Drugs

, Volume 57, Issue 2, pp 175–185 | Cite as

Preventing Postoperative Infections

Current Treatment Recommendations
Disease Management

Abstract

Surgical site infections (SSI) remain a major source of postoperative morbidity. The preventive effect of antimicrobial drugs on postoperative infections is without debate. The common basis of accepted indications for prophylaxis is available evidence of effect. Valid reasons to administer antimicrobial prophylaxis include a significant reduction of SSI or reducing the risk of SSI in procedures where the consequences of infection are serious or even disastrous. The antimicrobial drug must be effective against pathogens associated with infection after a given procedure. The first generation cephalosporin, cefazolin, has been considered one of the prophylactic drugs of choice in many authoritative guidelines.

The optimal timing of intravenous antimicrobial prophylaxis in surgery is considered to be about 30 minutes before incision, i.e. at induction of anaesthesia. A single dose of antimicrobial drugs before the operation is sufficient prophylaxis for most surgical procedures. The development of bacterial resistance is associated with antimicrobial use, and therefore prophylactic antibiotics should be used as little as possible; in addition, the spectrum of activity of drugs used should be as narrow as possible. Although the principles of antimicrobial prophylaxis in surgery have been clearly established, many reports continue to describe inappropriate drug use. Overconsumption in terms of invalid indications or use of drugs with too broad a spectrum of activity should be eliminated by adhering to accepted guidelines.

Practical suggestions are given to optimise timing, such as simple reminders on the daily operating programme, the display of prophylaxis regimens according to type of surgery in table format in the operating room and having the anaesthetist note the complete drug regimen on the patient’s anaesthesia record. Such measures will help to optimise antibiotic prophylaxis and restrict if to the operating room where it belongs.

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References

  1. 1.
    Dellinger EP, Gross PA, Barrett TL, et al. Quality Standard for antimicrobial prophylaxis in surgical procedures. Clin Infect Dis 1994; 18: 422–7PubMedCrossRefGoogle Scholar
  2. 2.
    Holzheimer RG, Haupt W, Thiede A, et al. The challenge of postoperative infections: does the surgeon make a difference? Infect Control Hosp Epidemiol 1997; 18: 449–56PubMedCrossRefGoogle Scholar
  3. 3.
    Horan TC, Gaynes RP, Martone WJ, et al. CDC definitions of nosocomial surgical site infections, 1992: a modification of CDC definitions of surgical wound infections. Am J Infect Control 1992; 20: 271–4PubMedCrossRefGoogle Scholar
  4. 4.
    Cruse PJE, Foord R. The epidemiology of wound infection: a 10-year prospective study of 62,939 wounds. Surg Clin North Am 1980; 60: 27–40PubMedGoogle Scholar
  5. 5.
    Olson MM, Lee JT. Continuous, 10-year wound infection surveillance results, advantages, and unanswered questions. Arch Surg 1990; 125: 794–803PubMedCrossRefGoogle Scholar
  6. 6.
    Culver DH, Horan TC, Gaynes RP, et al. Surgical wound infection rates by wound class, operative procedure and patient risk index. Am J Med 1991; 91: 152S–63SPubMedCrossRefGoogle Scholar
  7. 7.
    Sherertz RJ, Garibaldi RA, Marosok RD, et al. Consensus paper on the surveillance of surgical wound infections. Am J Infect Control 1992; 20: 263–70CrossRefGoogle Scholar
  8. 8.
    ASHP Commission on Therapeutics. ASHP therapeutic guidelines on antimicrobial prophylaxis in surgery. Clin Pharm 1992; 11: 483–513Google Scholar
  9. 9.
    Committee on Antimicrobial Agents, Canadian Infectious Disease Society, Wadell TK, et al. Antimicrobial prophylaxis in surgery. Can Med Assoc J 1994; 151: 925–31Google Scholar
  10. 10.
    Martin C, French Study Group on Antimicrobial Prophylaxis in Surgery, French Society of Anesthesia and Intensive Care. Antimicrobial prophylaxis in surgery: general concepts and clinical guidelines. Infect Control Hosp Epidemiol 1994; 15: 463–71PubMedCrossRefGoogle Scholar
  11. 11.
    Page CP, Bohnen JMA, Fletcher JR, et al. Antimicrobial prophylaxis for surgical wounds: guidelines for clinical care. Arch Surg 1993; 128: 79–88PubMedCrossRefGoogle Scholar
  12. 12.
    Baum ML, Anish DS, Chalmers TC, et al. A survey of clinical trials of antibiotic prophylaxis in colon surgery: evidence against further use of no-treatment controls. N Engl J Med 1981; 305: 795–9PubMedCrossRefGoogle Scholar
  13. 13.
    Gorbach SL. Antimicrobial prophylaxis for appendectomy and colorectal surgery. Rev Infect Dis 1991; 13 Suppl. 10: S815–20PubMedCrossRefGoogle Scholar
  14. 14.
    Hemsell DL, Johnson ER, Hemsell PG, et al. Cefazolin is inferior to cefotetan as single-dose prophylaxis for women undergoing elective total abdominal hysterectomy. Clin Infect Dis 1995; 20: 677–84PubMedCrossRefGoogle Scholar
  15. 15.
    Hemsell DL. Prophylactic antibiotics in gynecologic and obstetric surgery. Rev Infect Dis 1991; 13 Suppl. 10: S821–41PubMedCrossRefGoogle Scholar
  16. 16.
    Shapiro M. Prophylaxis in otolaryngologic surgery and neurosurgery: a critical review. Rev Infect Dis 1991; 13 Suppl. 10: S858–68PubMedCrossRefGoogle Scholar
  17. 17.
    Van Ek B, Dijkmans BAC, Van Dulken H, et al. Antibiotic prophylaxis in craniotomy: a prospective double-blind placebo-controlled study. Scand J Infect Dis 1988; 20: 633–9PubMedCrossRefGoogle Scholar
  18. 18.
    HillC, Margas F, Flamant R, et al. Prophylactic cefazolin versus placebo in total hip replacement. Lancet 1981; I: 795–7CrossRefGoogle Scholar
  19. 19.
    Boxma H, Broekhuizen T, Patka P, et al. Randomised controlled trial of single-dose antibiotic prophylaxis in surgical treatment of closed fractures: the Dutch trauma trial. Lancet 1996; 347: 1133–7PubMedCrossRefGoogle Scholar
  20. 20.
    Chetlin SH, Elliot DW. Preoperative antibiotics in biliary surgery. Arch Surg 1973; 107: 319–23PubMedCrossRefGoogle Scholar
  21. 21.
    Kluytmans JAJW, Mouton JW, VandenBergh MFQ, et al. Reduction of surgical-site infections in cardiothoracic surgery by elimination of nasal carriage of Staphylococcus aureus. Infect Control Hosp Epidemiol 1996; 17: 780–5PubMedCrossRefGoogle Scholar
  22. 22.
    Kernodle DS, Kaiser AB. Postoperative infections and antimicrobial prophylaxis. In: Mandell GL, Bennett JE, Dolin R, editors. Mandell, Douglas and Bennett’s principles and practice of infectious diseases. New York: Churchill Livingstone, 1995: 2742–56Google Scholar
  23. 23.
    Anonymous. Antimicrobial prophylaxis in surgery. Med Lett Drug Ther 1997 Oct; 37 (1012): 97–101Google Scholar
  24. 24.
    Platt R, Zaleznik DF, Hopkins CC, et al. Perioperative antibiotic prophylaxis for herniorrhaphy and breast surgery. N Engl J Med 1990; 322: 153–60PubMedCrossRefGoogle Scholar
  25. 25.
    Nichols RL. Surgical infections: prevention and treatment: 1965 to 1995. Am J Surg 1996; 172: 68–74PubMedCrossRefGoogle Scholar
  26. 26.
    Infection in Neurosurgery Working Party of the British Society for Antimicrobial Chemotherapy. Antimicrobial prophylaxis in neurosurgery and after head injury. Lancet 1994; 344: 1547–51CrossRefGoogle Scholar
  27. 27.
    Wilson APR. Antibiotic prophylaxis and infection control measures in minimally invasive surgery. J Antimicrob Chemother 1995; 36: 1–5PubMedCrossRefGoogle Scholar
  28. 28.
    Illig KA, Schmidt E, Cavenaugh J, et al. Are prophylactic antibiotics required for elective laparoscopic cholecystectomy? J Am Coll Surg 1997; 184: 353–6PubMedGoogle Scholar
  29. 29.
    Wieck JA, Jackson JK, O’Brien TJ, et al. Efficacy of prophylactic antibiotics in arthroscopic surgery. Orthopedics 1997; 20: 133–4PubMedGoogle Scholar
  30. 30.
    Cove JH, Eady EA, Cunliffe WJ. Skin carriage of antibiotic-resistant coagulase-negative staphylococci in untreated subjects. J Antimicrob Chemoth 1990; 25: 459–69CrossRefGoogle Scholar
  31. 31.
    Periti P, Mini E, Mosconi G. Antimicrobial prophylaxis in orthopaedic surgery: the role of teicoplanin. J Antimicrob Chemother 1998; 41: 329–40PubMedCrossRefGoogle Scholar
  32. 32.
    Sanderson PJ. Prophylaxis in orthopaedic implant surgery: should we use a glycopeptide? J Antimicrob Chemother 1998; 41: 322–25PubMedCrossRefGoogle Scholar
  33. 33.
    Weber RS, Raad I, Frankenthaler R, et al. Ampicillin-sulbactam vs clindamycin in head and neck oncologic surgery. Arch Otolaryngol Head Neck Surg 1992; 118: 1159–63PubMedCrossRefGoogle Scholar
  34. 34.
    Gross PA. The potential for clinical guidelines to impact appropriate antimicrobial agent use. Infect Dis Clin North Am 1997; 11: 803–12PubMedCrossRefGoogle Scholar
  35. 35.
    Wilson APR, Shrimpton S, Jaderberg M. A meta-analysis of the use of amoxicillin-clavulanic acid in surgical prophylaxis. J Hosp Infect 1992; 22 Suppl. A: 9–21PubMedCrossRefGoogle Scholar
  36. 36.
    Gyssens IC, Geerligs IEJ, Dony JMJ, et al. Optimising antimicrobial drug use in surgery: an intervention study in a Dutch university hospital. J Antimicrob Chemother 1996; 38:1001–12PubMedCrossRefGoogle Scholar
  37. 37.
    Rubin Grandis J, Vickers RM, Rihs JD, et al. Efficacy of topical amoxicillin plus clavulanate/ticarcillin plus clavulanate and clindamycin in contaminated head and neck surgery: effect of antibiotic spectra and duration of therapy. J Infect Dis 1994; 170: 729–32CrossRefGoogle Scholar
  38. 38.
    Espehaug B, Engesaeter LB, Vollset SE, et al. Antibiotic prophylaxis in total hip arthroplasty. J Bone Joint Surg 1997; 79-B: 590–5CrossRefGoogle Scholar
  39. 39.
    Burke JF. The effective period of preventive antibiotic action in experimental incisions and dermal lesions. Surgery 1961; 50: 161–8PubMedGoogle Scholar
  40. 40.
    Stone HH, Hooper CA, Kolb LD, et al. Antibiotic prophylaxis in gastric, biliary and colonic surgery. Ann Surg 1976; 184: 443–50PubMedCrossRefGoogle Scholar
  41. 41.
    Galandiuk S, Polk HC, Jagelman DG, et al. Re-emphasis of priorities in surgical antibiotic prophylaxis. Surg Gynecol Obstet 1989; 169: 219–22PubMedGoogle Scholar
  42. 42.
    Classen DC, Evans RS, Pestotnik SL, et al. The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection. N Engl J Med 1992; 326: 281–6PubMedCrossRefGoogle Scholar
  43. 43.
    DiPiro JT, Cheung RPF, Bowden TAJ, et al. Single dose systemic antibiotic prophylaxis of surgical wound infections. Am J Surg 1986; 152: 552–9PubMedCrossRefGoogle Scholar
  44. 44.
    Hemsell DL, Heard MC, Nobles BJ, et al. Single-dose prophylaxis for vaginal and abdominal hysterectomy. Am J Obstet Gynecol 1987; 157: 498–501PubMedGoogle Scholar
  45. 45.
    Wymenga AB, Van Horn J, Theeuwes A, et al. Cefuroxime for prevention of postoperative coxitis: one versus three doses tested in arandomized multicenter study of 2,651 arthroplasties. Acta Orthop Scand 1992; 63: 19–24PubMedGoogle Scholar
  46. 46.
    Nooyen SMH, Overbeek BP, Brutel de la Rivière A, et al. Prospective randomised comparison of single-dose versus multiple-dose cefuroxime for prophylaxis in coronary artery bypass grafting. Eur J Clin Microbiol Infect Dis 1994; 13: 1033–7PubMedCrossRefGoogle Scholar
  47. 47.
    Song F, Glenny AM. Antimicrobial prophylaxis in colorectal surgery: a systematic review of randomized controlled trials. Br J Surg 1998; 85: 1232–41PubMedCrossRefGoogle Scholar
  48. 48.
    Schein M, Wittman DH, Lorenz W. Forum statement: a plea for selective and controlled postoperative antibiotic administration. Eur J Surg Suppl 1996; 576: 66–9PubMedGoogle Scholar
  49. 49.
    Kucers A. Cephalosporins and related drugs. In: Kucers A, Crowe SM, Grayson ML, editors, et al. The use of antibiotics. 5th ed. Oxford: Butterworth-Heinemann, 1997: 251–427Google Scholar
  50. 50.
    Spencer RC. The role of antimicrobial agents in the aetiology of Clostridum difficile-associated disease. J Antimicrob Chemother 1998; 41 Suppl. C: 21–7PubMedCrossRefGoogle Scholar
  51. 51.
    Hospital Infection Control Practices Advisory Committee (HICPAC). Recommendations for preventing the spread of vancomycin resistance. Infect Control Hosp Epidemiol 1995; 16: 105–13CrossRefGoogle Scholar
  52. 52.
    Mehtar S. New strategies for the use of mupirocin for the prevention of serious infection. J Hosp Infect 1998; 40 Suppl. B: S39–44PubMedCrossRefGoogle Scholar
  53. 53.
    Widdison AL, Pope NR, Brown EM. Survey of guidelines for antimicrobial prophylaxis in surgery. J Hosp Infect 1993; 25: 199–295PubMedCrossRefGoogle Scholar
  54. 54.
    Lee KR, Ring JC, Leggiadro RJ. Prophylactic antibiotic use in pediatric cardiovascular surgery: a survey of current practice. Pediatr Infect Dis J 1995; 14: 267–9PubMedCrossRefGoogle Scholar
  55. 55.
    Gyssens IC, Knape JTA, Van Hal G, et al. The anaesthetist as determinant factor of quality of surgical antimicrobial prophylaxis. Pharm World Sci 1997; 19: 89–92PubMedCrossRefGoogle Scholar
  56. 56.
    Silver A, Eichorn A, Kral J, et al. Timeliness and use of antibiotic prophylaxis in selected inpatient surgical procedures. Am J Surg 1996; 171: 548–52PubMedCrossRefGoogle Scholar
  57. 57.
    Gyssens IC, Geerligs IEJ, Nannini-Bergman MG, et al. Optimizing the timing of antimicrobial drug prophylaxis in surgery: an intervention study. J Antimicrob Chemother 1996; 38: 301–8PubMedCrossRefGoogle Scholar
  58. 58.
    Finkelstein R, Reinhertz G, Embom A. Surveillance of the use of antibiotic prophylaxis in surgery. Isr J Med Sci 1996; 32: 1093–7PubMedGoogle Scholar
  59. 59.
    Goldmann DA, Weinstein RA, Wenzel RP, et al. Strategies to prevent and control the emergence and spread of antimicrobial-resistant microorganisms in hospitals. JAMA 1996; 275: 234–40PubMedCrossRefGoogle Scholar
  60. 60.
    Gyssens IC, Van den Broek PJ, Kullberg BJ, et al. Optimizing antimicrobial therapy: a method for antimicrobial drug evaluation. J Antimicrob Chemother 1992; 30: 724–7PubMedCrossRefGoogle Scholar
  61. 61.
    Pestotnik SL, Classen DC, Evans RS, et al. Implementing antibiotic practice guidelines through computer-assisted decision support: clinical and financial outcomes. Ann Intern Med 1996; 124: 884–90PubMedGoogle Scholar

Copyright information

© Adis International Limited 1999

Authors and Affiliations

  1. 1.Department of Medical Microbiology and Infectious DiseasesUniversity Hospital Rotterdam, DijkzigtRotterdamThe Netherlands

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