Antimicrobial prophylaxis and resistance Correspondence H. K. F. van Saene, Institute of Ageing and Chronic Diseases, University of Liverpool, Duncan Building, Daulby Street, L69 3GA, UK E-mail: [email protected] Conflicts of interest None Funding None doi: 10.1111/aas.12474

Sir, We welcome the debate initiated by Dr Peterson et al. focusing on the issue of antimicrobial prophylaxis and resistance in the critically ill requiring treatment on the intensive care unit (ICU).1 They acknowledge their use of peri-operative antibiotic prophylaxis, but they are opposed to the same application for pneumonia prophylaxis. We assume that the reason is that the use antibiotic prophylaxis to prevent wound infections does not cause resistance, and pneumonia prophylaxis does. We respectfully disagree. Critically ill patients who require treatment on the ICU following liver transplantation show surveillance cultures positive for aerobic Gram-negative bacilli resistant to the parenteral antimicrobial prophylaxis.2 This is not the case if enteral antimicrobials polymyxin E and tobramycin are added to the parenteral antimicrobials. This observation can be explained by the pathophysiological phenomenon of gut overgrowth, defined as ≥ 105 bacteria per gram of faeces and invariably present in the critically ill. Dr Peterson et al. find the prophylactic use of polymyxin E specifically cumbersome,3 a statement that is remarkable.4 A possible explanation may be that the Swedish investigators are unfamiliar with surveillance cultures. Gut overgrowth is associated with resistance following polyclonality due to hypermutation. We thank Dr Peterson et al. for their constructive contribution.

Acknowledgement We would like to thank Dr JH Rommes for carefully reviewing the manuscript.

References 1. Petersson J, Hyllienmark P, Brattström O, Larsson E, Martling CR, Oldner A. Trauma patients in the ICU need antimicrobial prophylaxis to prevent pneumonia: in reply. Acta Anaesthesiol Scand 2014; 58: 1288. 2. van Saene HKF, Zandstra DF. Selective decontamination of the digestive tract: rationale behind evidence-based use in liver transplantation. Liver Transpl 2004; 10: 828–33. 3. van Saene HKF, Taylor N, Damjanovic V, Sarginson RE. Microbial gut overgrowth guarantees increased spontaneous mutation leading to polyclonality and antibiotic resistance in the critically ill. Curr Drug Targets 2008; 9: 419–21. 4. Zandstra DF, Rommes JH, de la Cal MA, Silvestri L, Taylor N, van Saene HKF. Colistin resistance during selective digestive tract decontamination is uncommon. Antimicrob Agents Chemother 2014; 58: 626.

D. F. Zandstra, H. K. F. van Saene and M. Strinnholm

General anaesthesia vs. spinal anaesthesia for total hip arthroplasty Correspondence Thomas Mencke, Department of Anaesthesia and Intensive Care Medicine, University of Rostock, Schillingallee 35, Rostock 18057, Germany E-mail: [email protected]; [email protected] Conflicts of interest The authors have no conflicts of interest. Funding None. doi: 10.1111/aas.12486

Sir, We read with interest the study by Harsten et al. on the recovery profile after total hip arthroplasty comparing total intravenous general anaesthesia and spinal anaesthesia.1 The authors recommended general anaesthesia for total hip replacement because it resulted in reduced length of stay (26 h vs. 30 h; P = 0.004), less nausea, less dizziness and less pain after 6 h compared with the spinal anaesthesia group. Moreover, orthostatic

Acta Anaesthesiologica Scandinavica 59 (2015) 541–543 © 2015 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd




function was better and patients requested a change in the method of anaesthesia less often. However, patients in the spinal anaesthesia group fulfilled discharge criteria earlier. We were astonished about the conclusion. General anaesthesia resulted in a more favourable recovery, but the outcome after surgery was not mentioned. Morbidity and mortality were not studied in a controlled manner; there was only one interview via phone 6 months after surgery. This interview consisted of two questions, one about the experience of the anaesthesia and one about the type of anaesthesia if a total hip replacement surgery would be necessary again. Rodgers et al. analysed 141 trials with 9559 patients in their meta-analysis.2 They recommended a more widespread use of neuraxial blockade because mortality and morbidity were significantly reduced. Mortality was reduced by one third in patients with epidural or spinal anaesthesia. Moreover, serious complications like deep vein thrombosis and pulmonary embolism were reduced. The recovery profile in the first 24 h is important for the patient′s satisfaction. However, serious complications and mortality are more important. We know, that orthopaedic patients have a high risk to suffer from deep vein thrombosis; therefore, spinal or epidural anaesthesia are the preferable techniques.2 We think that the article should mention the potential benefit of neuraxial blockades. Especially patients with comorbidities may benefit from a neuraxial blockade concerning outcome after operation. Anaesthetists might change their recommendation concerning the type of anaesthesia (general anaesthesia vs. spinal anaesthesia) for the patients after reading the article. The results of the study are interesting because they show a shift towards better tolerance of general anaesthesia if performed as a total intravenous anaesthesia. We conducted a very similar study nearly 15 years ago.3 We performed general anaesthesia as a balanced anaesthesia. Many complications after surgery were similar in both groups, nausea, too; in the study by Harsten et al. nausea was reduced. References 1. Harsten A, Kehlet H, Ljung P, Toksvig-Larsen S. Total intravenous general anaesthesia vs. spinal

anaesthesia for total hip arthroplasty: a randomised, controlled trial. Acta Anaesthesiol Scand 2015; 59: 298–309. 2. Rodgers A, Walker N, Schug S, McKee A, Kehlet H, van Zundert A, Sage D, Futter M, Saville G, Clark T, MacMahon S. Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials. BMJ 2000; 32: 1–12. 3. Stober HD, Mencke T. General anesthesia or spinal anesthesia for hip prosthesis replacement? Studies of acceptance of both procedures by patients. Anaesthesiol Reanim 1999; 24: 151–6.

T. Mencke and S. Soltész

Total intravenous general anaesthesia vs. spinal anaesthesia for total hip arthroplasty Correspondence A. Harsten, Department of Anaesthesiology, Hässleholm Hospital, Box 351, 281 25 Hässleholm, Sweden E-mail: [email protected] Conflicts of interest None. Funding None. doi: 10.1111/aas.12495

Sir, We thank Dr Mencke and Dr Soltéz for their interesting comments about our study.1 Discharge from the ward (i.e. fulfilling the discharge criteria) was achieved earlier in the general anaesthesia group compared with the spinal anaesthesia group. However, discharge from postoperative care unit was achieved earlier in the spinal anaesthesia group. This could possibly be explained by the fact that we did not use local infiltration analgesia since it has been shown that it has no or limited effect in total hip arthroplasty surgery.2 As clearly stated in the discussion section, our study did not include serious adverse events or mortality. In order to do this in a prospective randomised trial, we would have to include a significantly larger study population. Furthermore, we do mention the study by Rodgers et al.3 pointing out that this review was based on studies performed 15–30 years ago. Acta Anaesthesiologica Scandinavica 59 (2015) 541–543



© 2015 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd

General anaesthesia vs. spinal anaesthesia for total hip arthroplasty.

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