Prophylaxis Of Postoperative Infections Research Articles

Prophylaxis for postoperative infections often inappropriate despite clear recommendations

Prophylaxis for postoperative infections often inappropriate despite clear recommendations

A comparison of teicoplanin versus cephradine plus metronidazole in the prophylaxis of post-operative infection in vascular surgery

A total of 272 patients were enrolled into this prospective, unblinded, randomized comparison of single-dose teicoplanin vs three doses of cephradine plus metronidazole as prophylaxis for vascular surgery at St James's and Seacroft Hospitals, Leeds, UK. In all, 71·3% of patients (194/272) were enrolled at St James's University Hospital. Patients received either a single dose of teicoplanin, 6 mg/kg i.v., or cephradine, 1 g i.v. with metronidazole, 1 g rectally, at induction of anaesthesia followed by two further 1 g doses of cephradine and metronidazole 8 and 16 hours later. There were 136 patients in each treatment group. The most common operations were femoropopliteal grafts (96) and aortic aneurysm repairs (47). In the ‘Intention-to-treat’ analysis, primary wound infections were seen in 4·4% of patients (6/136) receiving teicoplanin and 5·9% of patients (8/136) receiving cephradine plus metronidazole (95% CI −6·7%, +3·8%). Other disturbances to wound healing occurred in 23 patients (11 in the teicoplanin and 12 in the cephradine plus metronidazole group). Secondary respiratory tract infections occurred in 17 patients (8 receiving teicoplanin and 9 receiving cephradine plus metronidazole). In the evaluable patients analysis, primary wound infections occurred in 3·5% of patients (4/114) receiving telcoplanin and 5·1% of patients (6/117) receiving cephradine plus metronidazole. Staphylococcus aureus and Proteus sp. were the most common pathogens in primary wound infections. Despite the absence of Gramnegative cover in the teicoplanin group, Gram-negative infections occurred more often in the cephradine plus metronidazole group. Surgery of the lower extremities carried the highest risk of post-operative infection. Rates of infection were significantly higher at Seacroft Hospital ( P= 0001), and significantly higher for cephradine plus metronidazole between the two hospitals ( P= 00008). Adverse events occurred in 40 patients receiving teicoplanin (294%) and 39 patients receiving cephradine plus metronidazole (28·7%). In 19 patients receiving teicoplanin (14%) and 15 receiving cephradine plus metronidazole (11%) these events were considered to be related to the study drugs. The most often reported events were infections, cardiac events and vascular phenomena (haematoma or emboli). Marked changes in haematological parameters and liver function tests were noted seven days after operation in patients in each treatment group, but these resolved quickly as the effects of the operation subsided. ESR remained elevated in both groups at the six-month follow-up assessment. It is concluded from this two-centre study that a single dose of teicoplanin shows similar efficacy to a three-dose regimen of cephradine plus metronidazole as prophylaxis for wound infection in vascular surgery. Both regimens were well tolerated, and there was an equal incidence of adverse events in the two regimens, which reflected the poor general health status of this elderly study population.

Prophylaxis of postoperative infections after colon cancer surgery, especially pseudmonas infections

Prophylaxis of postoperative infections after colon cancer surgery, especially pseudmonas infections

AN EVALUATION OF CHEMICAL PREPARATION FOR PROPHYLAXIS OF POSTOPERATIVE INFECTION IN COLORECTAL SURGERY

For the purpose of prophylaxis of postoperative infection of surgical wound, mechanical lavage and chemical (microbiological) lavage have been performed in patients with colorectal cancer, but the merits and demerits of the chemical preparation are still controversial. In this study the relation of postoperative infection and preoperative chemical preparation was retrospectively investgated in a total of 247 patients undergoing operation for carcinoma of the colon and rectum from 1991 through 1994. Oral antibiotics were preoperatively administered in 32.8% of all patients as chemical preparation, but it has been decreasingly administered. The infection rate in the chemical preparation group (12.3%) was slightly lower than the control group (16.9%), where mechanical preparation alone was conducted. But, there were significant differences in some clinical factors between both groups, such as the location of the tumor and kind of postoperative antibiotics. Then the relation between the group of postoperative infection and that without infection was studied. Wound infection was noted in 15.4% of all cases. A significantly longer operation time and more extended lymph node metastasis were observed in the postoperative infection group than the non-infection group. In a multi-valiable analysis, significant correlations were confirmed between wound infection and operation time, and the extent of lymph node metastasis.

Antibiotic prophylaxis in cerebrospinal fluid shunting: a prospective randomized trial in 129 patients

The efficacy of a single dose of cefotiam, a cephalosporin of the second generation, as prophylaxis for postoperative infection was analyzed in a prospective randomized study of 129 patients undergoing cerebrospinal fluid shunting. The main focus of interest was the rate of shunt infection requiring operative shunt removal. Data were evaluated in the total group and subgroups formed for normal and high risk patients, respectively. The overall rate of shunt infection was 7.5% in the cefotiam group and 12.9% in the control group. In the high risk subgroup infection rate was 14.3% with and 26.3% without cefotiam as opposed to 4.3% and 6.9%, respectively, in the normal risk subgroup. Although our results do not reach statistical significance, there is a noticeable difference of infection rate between those patients who receive the antibiotic and those who do not. Therefore, we favor single dose antibiotic prophylaxis in shunting procedures.

Formulation of human body motion

The use of antibacterial prophylaxis of postoperative infections is firmly established within clean-contaminated procedures. For clean procedures, prophylaxis has traditionally been reserved for operations involving foreign-body implantation. However, evidence that postoperative infections from non-prosthetic clean procedures are highly under-reported suggests that prophylaxis is also advisable, at least for some non-prosthetic procedures, such as breast surgery and herniorrhaphy. Although cefazolin is recommended by current guidelines, cefuroxime and cefamandole have a broader antimicrobial spectrum and should be preferred in clean prosthetic surgery prophylaxis. In this type of surgery glycopeptides are not recommended for routine use but may have a role for major prosthetic implantation in units with a high incidence of methicillin-resistant staphylococci. In the case of clean-contaminated procedures, cefazolin is recommended for routine use, although colorectal procedures require an agent with improved anti-anaerobic activity. In addition, experience has shown that obstetric/gynaecological, gastroduodenal and biliary tract surgery and appendectomy all require broad-spectrum antibacterial prophylaxis. Suitable agents include cefoxitin, cefotetan, ureidopenicillins and beta-lactam/beta-lactamase inhibitor combinations. The traditional surgical classification scheme needs to be replaced with a classification that additionally accounts for patient-specific risk factors. The limitations of the current scheme may partly explain why current guidelines are so seldom followed in clinical practice.

Antibiotic prophylaxis with teicoplanin in patients undergoing breast reconstruction with the transverse rectus abdominis myocutaneous flap

The authors report the results of a randomized clinical trial of antibiotic prophylaxis for post-operative infection following breast reconstruction with the transverse rectus abdominis myocutaneous (TRAM) flap. The aim was to evaluate the efficacy and tolerability of short-term parenteral prophylaxis with teicoplanin; the endpoint of the study was the reduction of wound contamination assessed by microbiologic culture of drain fluid. From October 1990 to March 1992, 38 patients were recruited: 20 patients were included in the antibiotic prophylaxis arm (teicoplanin i.v. 400 mg one hour before operation and in the following 12 h plus 200 mg i.v. at 24 h after operation) and 18 patients in the control group. Analysis of drain fluid showed a higher contamination (15/18=83%) in the control group (Staphylococcus epidermides, Streptococcus alfa-emoliticus, Enterobacter aerogenes, Peptostreptococcus magnus) as compared to the prophylaxis arm with teicoplanin (2/20=10%) (Staphylococcus coagulase-negative) (p 37.5° C as compared to one patient in the antibiotic prophylaxis group (p<0.0001); the post-operation stay was 13.3±4.3 and 9.0±1.6 in the control and antibiotic arm, respectively (p=0.0002). There were no antibiotic related side effect in this study. These results seem to confirm the value of parenteral short-term antibiotic prophylaxis of post-operative infection in this type of “clean” operative procedure.

Antimicrobial prophylaxis for surgery

Infection of the surgical wound or deep structures violated during surgery account for a major portion of postoperative morbidity. The medical consultant should have an understanding of the principles of antimicrobial prophylaxis for postoperative infection in order to manage this complication in the postoperative period. This article assesses the risks for infection, patient preparation for surgery, and antibiotic usage in frequently performed surgeries.

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Ampicillin (ABPC) is widely used prophylactically and in the treatment of infection. When ABPC is administered for prophylaxis of postoperative infection, the target tissue is subjected to a surgical damage. Since the damaged tissue by surgery is different from the normal tissue, the distribution of ABPC might be affected. Thus, the present investigation was undertaken to compare between the ABPC concentrations in damaged tissue and normal tissue, using incised skin asa damaged tissue and untreated skin asa normal tissue. Pharmacokinetic analysis was also performed to show numerical differences of ABPC concentrations between incised and untreated skins.Wistar strain SPF male rats, 12-weeks old, were used. Ampicillin·Na (ABPC·Na, 100mg/kg) was administered intravenously. Rat head skin was incised immediately after administration of ABPC·Na.Specimens of incised skin (surgical tissue) and untreated skin (normal tissue), were collected at O.25, O.50, O.75, 1.0, 1.5, 2.0, 3.0, 4.0, 6.0 and 8.0 hours after administration of ABPC·Na.Blood samples were also taken at the those times. ABPC concentrations in serum and the skins were assayed by a paper disk method. The pharmacokinetic analysis was performed to compare the ABPC concentrations in serum and incised and untreated skins.The results are as follows:1. The concentration of ABPC in serum at O.25 hours after administration was 132.20±14.33μg/ml. ABPC level was rapidly deceased during O.25 to 1.0 hours after administraion, and then gradually decreased to reach 0.09±0.07μg/ml at 8.0 hours.2. ABPC concentrations in all incised skins were continually higher than those of the corresponding untreated skins (t-test, p<0.10).3.K13/V and K31 of incised skin weresmaller than those of untreated skin, and AUC of incised skin was larger. Reasonable differences between incised and untreated skins could be also shown by the pharmacokinetic parameters.

Prophylaxis of postoperative infections

The antibiotic most appropriate for prophylaxis of postoperative infections depends on the nature of the operation. In aseptic (clean) operations, gram-positive postoperative infections are the primary concern, and cefazolin is recommended because of its excellent pharmacokinetics and good activity against gram-positive pathogens, including staphylococci. In those operations where violation of the digestive tract creates a contaminated field, a cefotaxime-generation cephalosporin is the agent of choice because of the excellent safety profiles and the capability of agents of this class to kill essentially all pathogenic gram-negative aerobes as well as a substantial portion of anaerobes. Selection of resistant bacteria has not been significant and is unlikely to become so with single-dose prophylaxis. Occasionally, if there is a high probability that the operative field may be heavily contaminated by anaerobes, metronidazole should be added. Dosing should be sufficient to cover the operative period. Only a single prophylactic dose is necessary, given at the time of induction of anesthesia. For particularly long operations, a second dose of those antibiotics with half-lives shorter than 60 min is required two hours after the first. Single-injection prophylaxis is effective, inexpensive, has no side effects and does not induce bacterial resistance.

Comparative Evaluation of the Efficacy and Safety of Ceftriaxone and Cefotaxime in the Prophylaxis of Postoperative Infection in Coronary Bypass Surgery

60 consecutive admissions (52 adult males, 8 adult females) to St George’s Hospital, Beirut, for coronary bypass surgery were admitted into this study to compare the efficacy and tolerability of a single intravenous dose of ceftriaxone 1g preoperatively with intravenous cefotaxime 1g 2 to 4 times daily for 1 to 3 days. One patient received cefotaxime for 13 days but subsequently died of septic shock.

Infectious complications after 809 biliary tract operations and results of a prospective randomized single-blind study comparing cefoxitin versus ampicillin plus an inhibitor of β-lactamases

A retrospective analysis of 809 biliary tract operations revealed postoperative wound infections in 13.4% of 278 patients with bactericholia, compared to 6.9% in patients without bactericholia. More than one third of isolated bacteria were resistant to ampicillin. This was the basis to conduct a prospective randomized single-blind study to compare the efficacy of ampicillin in combination with the beta-lactamase-inhibitor sulbactam with cefoxitin as perioperative prophylaxis in elective biliary surgery. Patients received a single dose of either 2 g ampicillin plus 1 g sulbactam or 2 g cefoxitin as intravenous short-infusion approximately 30 min prior to skin incision. Both groups were comparable concerning demographic and nosographic data. 80 of 83 patients were evaluable for efficacy; 39 received ampicillin/sulbactam and 41 cefoxitin. In the cefoxitin group two wound infections were observed. In the ampicillin/sulbactam group one patient developed postoperative temperatures of greater than 39.0 degrees C, which was regarded as a wound-related infectious complication. In addition, there occurred five urinary tract infections (cefoxitin: 3; ampicillin/sulbactam: 2) but no pulmonary infection. In conclusion, no significant difference between the two groups could be shown. Both regimens were well tolerated with no significant differences between treatment groups. The combination of ampicillin with the beta-lactamase-inhibitor sulbactam can be regarded as safe and as effective compared to cefoxitin for single-dose prophylaxis of post-operative infections after biliary tract operations.

Concentrations of ceftriaxone in serum and gynecological tissues.

31 patients received an intravenous 15-min injection of 2 g ceftriaxone at various times before abdominal or vaginal hysterectomy. Ceftriaxone concentrations in salpinges were significantly higher than in myometrium and endometrium. Tissue concentrations of 20 micrograms/g could be maintained for at least 5 h. Due to its high tissue concentrations maintained for the whole operative procedure, ceftriaxone does seem to be one of the antibiotics of choice for single-dose prophylaxis of postoperative infections in gynecology.

Tinidazole: a review of clinical experience in anaerobic infections.

Oral and intravenous tinidazole have been evaluated in an extensive series of clinical trials for the treatment of anaerobic infections and for the prevention of infection after gastrointestinal and gynaecological surgery. In almost all studies simple dosage regimens were used; these were based on the pharmacokinetic properties of tinidazole and its in-vitro activity against almost all clinically relevant anaerobic bacteria. These characteristics permit the use of single pre-operative dpse in surgical prophylaxis and once daily dosage in treatment. Results in the therapy of proven and strongly suspected anaerobic infections in approximately 264 patients are summarized. Patients received tinidazole alone or together with an agent active against aerobes, usually an aminoglycoside. Very good efficacy and an almost complete freedom from significant side effects were observed in patients treated for a wide variety of anaerobic infections. These included septicaemia. upper respiratory infections and sinusitis, anginose infectious mononucleosis, broncho-pulmonary infections, osteomyelitis. pelvic infections. septic abortion, peritonitis and post-operative intra-abdominal sepsis, cellulitis and post-operative wound infection. Chemotherapy was often associated with surgical drainage. Findings with intravenous or oral tinidazole for the prophylaxis of post-operative infections after gastrointestinal and gynaecological surgery are reviewed. Almost all studies involved comparison with another drug regimen, double-blind comparison with placebo or the inclusion of a control group. Although tinidazole alone was used in most trials, an agent active against aerobic bacteria was included in some. A significant reduction in the incidence of infection after colorectal surgery, general abdominal surgery and gynaecological surgery (especially vaginal hysterectomy) was found in all studies. In addition, the prophylactic use of tinidazole was shown in several studies to cause a marked reduction in post-operative antibiotic usage and a shorter hospital stay. Few side effects were reported.

Systemic Antibiotics and Gentamicin-Containing Bone Cement in the Prophylaxis of Postoperative Infections in Total Hip Arthroplasty

In a prospective controlled multicenter study, the prophylactic effect of gentamicin-containing bone cement on postoperative infections in total hip arthroplasties was compared with that of systemically given antibiotics; 812 arthroplasties were randomly assigned to an antibiotic and 821 to a gentamicin-cement group. When the patients had been followed for a period of one to two years, 13 deep infections were diagnosed in the antibiotic group and three in the gentamicin-cement group. The difference was statistically significant.

Cloxacillin in the Prophylaxis of Postoperative Infections of the Hip

In two widely separated hospitals a double-blind study of 171 hip operations was done, one group of patients receiving prophylactic cloxacillin, the other receiving a placebo. The first group had no postoperative infections, while the second had twelve (in eighty-eight patients). All of the patients had major surgery to the hip, and ten of the twelve infections were staphylococcal.

Combined carbenicillin and gentamicin for prophylaxis of post-operative infection following major abdominal surgery

Abstract Bacteriological studies with carbenicillin and gentamicin individually and with the combination of these antibiotics suggest their effect to be additive in action and often synergistic. Of sixty-five organisms tested in vitro, the majority Gram-negative, forty-seven were resistant to ampicillin, thirty-seven to carbenicillin, twenty-four to gentamicin and only six to carbenicillin plus gentamicin. Out of sixty-seven patients undergoing major abdominal surgery, thirty were randomly allocated to receive carbenicillin plus gentamicin post-operatively and of these one developed an infection. The other thirty-seven patients received either ampicillin or no antibiotic and nine developed infections. The combined antibiotic regime seems suitable for prophylaxis for patients undergoing major abdominal surgery with a high risk of infection.

Experiences in exodontia and oral surgery at an army post

We have attempted to review some methods of treatment used in our everyday practice of oral surgery at an Army installation. The techniques mentioned are as applicable to civilian practice as to military. Essentially, scrupulous cleanliness, careful technique and attention to postoperative care of the patient are the aims of the Army or civilian surgeon. Routine attention to detail is the best prophylaxis for postoperative infection and discomfort. We should appreciate the good fortune of working in so resistant a field as the mouth and take care not to abuse its remarkable tolerance. Because of the unique healing powers of the mouth, if we but practice slight refinements in oral surgery, results can be very gratifying.