Discriminate Use of Antibiotic Prophylaxis In Gastroduodenal Surgery
R. T. Lewis, MB, FRCS(C), FACS, Montreal, Canada With the collaboration
of
Charles M. Allan, MD, FRCS(C), FACS, Montreal, Canada Ft. Graydon Goodall, MD, FRCS(C), FACS, Montreal, Canada Walker C. Lloyd-Smith, MD, FRCS(C), FACS, Montreal, Canada Breen Marien, MD, kRCS(C), Montreal, Canada Frederick M. Wiegand, MD, FRCS(C), FACS, Montreal, Canada
In 1969 Polk and Lopez-Mayor [1] showed that cephaloridine, given before as well as after operation, reduced the frequency of wound infections in patients undergoing gastric surgery. We subsequently realized that, depending on the main indication for operation, some of these patien”lr. are at high risk of developing postoperative sepsis and others are at low risk [2,3]. This suggested that prophylactic antibiotics might be safely limited to the high risk group. A prospective randomized study was therefore designed (1) to test this hypothesis of selective use of antibiotic prophylaxis in gastroduodenal surgery; (2) to determine the value of systemic antibiotic prophylaxis in those patients at high risk of postoperative sepsis; and (3) as our previous study had shown no increased risk of infection due to traditional indicators of impaired host resistance [3], to examine the value of an alternate index-the preoperative blood lymphocyte count-as a predictor of the risk of postoperative sepsis. Patients and Methods
Patients undergoing surgery for gaetroduodenal disease at the Queen Eliiabeth Hospital between November 1975 and June 1977 were divided into three groups. The patients in group I (low risk) were admitted for elective operation for chronic duodenal ulcer with pain intractable to medical From the Departments of Surgery, The Queen Elizabeth Hospital of Montreal Centre and McGill University, Montreal, Quebec. Reprint requests should be addressed to R. T. Lewis, MD, Duean Elizabeth Hospital. 2100 Marlowe Avenue, Montreal, Quebec, H4A 3L6, Canada,
640
treatment, or for duodenal ulcer with a history of repeated bleeding. These patients did not receive perioperative cephaloridine. The remaining patients (high risk) underwent elective operation for duodenal ulcer complicated by pyloric stenosis, or for gastric ulcer or malignancy; or they bad emergency surgery for perforated ulcer, or for bleeding from gastric cancer or peptic ulcer. These patients were randomly assigned to groups II and III. Group II patients were given 2 g of cephaloridine intravenously, 2 hours before operation and again 5 hours later; those in group III received no perioperative antibiotics. In some patients absolute blood lymphocyte counts were obtained before surgery. At operation a swab was taken from the open stomach and sent for routine culture. Abdominal wounds were inspected for evidence of infection on the fifth and seventh postoperative days. Erythematous, tender, or indurated wounds were observed until the inflammation resolved or they drained pus. A wound infection was diagnosed when pus discharged from a wound. A sample of the pus was then obtained for culture. Wound infections diagnosed after the patient left the hospital and up to 1 month after operation were recorded by the surgeon and included in the total wound infection rate. Postoperative pneumonia and urinary tract infections were noted and grouped together as “nonspecific postoperative infections.” Postoperative abscesses requiring surgical drainage, and bacteremia diagnosed on blood culture in patients with a postoperative temperature of 39°C or higher were characterized as “serious postoperative sepsis.” The age of the patient, duration of preoperative hospitalization, operative time “from skin to skin,” and the type of operation were noted in all patients, and a risk index of postoperative infection was calculated as recommended by Davidson et a 14.
The American Journal of Surgery
Antibiotic
TABLE I
Prophylaxis
in Gastroduodenal
Surgery
Comparison of Patient Data in the Three Stuay Groups -
Age (yr) Preoperative hospitalization (days) Duration of operation (min) Risk index Preoperative lymphocyte count (mean = SE/mm3) Emergency/elective operation (no.) ResectionaVnonresectional procedure (no.)
Group I
Group II
Group Hi
(no. = 24)
(no. = 41)
(no. = 42)
P
51.5 4.4
60.7 4.6
59.9 5.5
NS NS
128.3 40.6 1,880 f 93
143.7 45.6 1,409 f 84
149.2 45.8 1,314 f 95
NS NS NS
20121
16126
NS
3219
3715
NS
O/24 23/l
no. = number of patients; NS = not significant; p = probability of statistically significant difference between groups II and Ill; SE = standard error of the mean.
Results
We studied 107 patients, 24 in group I, 41 in group II, and 42 in group III. Table I compares the patient data in the three groups with respect to mean age, duration of hospitalization, duration of operation, preoperative lymphocyte count, risk index, emergency or elective operation, and type of operative procedure. The randomized groups II and III are well-matched. No wound infections were seen in group I. Wound infections occurred in 11 patients in group III (no antibiotic), but in none of the group II (antibiotic) patients (p
R. T. Lewis, MB, FRCS(C), FACS, Montreal, Canada With the collaboration
of
Charles M. Allan, MD, FRCS(C), FACS, Montreal, Canada Ft. Graydon Goodall, MD, FRCS(C), FACS, Montreal, Canada Walker C. Lloyd-Smith, MD, FRCS(C), FACS, Montreal, Canada Breen Marien, MD, kRCS(C), Montreal, Canada Frederick M. Wiegand, MD, FRCS(C), FACS, Montreal, Canada
In 1969 Polk and Lopez-Mayor [1] showed that cephaloridine, given before as well as after operation, reduced the frequency of wound infections in patients undergoing gastric surgery. We subsequently realized that, depending on the main indication for operation, some of these patien”lr. are at high risk of developing postoperative sepsis and others are at low risk [2,3]. This suggested that prophylactic antibiotics might be safely limited to the high risk group. A prospective randomized study was therefore designed (1) to test this hypothesis of selective use of antibiotic prophylaxis in gastroduodenal surgery; (2) to determine the value of systemic antibiotic prophylaxis in those patients at high risk of postoperative sepsis; and (3) as our previous study had shown no increased risk of infection due to traditional indicators of impaired host resistance [3], to examine the value of an alternate index-the preoperative blood lymphocyte count-as a predictor of the risk of postoperative sepsis. Patients and Methods
Patients undergoing surgery for gaetroduodenal disease at the Queen Eliiabeth Hospital between November 1975 and June 1977 were divided into three groups. The patients in group I (low risk) were admitted for elective operation for chronic duodenal ulcer with pain intractable to medical From the Departments of Surgery, The Queen Elizabeth Hospital of Montreal Centre and McGill University, Montreal, Quebec. Reprint requests should be addressed to R. T. Lewis, MD, Duean Elizabeth Hospital. 2100 Marlowe Avenue, Montreal, Quebec, H4A 3L6, Canada,
640
treatment, or for duodenal ulcer with a history of repeated bleeding. These patients did not receive perioperative cephaloridine. The remaining patients (high risk) underwent elective operation for duodenal ulcer complicated by pyloric stenosis, or for gastric ulcer or malignancy; or they bad emergency surgery for perforated ulcer, or for bleeding from gastric cancer or peptic ulcer. These patients were randomly assigned to groups II and III. Group II patients were given 2 g of cephaloridine intravenously, 2 hours before operation and again 5 hours later; those in group III received no perioperative antibiotics. In some patients absolute blood lymphocyte counts were obtained before surgery. At operation a swab was taken from the open stomach and sent for routine culture. Abdominal wounds were inspected for evidence of infection on the fifth and seventh postoperative days. Erythematous, tender, or indurated wounds were observed until the inflammation resolved or they drained pus. A wound infection was diagnosed when pus discharged from a wound. A sample of the pus was then obtained for culture. Wound infections diagnosed after the patient left the hospital and up to 1 month after operation were recorded by the surgeon and included in the total wound infection rate. Postoperative pneumonia and urinary tract infections were noted and grouped together as “nonspecific postoperative infections.” Postoperative abscesses requiring surgical drainage, and bacteremia diagnosed on blood culture in patients with a postoperative temperature of 39°C or higher were characterized as “serious postoperative sepsis.” The age of the patient, duration of preoperative hospitalization, operative time “from skin to skin,” and the type of operation were noted in all patients, and a risk index of postoperative infection was calculated as recommended by Davidson et a 14.
The American Journal of Surgery
Antibiotic
TABLE I
Prophylaxis
in Gastroduodenal
Surgery
Comparison of Patient Data in the Three Stuay Groups -
Age (yr) Preoperative hospitalization (days) Duration of operation (min) Risk index Preoperative lymphocyte count (mean = SE/mm3) Emergency/elective operation (no.) ResectionaVnonresectional procedure (no.)
Group I
Group II
Group Hi
(no. = 24)
(no. = 41)
(no. = 42)
P
51.5 4.4
60.7 4.6
59.9 5.5
NS NS
128.3 40.6 1,880 f 93
143.7 45.6 1,409 f 84
149.2 45.8 1,314 f 95
NS NS NS
20121
16126
NS
3219
3715
NS
O/24 23/l
no. = number of patients; NS = not significant; p = probability of statistically significant difference between groups II and Ill; SE = standard error of the mean.
Results
We studied 107 patients, 24 in group I, 41 in group II, and 42 in group III. Table I compares the patient data in the three groups with respect to mean age, duration of hospitalization, duration of operation, preoperative lymphocyte count, risk index, emergency or elective operation, and type of operative procedure. The randomized groups II and III are well-matched. No wound infections were seen in group I. Wound infections occurred in 11 patients in group III (no antibiotic), but in none of the group II (antibiotic) patients (p
