, 93.2% in clean-contaminated surgery and 87.5% in dirty surgery. Factors considered "very important" for antimicrobial selection were the degree of wound contamination, patient immunosuppression and use of prosthesis. The most frequently used antimicrobial was beta-lactamase-resistant (or potentiated) penicillin. Post-operative antimicrobial use was associated with participants without specific surgical postgraduate training. This study highlights an overuse of antimicrobials in perioperative procedures in small animal surgery in Spain. Therefore, evidence-based guidelines and further education regarding the correct use of antimicrobial prophylaxis are recommended.

The role of preoperative mechanical bowel preparation and oral antibiotics in prevention of anastomotic leakage following restorative resection for primary rectal cancer - a systematic review and meta-analysis

PURPOSE

Anastomotic leakage after colorectal cancer resection is a feared postoperative complication seen among up till 10-20% of patients, with a higher risk following rectal resection than colon resection. Recent studies suggest that the combined use of preoperative mechanical bowel preparation and oral antibiotics may have a preventive effect on anastomotic leakage. This systematic review aims to explore the association between preoperative mechanical bowel preparation combined with oral antibiotics and the risk of anastomotic leakage following restorative resection for primary rectal cancer.

METHODS

Three databases were systematically searched in February 2022. Studies reporting anastomotic leakage rate in patients, who received mechanical bowel preparation and oral antibiotics before elective restorative resection for primary rectal cancer, were included. A meta-analysis was conducted based on the risk ratios of anastomotic leakage.

RESULTS

Among 839 studies, 5 studies met the eligibility criteria. The median number of patients were 6111 (80-29,739). The combination of preoperative mechanical bowel preparation and oral antibiotics was associated with a decreased risk of anastomotic leakage (risk ratio = 0.52 (95% confidence interval 0.39-0.69), p-value < 0.001). Limitations included a low number of studies, small sample sizes and the studies being rather heterogenous.

CONCLUSION

This systematic review and meta-analysis found that the use of mechanical bowel preparation and oral antibiotics is associated with a decreased risk of anastomotic leakage among patients undergoing restorative resection for primary rectal cancer. The limitations of the review should be taken into consideration when interpreting the results.

Peritoneal contamination and associated post-operative infectious complications after natural orifice specimen extraction for laparoscopic colorectal surgery

BACKGROUND

Peritoneal contamination is a major concern during natural orifice specimen extraction after laparoscopic colorectal resection (LCR-NOSE), but few data are available. We explored the prevalence, risk factors, and association between clinical outcomes and infectious complications in patients with positive peritoneal drain fluid culture (PDFC) after LCR-NOSE.

METHOD

We retrospectively analyzed patient records in our prospectively maintained registry database who underwent LCR-NOSE between 2011and 2020. Peritoneal drain fluid was collected within 12 h post-operative and cultures for microorganisms were obtained. The relationships between PDFC, clinical variables, and infectious complications were examined by univariate and multivariable analysis.

RESULTS

Of 241 consecutive patients who underwent LCR-NOSE and drainage fluid culture, 59 (24.5%) had PDFC. Anterior resection (Odds ratio OR 2.40) was identified as an independent predictor for PDFC. Twenty-eight patients (11.6%) developed infectious complications. Multivariable analysis identified low anterior resection (OR 2.74), prolonged operative time (OR 3.20), and PDFC (OR 5.14) as independent risk factors. Pseudomonas aeruginosa was the most frequently found microorganism (OR 5.19) responsible for infectious complications.

CONCLUSIONS

Microorganisms are commonly present in the peritoneum after LCR-NOSE and play a critical role in the development of infectious complications and related morbidity. Specific caution is warranted in patients contaminated with specific types of microorganisms.

Oral antibiotics and a low-residue diet reduce the incidence of anastomotic leakage after left-sided colorectal surgery: a retrospective cohort study

PURPOSE

Anastomotic leakage is a potential complication after colorectal surgery. We investigated the effects of oral antibiotics and a low-residue diet on the incidence of anastomotic leakage after left-sided colorectal surgery.

METHODS

Outcomes were retrospectively compared between 64 patients who underwent mechanical bowel preparation alone (group A) and 183 patients who underwent mechanical bowel preparation with addition of oral kanamycin and metronidazole (group B) on the day before left-sided colorectal surgery. After surgery, patients in group A received a normal diet containing dietary fiber and those in group B received a low-residue diet. The primary outcome was the incidence of anastomotic leakage. Secondary outcomes were rates of other postoperative complications, length of postoperative hospital stay, and laboratory data.

RESULTS

Anastomotic leakage, surgical site infection, and diarrhea were less common in group B than in group A (4.9% vs 18.8%, 6.6% vs 23.4%, and 25.7% vs 43.8%, respectively). Postoperative C-reactive protein levels were significantly lower in group B. The median postoperative hospital stay was significantly shorter in group B than in group A (8 days vs 9 days, P = 0.010). Adaptive double least absolute shrinkage and selection operator regression revealed that use of preoperative oral antibiotics and a postoperative low-residue diet were associated with lower incidence of anastomotic leakage (odds ratio 0.163, 95% confidence interval 0.062-0.430; P < 0.001).

CONCLUSION

Oral antibiotics and a low-residue diet reduced the incidence of anastomotic leakage and shortened the postoperative hospital stay by 1 day.

Management of Perineal Wounds Following Pelvic Surgery

Despite advancements in understanding and technique, there remain significant challenges in the management of a complex perineal wound following pelvic surgery. Complications including wound sepsis, fistulation, persistent sinus, and herniation produce additional morbidity and health care costs. This article details the methods of optimizing patient and operative factors to mitigate this risk, alongside strategies to deal with sequelae of wound failure.

Evaluation of amoxicillin, metronidazole and gentamicin dosage regimens for use in antibiotic prophylaxis in colorectal surgery

OBJECTIVES

To evaluate amoxicillin, metronidazole and gentamicin dosage regimens for antibiotic prophylaxis in colorectal surgery.

METHODS

The study was conducted in 20 patients undergoing colorectal surgery. Patients received one or two doses of amoxicillin 1000 mg, metronidazole 500 mg and gentamicin 3 mg/kg ideal body weight, banded by height. Antibiotic concentrations were measured up to 7 h post dose. Population pharmacokinetic (PopPK) analysis with NONMEM followed by Monte Carlo simulation of different dosage regimens was used to estimate the PTA for potential organisms associated with surgical site infections (SSIs).

RESULTS

A median of 5 (range 3-6) concentrations were available per patient. CL and V of all antibiotics were related to weight; gentamicin CL was also related to CLCR. The administered doses maintained the desired PTA up to 8 h for the Streptococcus anginosus group but not for enterococci, Bacteroides fragilis group, MSSA, and Escherichia coli. An additional 500 mg amoxicillin every 4 h was sufficient to achieve the PTA for most relevant organisms but 2 hourly dosing was required for patients at risk of infective endocarditis. A metronidazole dose of 1000 mg was required for patients >85 kg. In patients with CLCR >50 mL/min, 5 mg/kg gentamicin (with an additional 2.5 mg/kg in prolonged surgery at 6 h) maintained PTA targets for >10 h.

CONCLUSIONS

PopPK analysis with Monte Carlo simulation identified prophylactic antibiotic regimens that would maintain the PTA for organisms associated with SSIs during short- and long-duration colorectal surgery.

Mechanical bowel preparation combined with oral antibiotics in colorectal cancer surgery: a nationwide population-based study

BACKGROUND

The guidelines for reducing surgical site infection in colorectal surgery recommend mechanical bowel preparation with oral antibiotics; however, this recommendation remains controversial. This study aimed to reveal the effect of oral antibiotics combined with mechanical bowel preparation in colorectal surgery.

METHODS

This study was a nationwide population-based retrospective study. Data between January 1, 2016, and December 31, 2018, from the Korean National Health Insurance Service database were analyzed. Patients who underwent elective colorectal cancer surgery were included.

RESULTS

A total of 20,740 patients were finally included, comprising 14,554 (70.2%) who underwent mechanical bowel preparation alone and 6186 (29.8%) who underwent mechanical bowel preparation with oral antibiotics. The mechanical bowel preparation alone group was older than the mechanical bowel preparation with oral antibiotics group (65.7 ± 11.9 vs. 64.7 ± 11.8 years, p < 0.001). Rectal cancer patients and patients who underwent open surgery were more likely to receive mechanical bowel preparation with oral antibiotics. Patients who underwent mechanical bowel preparation with oral antibiotics demonstrated lower surgical-site infection rate (2.9% vs. 9.4%, p < 0.001), shorter hospital stay (11.7 ± 5.5 vs. 13.5 ± 7.3 days, p < 0.001), and lower medical cost (US$7414 ± 2762 vs. US$7791 ± 3235, p < 0.001) than those who underwent mechanical bowel preparation alone. The 30-day readmission rates and mortality were not significantly different.

CONCLUSIONS

The use of mechanical bowel preparation with oral antibiotics reduces surgical site infection, hospital stay, and medical cost in colorectal cancer 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.

Disinfection with single or double usage of new antiseptic olanexidine gluconate in general surgery: a randomized study

PURPOSE

Olanexidine gluconate is a newly developed solution for skin disinfection that was recently approved in Japan. We aimed to compare single and double application of the solution in preventing surgical site infection (SSI) in patients undergoing general surgery.

METHODS

This randomized study was conducted at the Tottori University Hospital. Patients scheduled to undergo gastrointestinal or hernia surgery were randomly assigned to one of two groups using either one or two Olanedine applicators for skin disinfection. The primary endpoint was the difference in SSI incidence between the two groups. The secondary endpoint was all adverse events related to olanexidine gluconate.

RESULTS

A total of 393 patients qualified for the study protocol: 193 received a single application, and 200 received a double application of Olanedine. SSI occurred in 10 patients (2.5%) overall; nine were superficial incisional SSIs, and one patient had a deep incisional SSI. Of the 10 patients who developed SSI, six (3.1%) were in the group receiving a single application, and four (2.0%) were in the group receiving a double application; there was no statistically significant difference between the two groups (P = 0.537). Allergic reactions or skin disorders related to olanexidine gluconate were not observed.

CONCLUSION

There was no difference in the SSI incidence between the use of one or two Olanedine applicators for skin preparation in elective general surgery. Therefore, a single application of Olanedine is sufficient and is recommended for general surgery as a standard disinfection precaution.

TRIAL REGISTRATION NUMBER

UMIN000027319; 5/12/2017.

Bowel resection or repair at the time of cytoreductive surgery for ovarian malignancy is associated with increased complication rate: An ACS-NSQIP study

OBJECTIVES

Bowel procedures are commonly performed as part of ovarian cancer cytoreduction. The aim of this study was to assess the postoperative complication rates among women with an ovarian malignancy undergoing bowel resection/repair at the time of cytoreductive surgery compared with a control group (cytoreductive surgery without bowel resection or repair).

METHODS

Analysis of 4965 cytoreductive surgeries for suspected ovarian malignancies recorded in the American College of Surgeons' National Surgical Quality Improvement Program (NSQIP) datasets (2006-2017) was performed. One-way ANOVA, Kruskal-Wallis H and Chi-squared tests were used to evaluate and compare baseline characteristics between the groups and controls. Postoperative surgical site infection rates and other 30-day post-operative outcomes were assessed with multivariable logistic and linear regressions.

RESULTS

8.3% (413/4965) of cytoreductive procedures had an associated repair of enterotomy (small or large bowel), 10.9% (541/4947) had an associated colectomy with primary anastomosis, and 2.1% (104/4965) had an associated colectomy with colostomy. Surgical site infections (SSI, either superficial incisional, deep incisional, organ space or wound dehiscence) were significantly more prevalent in the bowel resection/repair group (16.9% vs 5.7%, p < 0.0001). The odds of surgical infections were 2.67 times higher in patients who underwent a bowel resection or repair after controlling for age, BMI, ASA status, pre-operative weight loss, hypoalbuminemia, NSQIP morbidity score, length and complexity of surgical procedure.

CONCLUSION

Patients undergoing bowel resection/repair at the time of cytoreductive surgery are at increased risk of surgical site infections, without increased risk of 30-day mortality. Interventions to mitigate the risk of infectious complications in these patients should be evaluated in a prospective fashion.

Prospective randomised controlled trial using the REthinking Clinical Trials (REaCT) platform and National Surgical Quality Improvement Program (NSQIP) to compare no preparation versus preoperative oral antibiotics alone for surgical site infection rates in elective colon surgery: a protocol

INTRODUCTION

Despite 40 randomised controlled trials (RCTs) investigating preoperative oral antibiotics (OA) and mechanical bowel preparation (MBP) to reduce surgical site infection (SSI) rate following colon surgery, there has never been an RCT published comparing OA alone versus no preparation. Of the four possible regimens (OA alone, MBP alone, OA plus MBP and no preparation), randomised evidence is conflicting for studied groups. Furthermore, guidelines vary, with recommendations for OA alone, OA plus MBP or no preparation. The National Surgical Quality Improvement Program (NSQIP) has automated data collection for surgical patients. Similarly, the 'REthinking Clinical Trials' (REaCT) platform increases RCT enrolment by simplifying pragmatic trial design. In this novel RCT protocol, we combine REaCT and NSQIP to compare OA alone versus no preparation for SSI rate reduction in elective colon surgery. To our knowledge, this is the first published RCT protocol that leverages NSQIP for data collection. In our feasibility study, 67 of 74 eligible patients (90%) were enrolled and 63 of 67 (94%) were adherent to protocol. The 'REaCT-NSQIP' trial design has great potential to efficiently generate level I evidence for other perioperative interventions.

METHODS AND ANALYSIS

SSI rates following elective colorectal surgery after preoperative OA or no preparation will be compared. We predict 45% relative rate reduction of SSI, improvement in length of stay, reduced costs and increased quality of life, with similar antibiotic-related complications. Consent, using the 'integrated consent model', and randomisation on a mobile device are completed by the surgeon in a single clinical encounter. Data collection for the primary end point is automatic through NSQIP. Analysis of cost per weighted case, cost utility and quality-adjusted life years will be done.

ETHICS AND DISSEMINATION

This study is approved by The Ontario Cancer Research Ethics Board. Results will be disseminated in surgical conferences and peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT03663504; Pre-results, recruitment phase.

Left lower transverse incision versus Pfannenstiel-Kerr incision for specimen extraction in laparoscopic sigmoidectomy: a match pair analysis

OBJECTIVE

The ideal location of specimen extraction in laparoscopic-assisted colorectal surgery is still debatable. The aim of this study was to compare the incidence of incisional hernias and surgical site infections in patients undergoing elective laparoscopic resection for recurrent sigmoid diverticulitis by performing specimen extraction through left lower transverse incision or Pfannenstiel-Kerr incision.

METHODS

A total of 269 patients operated between January 2014 and December 2017 were retrospectively screened for inclusion in the study. Patients with specimen extraction through left lower transverse incision (LLT) and patients with specimen extraction through Pfannenstiel-K incision (P-K) were matched in 1:1 proportion regarding age, sex, comorbidities, and previous abdominal surgery. The incidence of incisional hernias and surgical site infections were compared by using Fisher's exact test.

RESULTS

After matching 77 patients in the LLT group and 77 patients in the P-K group, they were found to be homogenous regarding the above mentioned descriptive characteristics. No patients in the P-K group developed an incisional hernia compared with 10 patients (13%) in the LLT group (p = 0.001). All these patients required hernia repair with mesh augmentation. The rate of surgical site infections was 1/77 in the P-K group and 0/77 in the LLT group (p = 1.0). In the P-K group, a wound protector was used in 86% of patients whereas in the LLT group, 39% of the wounds were protected during specimen extraction (p < 0.0001).

CONCLUSION

The Pfannenstiel-Kerr incision may be the preferred extraction site compared with the left lower transverse incision given the significant reduction of the risk of incisional hernias.

Efficacy of Preoperative Oral Antibiotic Prophylaxis for the Prevention of Surgical Site Infections in Patients With Crohn Disease: A Randomized Controlled Trial

OBJECTIVES

We investigated the efficacy of oral antimicrobial prophylaxis in patients undergoing surgery for Crohn disease.

BACKGROUND

Although oral antibiotic prophylaxis with mechanical bowel preparation has been recommended for colorectal surgery, the use of this approach remains somewhat controversial. Moreover, the efficacy of this approach for inflammatory bowel disease also remains unclear.

METHODS

This study was conducted as a randomized controlled trial at the Hyogo College of Medicine. The study protocols were registered with the University Hospital Medical Information Network Clinical Trials Registry (000013369). In this study, 335 patients with Crohn disease who were scheduled to undergo intestinal resection with an open approach were randomly assigned to either group A or group B. The patients in group A received both preoperative oral antibiotics and intravenous antimicrobial prophylaxis, and intravenous antimicrobial prophylaxis alone was given to the patients in group B. All patients underwent preoperative mechanical bowel preparation with sodium picosulfate hydrate. The primary endpoint of this study was the incidence of surgical site infection (SSI) according to an intention-to-treat analysis.

RESULTS

Although the incidences of overall and organ/space SSI were not significantly different, the incidence of incisional SSI was significantly lower in group A (12/163; 7.4%) than in group B (27/162; 16.6%) (P = 0.01). In the multivariate analysis, the absence of oral antibiotic prophylaxis was an independent risk factor for incisional SSI (odds ratio: 3.3; 95% confidence interval: 1.3-8.3; P = 0.01).

CONCLUSIONS

Combined oral and intravenous antimicrobial prophylaxis in patients with Crohn disease contributed to the prevention of SSI.

Evaluation of different antibiotic prophylaxis strategies for hepatectomy: A network meta-analysis

BACKGROUND

The application of antibiotic prophylaxis for hepatectomy remains uncertain. This research aims to evaluate different antibiotic prophylaxis strategies for hepatectomy based on network meta-analysis.

METHODS

Literature retrieval was conducted in globally recognized databases, namely, MEDLINE, EMBASE and Cochrane Central, to address relative randomized controlled trials (RCTs) investigating antibiotic prophylaxis strategies for hepatectomy. Relative parametric data, including surgical site infection (SSI), remote site infection (RSI) and total infection (TI), were quantitatively pooled and estimated based on the Bayesian theorem. The values of surface under the cumulative ranking curve (SUCRA) probabilities regarding each parameter were calculated and ranked. Node-splitting analysis was performed to test the inconsistency of the main results, and publication bias was assessed by examining the funnel plot symmetry. Additional pairwise meta-analyses were performed to validate the differences between respective strategies at the statistical level.

RESULTS

After a detailed review, a total of 5 RCTs containing 4 different strategies were included for the network meta-analysis. The results indicated that the application of no antibiotics possessed the highest possibility of having the best clinical effects on SSI (SUCRA, 0.56), RSI (SUCRA, 0.46) and TI (SUCRA, 0.61). Moreover, node-splitting analysis and funnel plot symmetries illustrated no inconsistencies in the current study. Additional pairwise meta-analyses determined that additional and long-duration applications had no clinical benefit.

CONCLUSION

Based on current evidence, we concluded that antibiotic prophylaxis did not reveal clinical benefit in hepatectomy. However, more relative trials and statistical evidence are still needed.

The Role of Bowel Preparation in Colorectal Surgery: Results of the 2012-2015 ACS-NSQIP Data

OBJECTIVE

To analyze potential benefits with regards to infectious complications with combined use of mechanical bowel preparation (MBP) and ABP in elective colorectal resections.

BACKGROUND

Despite recent literature suggesting that MBP does not reduce infection rate, it still is commonly used. The use of oral antibiotic bowel preparation (ABP) has been practiced for decades but its use is also controversial.

METHODS

Patients undergoing elective colorectal resection in the 2012 to 2015 American College of Surgeons National Surgical Quality Improvement Program cohorts were selected. Doubly robust propensity score-adjusted multivariable regression was conducted for infectious and other postoperative complications.

RESULTS

A total of 27,804 subjects were analyzed; 5471 (23.46%) received no preparation, 7617 (32.67%) received MBP only, 1374 (5.89%) received ABP only, and 8855 (37.98%) received both preparations. Compared to patients receiving no preparation, those receiving dual preparation had less surgical site infection (SSI) [odds ratio (OR) = 0.39, P < 0.001], organ space infection (OR = 0.56, P ≤ 0.001), wound dehiscence (OR = 0.43, P = 0.001), and anastomotic leak (OR = 0.53, P < 0.001). ABP alone compared to no prep resulted in significantly lower rates of surgical site infection (OR = 0.63, P = 0.001), organ space infection (OR = 0.59, P = 0.005), anastomotic leak (OR = 0.53, P = 0.002). MBP showed no significant benefit to infectious complications when used as monotherapy.

CONCLUSIONS

Combined MBP/ABP results in significantly lower rates of SSI, organ space infection, wound dehiscence, and anastomotic leak than no preparation and a lower rate of SSI than ABP alone. Combined bowel preparation significantly reduces the rates of infectious complications in colon and rectal procedures without increased risk of Clostridium difficile infection. For patients undergoing elective colon or rectal resection we recommend bowel preparation with both mechanical agents and oral antibiotics whenever feasible.

Population Pharmacokinetic Study of Cefazolin Used Prophylactically in Canine Surgery for Susceptibility Testing Breakpoint Determination

This study aimed to determine the population pharmacokinetic (Pop PK) parameters of cefazolin administered prophylactically at 25 mg/kg intravenously (IV) 30 min before surgery in a canine population of 78 dogs and assess whether covariates, such as sex, age, body weight (BW), breed, health status, creatinine level, and surgery time, have an influence on cefazolin disposition. The ultimate goal was to compute PK/PD cut off values and subsequently establish a specific clinical breakpoint (CBP) for the development of an antimicrobial susceptibility test (AST) of cefazolin in dogs according to the VetCAST approach. Two to 11 blood samples were collected from each dog from 5 to 480 min after cefazolin administration. A two-compartment model was selected, and parameterization was in terms of serum clearance (CL), intercompartmental CL(s) (Q) and volume(s) of distribution (V). The percentage of cefazolin binding to serum protein was 36.2 ± 5.3%. Population primary parameter estimates V1, V2, CL, and Q were (typical value ± SE) 0.116 ± 0.013 L/kg, 0.177 ± 0.011 L/kg, 0.0037 ± 0.0002 L/kg/min, and 0.0103 ± 0.0013 L/kg/min, respectively. Cefazolin presented rapid distribution and elimination half-lives (mean ± SE) 4.17 ± 0.77 min and 57.93 ± 3.11 min, respectively. The overall between-subject variability (BSV) for estimated primary parameters ranged from 36 to 42%, and none of the seven explored covariates were able to reduce this variability by an amplitude clinically relevant. By Monte Carlo simulation, the probability of a PK/PD target attainment (here to achieve a free serum concentration exceeding the MIC for 50% of the dosing interval in 90% of dogs) was computed with a dosage of 25 mg/kg administered IV every 6 h for 4 administrations in 24 h. The computed PK/PD cut off value was 2 mg/L. In conclusion, cefazolin administered prophylactically in surgical dogs at 25 mg/kg IV every 6 h was deemed effective against pathogens with a MIC value ≤ 2 mg/L and from a PK/PD perspective, can be recommended in a wide range of canine patient populations with no necessary dose adjustment for special dog subpopulations.

Mechanical and Oral Antibiotic Bowel Preparation in the Era of Minimally Invasive Surgery and Enhanced Recovery

INTRODUCTION

In the modern era of minimally invasive colorectal surgery and enhanced recovery pathways, the value of preoperative bowel preparation remains debated. In this review, we evaluate evidence regarding the use of mechanical bowel preparation (MBP) and oral antibiotic bowel preparation to make recommendations for their application in contemporary practice.

METHODS

We searched the PubMed database through December 2017 for relevant randomized controlled trials, Cochrane Reviews, American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database studies, and other reviews pertaining to MBP and oral antibiotic bowel preparation in elective colorectal surgery and conducted a narrative review.

RESULTS

The combination of MBP and oral antibiotics reduces the incidence of surgical site infection, anastomotic leak, and postoperative sepsis. MBP improves laparoscopic surgical viewing and facilitates intraoperative manipulation of the bowel in minimally invasive surgery.

CONCLUSION

Based on existing data, we recommend that preoperative care includes MBP and oral antibiotics in elective minimally invasive colorectal surgery.

Timing of surgical site infection and pulmonary complications after laparotomy

BACKGROUND

Surgical site infection (SSI) and other postoperative complications are associated with high costs, morbidity, secondary surgery, and mortality. Many studies have identified factors that may prevent SSI and pulmonary complications, but it is important to know when they in fact occur. The aim of this study was to investigate the diagnostic timing of surgical site infections and pulmonary complications after laparotomy.

MATERIAL AND METHODS

This is a secondary analysis of the PROXI trial which was a randomized clinical trial conducted in 1400 patients undergoing elective or emergent laparotomy. Patients were randomly allocated to either 80% or 30% perioperative inspiratory oxygen fraction.

RESULTS

SSI or pulmonary complications were diagnosed in 24.2% (95% CI: 22.0%-26.5%) of the patients at a median of 9 days [IQR: 5-15] after surgery. Most common was surgical site infection (19.6%); median time 10 days after surgery [IQR: 7-18]. The corresponding figures for anastomotic leakage was 5.7%, 8 days [IQR: 6-10]; pneumonia 3.5%, 5 days [IQR: 3-9]; and respiratory failure 2.3%, 3 days [IQR: 1-8]. The oxygen allocation was not significantly related to time of diagnosis for postoperative surgical site infections or pulmonary complications.

CONCLUSION

A high percentage of patients undergoing laparotomy develop a postoperative complication. This study adds new knowledge by identifying time intervals within which medical professionals should be aware of surgical site infections and pulmonary complications in order to initiate appropriate treatment of the patients.

Role of oral antibiotics for prophylaxis against surgical site infections after elective colorectal surgery

Over the past few decades, surgeons have made many attempts to reduce the incidence of surgical site infections (SSI) after elective colorectal surgery. Routine faecal diversion is no longer practiced in elective colonic surgery and mechanical bowel preparation is on the verge of being eliminated altogether. Intravenous antibiotics have become the standard of care as prophylaxis against SSI for elective colorectal operations. However, the role of oral antibiotics is still being debated. We review the available data evaluating the role of oral antibiotics as prophylaxis for SSI in colorectal surgery.

Surgical Site Infection in Colorectal Surgery: A Study in Antibiotic Duration

BACKGROUND

Despite distant historical studies that demonstrated the adequacy of preoperative antibiotic prophylaxis, current surgical practice continues to use antibiotics for postoperative coverage up to 24 hours.

OBJECTIVE

The aim of this study was to evaluate a change in antibiotic prophylaxis duration and its effect on surgical site infection in a high-volume modern colorectal practice.

DESIGN

A case-controlled series retrospectively reviewed outcomes through a prospective validated data base.

SETTING

The study was conducted at Mayo Clinic, Rochester, Minnesota.

PATIENTS

A total of 965 patients were evaluated. Our study analyzed patient outcomes related to surgical site infection comparing cohort 1 (2012-2013), which had the same antibiotic coverage preoperatively up to 24 hours postoperatively, and cohort 2 (2014-2015), which eliminated postoperative doses and relied solely on pre- and intraoperative dosing duration.

MAIN OUTCOME MEASURES

The primary outcomes of this study are superficial and deep surgical site infection.

RESULTS

There were no differences identified for superficial or deep surgical site infection rates between cohorts. Before the change in antibiotic dosing duration (2012-2013), 28 of 493 patients (5.7%) vs after the practice change (2014-2015), 25 of 472 patients (5.3%) were reported to have superficial or deep surgical site infection (p = 0.794).

LIMITATIONS

This study is limited by its retrospective design within a single institution.

CONCLUSION

These equivalent results present an opportunity for surgeons to reconsider optimal antibiotic duration and minimize unnecessary antibiotic dosing. See Video Abstract at http://links.lww.com/DCR/A322.

Prophylactic Antibiotics and Postoperative Complications of Radical Cystectomy: A Population Based Analysis in the United States

PURPOSE

Infectious, wound and soft tissue events contribute to the morbidity of radical cystectomy but the association between these events and antibiotic prophylaxis is not clear. We sought to describe the contemporary use of antibiotic prophylaxis in radical cystectomy and adherence to published guidelines, and identify regimens with the lowest rates of infectious events.

MATERIALS AND METHODS

We identified the intraoperative antibiotic prophylaxis regimen in a population based, retrospective cohort study of patients who underwent radical cystectomy across the United States between 2003 and 2013. Multivariable regression was done to evaluate 90-day infectious events and length of stay.

RESULTS

In a weighted cohort of 52,349 patients there were 579 unique antibiotic prophylaxis regimens. Cefazolin was the most commonly used antibiotic (16% of cases). The overall infectious event rate was 25%. Only 15% of patients received antibiotic prophylaxis based on guidelines. Of guideline based antibiotic prophylaxis ampicillin/sulbactam had the lowest odds of infectious events (OR 0.34, p <0.001). In 2.7% of patients a penicillin based regimen with a β-lactamase inhibitor was associated with a prominent reduction in the odds of infectious events (OR 0.45, p = 0.001) and decreased length of stay (-1.3 days, p = 0.016).

CONCLUSIONS

Antibiotic prophylaxis practices are highly heterogeneous in radical cystectomy. There is a lack of adherence to published guidelines. We observed decreased infectious event rates and shorter length of stay with regimens that included broad coverage of common skin, genitourinary and gastrointestinal flora. The ideal antibiotic regimen requires further study to optimize perioperative outcomes.

Risk factors for perineal wound infection after abdominoperineal resection of advanced lower rectal cancer

PURPOSE

Abdominoperineal resection (APR) of advanced lower rectal cancer carries a high incidence of perineal wound infection. The aim of this study was to retrospectively evaluate risk factors for perineal wound infection after APR.

METHODS

The study group comprised 154 patients who underwent APR for advanced lower rectal cancer in our department from January 1990 through December 2012. The following 15 variables were studied as potential risk factors for perineal wound infection: sex, age, body-mass index, American Society of Anesthesiologists score, diabetes mellitus, preoperative albumin level, preoperative hemoglobin level, neoadjuvant chemoradiotherapy(NCRT), surgical procedure (open surgery vs. laparoscopic surgery), operation time, bleeding volume, intraoperative transfusion, tumor diameter, invasion depth, and histopathological stage.

RESULTS

Among the 154 patients, 30 (19%) had perineal wound infection. Univariate analysis showed that a hemoglobin level of ≤11 g/dL (p = 0.001) and NCRT (p = 0.001) were significantly related to perineal wound infection. On multivariate analysis including the preoperative albumin level (≤3.5 g/dL) in addition to the above 2 variables, neoadjuvant chemoradiotherapy (NCRT) was the only independent risk factor for perineal wound infection. Perineal wound infection developed in 31% of patients who received NCRT, as compared with 10% of patients who did not receive NCRT. The relative risk of perineal infection in the former group was 4.092 as compared with the latter group (p = 0.0002).

CONCLUSIONS

NCRT is a risk factor for perineal wound infection after APR in patients with advanced lower rectal cancer.

Implementation of Enhanced Recovery (ERAS) in Colorectal Surgery Has a Positive Impact on Non-ERAS Liver Surgery Patients

BACKGROUND

Enhanced recovery after surgery (ERAS) reduces complications and hospital stay in colorectal surgery. Thereafter, ERAS principles were extended to liver surgery. Previous implementation of an ERAS program in colorectal surgery may influence patients undergoing liver surgery in a non-ERAS setting, on the same ward. This study aimed to test this hypothesis.

METHODS

Retrospective analysis based on prospective data of the adherence to the institutional ERAS-liver protocol (compliance) in three cohorts of consecutive patients undergoing elective liver surgery, between June 2010 and July 2014: before any ERAS implementation (pre-ERAS n = 50), after implementation of ERAS in colorectal (intermediate n = 50), and after implementation of ERAS in liver surgery (ERAS-liver n = 74). Outcomes were functional recovery, postoperative complications, hospital stay, and readmissions.

RESULTS

The three groups were comparable for demographics; laparoscopy was more frequent in ERAS-liver (p = 0.009). Compliance with the enhanced recovery protocol increased along the three periods (pre-ERAS, intermediate, and ERAS-liver), regardless of the perioperative phase (pre-, intra-, or postoperative). ERAS-liver group displayed the highest overall compliance rate with 73.8 %, compared to 39.9 and 57.4 % for pre-ERAS and intermediate groups (p = 0.072/0.056). Overall complications were unchanged (p = 0.185), whereas intermediate and ERAS-liver groups showed decreased major complications (p = 0.034). Consistently, hospital stay was reduced by 2 days (p = 0.005) without increased readmissions (p = 0.158).

CONCLUSIONS

The previous implementation of an ERAS protocol in colorectal surgery may induce a positive impact on patients undergoing non-ERAS-liver surgery on the same ward. These results suggest that ERAS is safely applicable in liver surgery and associated with benefits.

Randomized clinical trial of oral and intravenous versus intravenous antibiotic prophylaxis for laparoscopic colorectal resection

Background

The use of oral prophylactic antibiotics for the prevention of surgical-site infection (SSI) in patients undergoing laparoscopic surgery for colorectal cancer is controversial. The aim of this RCT was to evaluate whether intravenous perioperative antibiotics are inferior to combined preoperative oral and perioperative intravenous antibiotics in this setting.

Methods

Patients undergoing elective laparoscopic colorectal resection in a single cancer centre were assigned randomly to combined preoperative oral antibiotics (metronidazole and kanamycin) and perioperative intravenous antibiotics (cefmetazole) (oral/IV group) or to perioperative intravenous antibiotics (cefmetazole) alone (IV-only group). Patients were stratified for the analyses based on type of operation (colonic surgery, anterior resection or abdominoperineal resection), preoperative use of mechanical bowel preparation, preoperative chemoradiotherapy and the presence of diabetes mellitus. The primary endpoint was the overall rate of SSI. Secondary endpoints were the rates of incisional site infection, organ/space infection, anastomotic leakage, intra-abdominal abscess, adverse events and postoperative complications.

Results

Of 540 patients offered participation in the trial in 2013–2014, 515 agreed to take part and were randomized. Some 256 patients in the IV-only group and 255 in the oral/IV group completed the treatment per protocol. The overall rate of SSI was 7·8 per cent (20 of 256) in the IV-only group and 7·8 per cent (20 of 255) in the oral/IV group, confirming that perioperative administration of intravenous antibiotics alone was not inferior to the combined regimen (P = 0·017). There were no differences in rates of incisional site infection (5·5 versus 5·9 per cent respectively), organ/space infection (2·3 versus 2·0 per cent) or other secondary endpoints between the two groups.

Conclusion

Intravenous perioperative antimicrobial prophylaxis alone is not inferior to combined preoperative oral and intravenous perioperative prophylaxis with regard to SSI in patients with colorectal cancer undergoing elective laparoscopic resection. Registration number: UMIN000019339 (http://www.umin.ac.jp/ctr/).

Characteristics of Antibiotic Prophylaxis and Risk of Surgical Site Infections in Open Colectomies

BACKGROUND

Despite numerous trials assessing optimal antibiotic prophylaxis strategies for colorectal surgery, few studies have assessed real-world practice on a national scale with respect to risk of surgical site infections.

OBJECTIVE

Using a large national claims database we aimed to describe current use of prophylactic antibiotics (type and duration) and associations with surgical site infection after open colectomies.

DESIGN

This was a retrospective study using the Premier Perspective database.

SETTINGS

Included were patient hospitalizations nationwide from January 2006 to December 2013.

PATIENTS

A total of 90,725 patients who underwent an open colectomy in 445 different hospitals were included in the study.

MAIN OUTCOME MEASURES

Multilevel, multivariable logistic regressions measured associations between surgical site infection and type of antibiotic used and duration (day of surgery only, day of surgery and the day after, and >1 day after surgery).

RESULTS

Overall surgical site infection prevalence was 5.2% (n = 4750). Most patients (41.8%) received cefoxitin for prophylaxis; other choices were ertapenem (18.2%), cefotetan (10.3%), metronidazole with cefazolin (9.9%), and ampicillin with sulbactam (7.6%), whereas 12.2% received other antibiotics. Distribution of prophylaxis duration was 51.6%, 28.5%, and 19.9% for day of surgery only, day of surgery and the day after, and >1 day after surgery, respectively. Compared with cefoxitin, lower odds for surgical site infection were observed for ampicillin with sulbactam (OR = 0.71 (95% CI, 0.63-0.82)), ertapenem (OR = 0.65 (95% CI, 0.58-0.71)), metronidazole with cefazolin (OR = 0.56 (95% CI, 0.49-0.64)), and "other" (OR = 0.81 (95% CI, 0.73-0.90)); duration was not significantly associated with altered odds for surgical site infection. Sensitivity analyses supported the main findings.

LIMITATIONS

The study was limited by its lack of detailed clinical information in the billing data set used.

CONCLUSIONS

In this national study assessing real-world use of prophylactic antibiotics in open colectomies, the type of antibiotic used appeared to be associated with up to 44% decreased odds for surgical site infections. Although there are numerous trials on optimal prophylactic strategies, studies that particularly focus on factors that influence the choice of prophylactic antibiotic might provide insights into ways of reducing the burden of surgical site infections in colorectal surgeries.

The effects of preoperative oral antibiotic use on the development of surgical site infection after elective colorectal resections: A retrospective cohort analysis in consecutively operated 90 patients

PURPOSE

The influence of oral antibiotic use together with mechanical bowel preparation (MBP) on surgical site infection (SSI) rate, length of hospital stay and total hospital costs in patients undergoing elective colorectal surgery were evaluated in this study.

METHODS

Data from 90 consecutive patients undergoing elective colorectal resection between October 2006 and September 2009 was analyzed retrospectively. All patients received MBP. Patients in group A were given oral antibiotics (a total 480 mg of gentamycin, 4 gr of metronidazole in two divided doses and 2 mg of bisacodyl PO), whereas patients in group B received no oral antibiotics. Exclusion criteria were emergent operations, laparoscopic operations, preoperative chemoradiotherapy, intraoperative colonoscopy prior to the creation of an anastomosis or antibiotic use within the previous 10 days. SSI, length of hospital stays and total hospital charges were evaluated.

RESULTS

Patients in both study groups, group A (n = 45) and group B (n = 45), were similar in terms of age, BMI, diverting ileostomy creation, localization and stage of the disease. Patients receiving oral antibiotics demonstrated a lower rate of wound infections (36% vs. 71%, p < 0.001), shorter hospital stay (8.1 ± 2.4 days vs. 14.2 ± 10.9 days, respectively, p < 0.001) and similar rates for anastomotic leakage (2% vs. 11%, p = 0.20). The mean ± SD total hospital charges were significantly lower in Group A (2.699 ± 0.892$) than that in Group B (4.411 ± 4.995$, p = 0.029).

CONCLUSION

Preoperative oral antibiotic use with MBP may provide faster recovery with less SSI and hospital charges.

Local Application of Gentamicin in the Prophylaxis of Perineal Wound Infection After Abdominoperineal Resection: A Systematic Review

BACKGROUND

Use of topical antibiotics to improve perineal wound healing after abdominoperineal resection (APR) is controversial. The aim of this systematic review was to determine the impact of local application of gentamicin on perineal wound healing after APR.

METHODS

The electronic databases Pubmed, EMBASE, and Cochrane library were searched in January 2015. Perineal wound outcome was categorized as infectious complications, non-infectious complications, and primary perineal wound healing.

RESULTS

From a total of 582 articles, eight studies published between 1988 and 2012 were included: four randomized controlled trials (RCTs), three comparative cohort studies, and one cohort study without control group. Gentamicin was administered using sponges (n = 3), beads (n = 4), and by local injection (n = 1). There was substantial heterogeneity regarding underlying disease, definition of outcome parameters and timing of perineal wound evaluation among the included studies, which precluded meta-analysis with pooling. Regarding infectious complications, three of six evaluable studies demonstrated a positive effect of local application of gentamicin: one of four RCTs and both comparative cohort studies. Only two RCTs reported on non-infectious complications, showing no significant impact of gentamicin sponge. All three comparative cohort studies demonstrated a significantly higher percentage of primary perineal wound healing after local application of gentamicin beads, but only one out of three evaluable RCTs did show a positive effect of gentamicin sponges.

CONCLUSION

Currently available evidence does not support perineal gentamicin application after APR.

Antimicrobial Bowel Preparation for Elective Colon Surgery

BACKGROUND

Mechanical bowel preparation continues to be a controversial subject for the pre-operative management of patients undergoing elective colon resection.

METHODS

The English literature on bowel preparation was searched to identify pertinent publications.

RESULTS

The published literature over the past 80 y confirms that mechanical bowel preparation alone does not reduce surgical site infections. However, the use of appropriate oral antibiotics following mechanical bowel preparation with pre-operative systemic antibiotics reduces rates of surgical site infections and anastomotic leaks when compared with systemic antibiotics alone.

CONCLUSIONS

Mechanical bowel preparation with pre-operative oral antibiotics and pre-operative systemic antibiotics are the standard of care for elective colon surgery. Refinement in methods of bowel preparation needs additional clinical investigations to further enhance outcomes.

Orally Administered Trimethoprim-Sulfamethoxazole and Metronidazole as Infection Prophylaxis in Elective Colorectal Surgery

BACKGROUND

This randomized clinical trial evaluated orally administered trimethoprim-sulfamethoxazole and metronidazole (TSM) in elective colorectal surgery as prophylactic for post-operative surgical site infections (SSI).

METHODS

Patients undergoing elective colorectal resection were evaluated for inclusion. Randomized subjects received either orally administered TSM or intravenously administered cefuroxime and metronidazole (control group, CXM). The primary endpoint was the rate of SSI.

RESULTS

A total of 1073 subjects were randomized to either control (540) or TSM (533). 486 patients in the TSM group and 499 in the control group were followed-up with after 4 weeks. Thirty-seven (3.8%) patients were afflicted by SSI at discharge from hospital and 69 (7.0%) at follow-up four weeks after surgery. After four weeks, the rate of incisional SSI was 7.0% in the TSM group and 3.6% in the control group (p=0.022). For organ/space SSI and the other complications monitored in the study, no differences were observed between the groups.

CONCLUSION

Orally administered TSM as prophylaxis before elective colorectal surgery results in a low rate of organ/space SSI but an increased rate of incisional SSI compared with intravenously administered cefuroxime and metronidazole. Thus, when considering orally administered TSM, because of environmental concerns or for economic reasons, the slightly increased infection rate has to be kept in mind.

Complex systematic review - Perioperative antibiotics in conjunction with dental implant placement

OBJECTIVES

The aim of this study was to revisit the available scientific literature regarding perioperative antibiotics in conjunction with implant placement by combining the recommended methods for systematic reviews and complex systematic reviews.

MATERIAL AND METHODS

A search of Medline (OVID), The Cochrane Library (Wiley), EMBASE, PubMed and Health technology assessment (HTA) organizations was performed, in addition to a complementary hand-search. Selected systematic reviews and primary studies were assessed using GRADE and AMSTAR, respectively. A meta-analysis was performed.

RESULTS

The literature search identified 846 papers of which 10 primary studies and seven systematic reviews were included. Quality assessment of the systematic reviews revealed two studies of moderate risk of bias and five with high risk of bias. The two systematic reviews of moderate risk of bias stated divergent numbers needed to treat (NNT) to prevent one patient from implant failure. Four of the primary studies comparing antibiotic prophylaxis with placebo were estimated to be of low, or moderate, risk of bias and subjected to meta-analysis. The NNT was 50 (pooled RR 0.39, 95% CI 0.18, 0.84; P = 0.02). None of these four studies individually show a statistical significant benefit of antibiotic prophylaxis. Furthermore, narrative analysis of the studies eligible for meta-analysis reveals clinical heterogeneity regarding intervention and smoking.

CONCLUSION

Antibiotic prophylaxis in conjunction with implant placement reduced the risk for implant loss by 2%. However, the sub-analysis of the primary studies suggests that there is no benefit of antibiotic prophylaxis in uncomplicated implant surgery in healthy patient.

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.

Gentamicin-containing collagen implant reduces sternal wound complications after cardiac surgery: a retrospective analysis

INTRODUCTION

The majority of evidence for use of gentamicin-containing collagen implants (GCCI) demonstrates a positive impact on infection prophylaxis despite the equivocal results of a recently published large-scale study. The primary aim of the study was to evaluate the impact of prophylactic use of GCCI on SWI following cardiac surgery in a routine clinical setting. A secondary aim was to identify the risk factors for SWI among the patient cohort.

METHODS

A consecutive series of patients who had undergone sternotomy were analysed on a retrospective basis. Patient characteristics, risk factors and procedure-related variables were analysed for Group I (superficial sternal wound infection [SSWI]) and Group II (deep sternal wound infection [DSWI]) in relation to patients with complete wound healing.

RESULTS

A total of 1118 patients met the inclusion criteria. The bivariate analysis demonstrated that the SSWI rate was significantly reduced by 43% in the GCCI group vs. standard treatment. Multivariate analysis demonstrated that addition of GCCI to standard treatment reduced the DSWI rate by 59% vs. standard treatment alone. Arterial hypertension, permanent/persistent atrial fibrillation and chest revision were identified as new risk factors for SSWI and pulmonary hypertension and chest revision were identified as new risk factors for DSWI.

DISCUSSION

This study confirms the positive results with GCCI seen in the majority of published studies in cardiac surgery.

CONCLUSION

In routine clinical practice the addition of GCCI to standard infection prophylaxis reduces the risk of both SSWI and DSWI in high-risk patients undergoing cardiac surgery.

Antibiotic prophylaxis for third- and fourth-degree perineal tear during vaginal birth

BACKGROUND

One to eight per cent of women suffer third-degree perineal tear (anal sphincter injury) and fourth-degree perineal tear (rectal mucosa injury) during vaginal birth, and these tears are more common after forceps delivery (28%) and midline episiotomies. Third- and fourth-degree tears can become contaminated with bacteria from the rectum and this significantly increases in the chance of perineal wound infection. Prophylactic antibiotics might have a role in preventing this infection.

OBJECTIVES

To assess the effectiveness of antibiotic prophylaxis for reducing maternal morbidity and side effects in third- and fourth-degree perineal tear during vaginal birth.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 August 2014) and the reference lists of retrieved articles.

SELECTION CRITERIA

Randomised controlled trials comparing outcomes of prophylactic antibiotics versus placebo or no antibiotics in third- and fourth-degree perineal tear during vaginal birth.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the trial reports for inclusion and risk of bias, extracted data and checked them for accuracy.

MAIN RESULTS

We identified and included one trial (147 women from a pre-planned sample size of 310 women) that compared the effect of prophylactic antibiotic (single-dose, second-generation cephalosporin - cefotetan or cefoxitin, 1 g intravenously) on postpartum perineal wound complications in third- or fourth-degree perineal tears compared with placebo. Perineal wound complications (wound disruption and purulent discharge) at the two-week postpartum check up were 8.20% and 24.10% in the treatment and the control groups respectively (risk ratio (RR) 0.34, 95% confidence interval (CI) 0.12 to 0.96). However, the high failed-appointment rate may limit the generalisability of the results. The overall risk of bias was low except for incomplete outcome data. The quality of the evidence using GRADE was moderate for infection rate at two weeks' postpartum, and low for infection rate at six weeks' postpartum.

AUTHORS' CONCLUSIONS

Although the data suggest that prophylactic antibiotics help to prevent perineal wound complications following third- or fourth-degree perineal tear, loss to follow-up was very high. The results should be interpreted with caution as they are based on one small trial.