Antibiotic prophylaxis in surgery

Influence of prophylactic antibiotic duration on postoperative pneumonia following pulmonary lobectomy for non-small cell lung cancer

Background

Although postoperative pneumonia after radical surgery for non-small cell lung cancer (NSCLC) carries a mortality risk, the duration of postoperative prophylactic antibiotics against pneumonia has not been elucidated. This study aimed to evaluate the influence of the duration of prophylactic antibiotics on postoperative pneumonia following radical surgery for NSCLC in patients who received antibiotics intraoperatively (short period) and in those who received antibiotics both intraoperatively and postoperatively (long period).

Methods

A total of 477 patients who underwent radical lobectomy for NSCLC were analyzed retrospectively. Propensity score analysis generated two matched pairs of 152 patients in both the short and long period groups.

Results

After propensity score matching, the incidence of postoperative pneumonia following pulmonary lobectomy was significantly less in the long period group than in the short period group (3.9% vs. 16.4%, P<0.001). On logistic regression analysis, short period of prophylactic antibiotic administration was the independent risk factor for postoperative pneumonia (odds ratio: 6.82, P<0.001).

Conclusions

Prophylactic antibiotic administration in both the intraoperative and postoperative periods reduced the incidence of pneumonia after pulmonary lobectomy for NSCLC.

Outcomes of abdominal wall reconstruction with acellular dermal matrix are not affected by wound contamination

BACKGROUND

The optimal type of mesh for complex abdominal wall reconstruction has not been elucidated. We hypothesized that AWRs using acellular dermal matrix (ADM) experience low rates of surgical site occurrence (SSO) and surgical site infection, despite increasing degrees of wound contamination.

STUDY DESIGN

We retrospectively reviewed prospectively collected data from consecutive abdominal wall reconstructions with ADM over a 9-year period. Outcomes of abdominal wall reconstructions were compared between patients with different CDC wound classifications. Univariate and multivariate logistic regression and Cox proportional hazard regression analyses identified potential associations and predictive/protective factors.

RESULTS

The 359 patients had a mean follow-up of 28.3 ± 19.0 months. Reconstruction of clean wounds (n = 171) required fewer reoperations than that of combined contaminated (n = 188) wounds (2.3% vs 11.2%; p = 0.001) and trended toward experiencing fewer SSOs (19.9% vs 28.7%, p = 0.052). There were no significant differences between clean and combined contaminated cases in 30-day SSI (8.8% vs 8.0%), hernia recurrence (9.9% vs 10.1%), and mesh removal (1.2% vs 1.1%) rates. Independent predictors of SSO included body mass index ≥30 kg/m(2) (odds ratio [OR] 3.6; p < 0.001), 1 or more comorbidities (OR 2.5; p = 0.008), and defect width ≥15 cm (OR 1.8; p = 0.02).

CONCLUSIONS

Complex abdominal wall reconstructions using ADM demonstrated similar rates of complications between the different CDC wound classifications. This is in contradistinction to published outcomes for abdominal wall reconstruction using synthetic mesh that show progressively higher complication rates with increasing degrees of contamination. These data support the use of ADM rather than synthetic mesh for complex abdominal wall reconstruction in the setting of wound contamination.

Surgical site infection prevention: how we do it

BACKGROUND

Efforts to prevent surgical site infection (SSI) employ methods that are valid scientifically, but each institution and each surgeon also incorporates methods believed to be useful although this has not been proved by clinical trials.

METHODS

The surgical literature was reviewed, as were practices at the University of Virginia that the authors believe are of value for the prevention of SSI.

RESULTS

Preventive antibiotics are established measures. A case can be made for increasing the dose in patients with a large body mass, and antibiotics probably should be re-administered during procedures lasting longer than 3 h. Chlorhexidine showers for the patient are not proven; however, they are inexpensive and of potential benefit. Hair removal is always done with clippers and in the operating room at the time of the procedure. No scientific case can be made specifically for using antiseptic at the surgical site before the incision. Keeping the blood glucose concentration and the core body temperature near normal probably are important, but how close to normal is unclear. Transfusion enhances SSI, but leukocyte reduction of transfused blood may be of benefit. Some evidence supports the value of antibacterial suture in preventing SSI.

CONCLUSIONS

Many proven and potentially valid methods are employed to prevent SSI. Coordinated and standardized protocols with good data collection can assist the multi-disciplinary efforts to reduce SSI within the unique practices of a given institution.

Antibacterial prophylaxis in dermatologic surgery: an evidence-based review

Clean, non-contaminated skin surgery is associated with low rates of surgical site infection (SSI), bacterial endocarditis, and joint prosthesis infection. Hence, antibacterial prophylaxis, which may be associated with adverse effects, the emergence of multidrug-resistant pathogens, and anaphylaxis, is generally not recommended in dermatologic surgery. Some body sites and surgical reconstructive procedures are associated with higher infection rates, and guidelines for SSI antibacterial prophylaxis have been proposed for these cases. Large prospective, controlled trials are needed to ascertain the role of oral SSI prophylaxis for these surgical sites and procedures especially in patients with diabetes mellitus who are intrinsically at greater risk of SSI. Topical antibacterial ointment and sterile paraffin appear to make no difference to healing or the incidence of SSIs in clean wounds. Although further research is needed, preliminary studies have shown that intraincisional antibacterials, which may be associated with fewer adverse effects and a lower risk of multidrug-resistant bacteria, could potentially be helpful for SSI prophylaxis. Trials using honey- and silver-impregnated dressings have found no advantage in the healing of chronic wounds. However, several case studies, which need corroboration in larger studies, suggest that these dressings may be helpful in preventing and treating SSIs. Bacterial endocarditis and joint prosthesis infection prophylaxis are not routinely recommended in cutaneous surgery. The updated 2007 American Heart Association guidelines now advocate bacterial endocarditis prophylaxis for high-risk cardiac patients having surgery involving the oral mucosa or infected skin. The latest American Dental Association/American Academy of Orthopaedic Surgery guidelines recommend considering antibacterial prophylaxis for oral procedures where bleeding is anticipated and for surgery involving acute orofacial skin infections if the patient has had a total joint replacement within 2 years or is in a high-risk group and has had a joint replacement at any time.

Staphylococcal surgical site infections

Staphylococcus aureus is the leading cause of surgical site infections (SSI) in the United States. In particular, SSI caused by methicillin-resistant Staphylococcus aureus (MRSA) has emerged as a devastating complication, leading to increased mortality rates, increased length of hospitalization, and increased costs. Proven strategies for prevention of SSI caused by S aureus include addressing modifiable risk factors and correct choice and timing of antimicrobial prophylaxis. Other strategies, including decolonization and the use of vancomycin, remain controversial.

Multicenter phase II study of antimicrobial prophylaxis in low-risk patients undergoing distal gastrectomy for gastric cancer

BACKGROUND

In Japan, antimicrobial prophylaxis (AMP) is typically administered for 3 to 4 days postoperatively for clean-contaminated operations such as distal gastrectomy. This far exceeds the recommended 2h or less laid out by the Centers for Disease Control (CDC) guidelines for the prevention of surgical-site infections (SSIs), after a clean-contaminated operation.

METHODS

Patients with gastric cancer, which was curable by distal gastrectomy with D2 lymphandectomy, were assigned to a multicenter phase II study. One gram of cefazolin within 3 min of the first surgical incision and intraoperative supplements of g of cefazolin every h were administered. AMP was not administered after skin closure unless postoperative infection occurred. The occurrence of SSIs was monitored until postoperative day 30 as the primary endpoint of this study.

RESULTS

In 56 patients, three SSIs (5.4%) and one remote site infection (1.8%) developed. No other postoperative infections were observed.

CONCLUSION

Our data indicate that the CDC guidelines regarding AMP may also be sufficient for patients undergoing clean-contaminated operations in Japan.

Update on the Use of Antibiotics in Cutaneous Surgery

BACKGROUND

Antibiotics are often prescribed in perioperative settings, including dermatologic surgery. Given the continued evolution in the breadth and complexity of cutaneous procedures performed and inevitable localized or distant infections that occasionally occur, it seems prudent to periodically evaluate findings and recommendations from the literature regarding the use of antibiotics in cutaneous surgery.

MATERIALS AND METHODS

Literature review from English-language sources from the past 30 years, especially focusing on sources from the past 5 to 10 years. Data were examined for a variety of cutaneous surgical procedures, routes of antibiotic administration, and consideration of both cutaneous and distant infections.

RESULTS

The literature suggests that, for most routine skin procedures, antibiotic use is probably not warranted for the prevention of surgical wound infection, endocarditis, and late prosthetic joint infections. During prolonged Mohs procedures, delayed repairs, grafts, takedowns of interpolation flaps, or any procedure that breaches a mucosal surface, the evidence is less clear, and decisions should be made on a case-by-case basis. Topical antibiotics are probably overused, although silver sulfadiazine may have an undeserved negative reputation among dermatologists. Systemic prophylactic antibiotics for laser resurfacing and liposuction appear not to be routinely necessary, although patients with known prior herpes infection likely should receive antiviral prophylaxis. The overall reported infection rates and infectious complications remain low in dermatologic surgery, and antibiotic therapy may be prescribed excessively or inappropriately as a result. CONCLUSION.: Antibiotics continue to be widely used, and through varying routes of administration, in the setting of dermatologic surgery. Prudent use of these agents is indicated in high-risk patients, certain anatomic locations, and the presence of overt infection. Additional studies may help clarify the most appropriate indications, and in which patient populations, in the future.

Is single-dose antibiotic prophylaxis sufficient for any surgical procedure?

The objective of perioperative prophylaxis is to prevent postoperative infections, which are the primary cause of morbidity and mortality in patients undergoing surgery today. One cannot predict with certainty when bacterial contamination at the operative site may occur during surgery. Furthermore, it has been suggested that the period of highest risk may actually be at the end, rather than at the beginning, of the operation. Therefore, the effect of antimicrobial prophylaxis ideally should cover the entire perioperative "period of risk". It should be remembered that the period of risk for postoperative infection may last substantially longer than the actual surgical procedure. The duration of the risk period also may vary based on a number of other factors, such as the age and general condition of the patient, presence of concomitant disease, amount of blood loss during surgery, and number of blood transfusions required. Antimicrobial prophylaxis that provides coverage throughout the entire perioperative period of risk will reduce not only the risk of wound infections but may also reduce the danger of other types of infectious complications. Numerous clinical studies have clearly shown that appropriately-timed "single shot" prophylaxis is as effective as multiple-dose prophylaxis. This paper considers the evolution of this therapeutic intervention and reviews the opportunities available for antibiotic prophylaxis in surgery, with particular attention to the long-acting cephalosporin, ceftriaxone.

Antimicrobial prophylaxis in surgery: the role of pharmacokinetics

Even though surgical infection rates have decreased dramatically during the past 25 years, morbidity and mortality of infection in surgical treatment remains substantial. From a pharmacological point of view, the key factor of the efficacy of antibiotic prophylaxis is to attain bactericidal levels of antibiotic in serum and tissues (target site) during the whole intraoperative and early postoperative period. The success of antibiotic prophylaxis is assured only when the chosen antibiotic with a targeted spectrum and high antimicrobial efficacy is available at the critical moment, at the correct site and in sufficiently high concentration to prevent bacterial contamination of the surgical area. It would be desirable for reasons of convenience and cost if a single preoperative administration were sufficient. The pharmacokinetics and the half-life of antibiotics in the serum are directly related to the duration of activity of antibiotic in the tissue. Antibiotics with longer half-lives maintain levels in the tissues for longer periods than do antibiotics with shorter half-lives and they cover with a single dose the time required for prophylaxis even for longer operations. Finally, the application of the pharmacokinetic properties of antibiotics to surgical prophylaxis can provide the surgeon with certainty that adequate coverage and protection with antibiotics are achieved before and throughout the operation.

Guideline for Prevention of Surgical Site Infection, 1999. Centers for Disease Control and Prevention (CDC) Hospital Infection Control Practices Advisory Committee

EXECUTIVE SUMMARY The "Guideline for Prevention of Surgical Site Infection, 1999" presents the Centers for Disease Control and Prevention (CDC)'s recommendations for the prevention of surgical site infections (SSIs), formerly called surgical wound infections. This two-part guideline updates and replaces previous guidelines.1,2 Part I, "Surgical Site Infection: An Overview," describes the epidemiology, definitions, microbiology, pathogenesis, and surveillance of SSIs. Included is a detailed discussion of the pre-, intra-, and postoperative issues relevant to SSI genesis. Part II, "Recommendations for Prevention of Surgical Site Infection," represents the consensus of the Hospital Infection Control Practices Advisory Committee (HICPAC) regarding strategies for the prevention of SSIs.3 Whenever possible, the recommendations in Part II are based on data from well-designed scientific studies. However, there are a limited number of studies that clearly validate risk factors and prevention measures for SSI. By necessity, available studies have often been conducted in narrowly defined patient populations or for specific kinds of operations, making generalization of their findings to all specialties and types of operations potentially problematic. This is especially true regarding the implementation of SSI prevention measures. Finally, some of the infection control practices routinely used by surgical teams cannot be rigorously studied for ethical or logistical reasons (e.g., wearing vs not wearing gloves). Thus, some of the recommendations in Part II are based on a strong theoretical rationale and suggestive evidence in the absence of confirmatory scientific knowledge.It has been estimated that approximately 75% of all operations in the United States will be performed in "ambulatory," "same-day," or "outpatient" operating rooms by the turn of the century.4 In recommending various SSI prevention methods, this document makes no distinction between surgical care delivered in such settings and that provided in conventional inpatient operating rooms. This document is primarily intended for use by surgeons, operating room nurses, postoperative inpatient and clinic nurses, infection control professionals, anesthesiologists, healthcare epidemiologists, and other personnel directly responsible for the prevention of nosocomial infections. This document does not: Specifically address issues unique to burns, trauma, transplant procedures, or transmission of bloodborne pathogens from healthcare worker to patient, nor does it specifically address details of SSI prevention in pediatric surgical practice. It has been recently shown in a multicenter study of pediatric surgical patients that characteristics related to the operations are more important than those related to the physiologic status of the patients.5 In general, all SSI prevention measures effective in adult surgical care are indicated in pediatric surgical care. Specifically address procedures performed outside of the operating room (e.g., endoscopic procedures), nor does it provide guidance for infection prevention for invasive procedures such as cardiac catheterization or interventional radiology. Nonetheless, it is likely that many SSI prevention strategies also could be applied or adapted to reduce infectious complications associated with these procedures. Specifically recommend SSI prevention methods unique to minimally invasive operations (i.e., laparoscopic surgery). Available SSI surveillance data indicate that laparoscopic operations generally have a lower or comparable SSI risk when contrasted to open operations.6-11 SSI prevention measures applicable in open operations (e.g., open cholecystectomy) are indicated for their laparoscopic counterparts (e.g., laparoscopic cholecystectomy). Recommend specific antiseptic agents for patient preoperative skin preparations or for healthcare worker hand/forearm antisepsis. Hospitals should choose from products recommended for these activitie

Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices Advisory Committee

The “Guideline for Prevention of Surgical Site Infection, 1999” presents the Centers for Disease Control and Prevention (CDC)'s recommendations for the prevention of surgical site infections (SSIs), formerly called surgical wound infections. This two-part guideline updates and replaces previous guidelines.

Part I, “Surgical Site Infection: An Overview,” describes the epidemiology, definitions, microbiology, pathogenesis, and surveillance of SSIs. Included is a detailed discussion of the pre-, intra-, and postoperative issues relevant to SSI genesis.

Prophylactic use of antimicrobial agents in adult patients

The prophylactic use of antimicrobial agents is recommended for prevention of numerous infections, including tuberculosis, endocarditis, rheumatic fever, recurrent cellulitis and lymphangitis in patients with lymphedema, meningococcal meningitis, and bite wounds. In addition, the prophylactic use of antimicrobial agents has proved effective in certain surgical procedures such as various abdominal operations, hysterectomy, and major operations that involve the head and neck. Except for oral bowel preparations, antimicrobial prophylaxis should be limited, in general, to the operative period. Prolonged perioperative prophylaxis has not been shown to enhance effectiveness and may result in increased toxicity, resistant superinfections, and inflated costs. The investigation of antimicrobial prophylaxis necessitates adequate evaluation of the potential advantages and disadvantages in a prospective, double-blind fashion.

Surgical wound infection

Wound infections remain a major source of postoperative morbidity, accounting for about a quarter of the total number of nosocomial infections. Today, many of these infections are first recognized in the outpatient clinic or in the patient's home due to the large number of operations done in the outpatient setting. This leads to errors in establishing the true incidence of their occurrence but undoubtedly decreases the overall real cost and length of hospital stay. The pathogens implicated in the development of wound infections remain largely the human microorganisms from the exogenous environment and the endogenous organ microflora. Many perioperative factors have been identified that increase the incidence of the development of postoperative wound infection. Avoidance of these factors as well as the appropriate use of perioperative antibiotic prophylaxis has decreased the incidence of wound infection. During the last decade many studies have reported on the individual risk factors that favor the development of postoperative infectious complications in various surgical procedures. It is hoped that this knowledge may allow for prospective alterations in the preventative and therapeutic modalities in the high-risk patient in the studies designed in the 1990s. The use of effective infection surveillance both in the hospital and in the outpatient setting is mandatory in order to collect meaningful data. The use of computer technology will greatly facilitate the proper surveillance, analysis, and control of infections in the surgical patient.