Drugs 10: 333-335 (1975)
Systemic Antibiotic Prophylaxis in Surgical Patients E.S.R. Hughes and J.P. Masterton Department of Surgery, Monash University. Alfred Hospital, Melbourne
In the spectrum of surgical endeavour there is at one end the operation in a clean field performed by an able surgeon with the help of diligent assistants in a well run operating theatre. Mastectomy , thyroidectomy , inguinal hernia repair or meniscectomy are a few of these non-infective or clean operations. IJi these and many similar instances prophylactic antibiotics are absolutely unnecessary and indeed may be harmful. They are harmful to the community because of the change towards virulent organisms in a bacterial population, and they are harmful to the individual because of possible serious side-effects such as enterocolitis and pseudomembranous colitis. These can threaten life and linger long after the effects of the operation itself. In the management of these patients a rise in temperature in the first day or two post-operatively is not an absolute indication for the use of antibiotics and each problem should be treated on its merits. Due attention must be paid to the evidence that there is infection really present. Pus and isolation of an organism are criteria for treatment that are too often anticipated before they appear. Consequently, patients are treated unnecessarily or inappropriately with the wrong antibiotic. So much for the straight-forward case. In consideration of the role of systemic antibiotics, it is perhaps useful to focus on procedures within the peritoneal cavity. At the opposite end of the spectrum of operations there are those where tissues are already inflamed as a result of infection. Acute diverticulitis with a prarcolic abscess requiring drainage comes within this group. In these situations there are good theoretical reasons for giving prophylactic antibiotics. Even so, it is prudent to consider that these patients do well without antibiotics if attention is paid to the principles of adequate initial and continuing
Systemic Antibiotic Prophylaxis in Surgical Patients
334
effective drainage, rest and delayed wound closure. The latter is too often neglected with unfortunate consequences. Antibiotics do not replace these measures; they simple enhance them. If antibiotics are to be used they are best given in the pre- or peri-operative period . Between the two extremes of the spectrum there is a third group of surgical situations regarding which a genuine controversy exists and may well continue to exist. This is the group where contamination occurs during surgery and is to all intents and purposes unavoidable. If one continues to consider the specific area of abdominal surgery, a typical example of this is in a low anterior resection and anastomosis. It has been shown in prospective clinical trials [I] that in such circumstances wound infection can be reduced to a minimum by mechanical protection and meticulous attention to the detail of operative technique. If this is done antibiotics are not required as a preventive of wound infection. However, there is an inherent problem in this view and that is that the technique of mechanical protection requires a degree of care and discipline that 'cannot necessarily be reproduced with the same rigour by every surgical team. To be universally acceptable any technique should work across the board of surgical skill and practice, and this one should be no exception. That may in fact be its Achilles heel. It is because of this and in circumstances when it is impossible to prevent intra-peritoneal contamination that a strong case can be made supporting Burke's recommendation [2] that prophylactic antibiotics be used. It has been shown conclusively that pre- and intra-operative antibiotics are superior to those given post-operatively [3]. Accordingly, this should be the regimen followed. If antibiotics are to be used, the surgeon may have a clear concept of what he should do when pus is present and when there is obvious soiling. However, there are other mitigating factors for which we do not have a clear answer. Even in the clean case, is there a place for antibiotics when the surgery is prolonged, when the patient is old or undernourished, or when there is widespread cancer? There are imponderables which lead to decisions based on impressions rather than facts . The facts are lacking. The choice of antibiotics is too wide a subject for a brief editorial. It is axiomatic that wherever possible we must choose drugs that are effective yet safe from serious side-effects. On occasion, this can be difficult. It is known, for example, that the anaerobic Gram-negative bacilli, Bacteroides [4] , are an important cause of sepsis after colo-rectal surgery. Both lincomycin and its 7-cWoro derivative, clindamycin , are effective against Bacteroides. but both have been incriminated as a cause of non-specific or pseudomembranous colitis, although the precise relationship is still unclear. The question must arise whether it is justifiable to use such drugs when these risks exist? It should be pointed out that an acute colitis is by no means an inevitable consequence of the administration of either of these drugs.
Systemic Antibiotic Prophylaxis in Surgical Patients
335
As an alternative the cephalosporins can be used both pre- and intraoperatively but their activity may be less predictable, particularly against Bacteroides. It is evident that much has yet to be done in the area of identification of causative organisms and safe and effective antibiotics, whether these are used in prophylaxis or treatment.
References
2 3
Hughes, E.S.R.: Asepsis in large bowel surgery. Annals of Royal College of Surgeons of England 51: 347-356 (1972). Burke, J .F.: Use of preventive antibiotics in clinical surgery. American Journal of Surgery 39: 6-11 (1973) . Alexander, J.W. and Altemeier, W.A.: Penicillin
4
prophylaxis of experimental staphylococcal wound infections. Surgery, Gynecology and Obstetrics 120: 243-254 (1965) . Keighley, M.R.B.; Burdon, D.W.; Slaney, G.; Cooke, W.T. and Alexander-Williams, J .: Abstract of communication to British Society of Gastroenterology . Gut 16: 408 (1975) .
Authors' address: Dr E.S.R. Hughes and Professor J.P. Masterton, Department of Surgery, Alfred Hospital, Prahran, Victoria 3181 (Australia) .
Systemic Antibiotic Prophylaxis in Surgical Patients E.S.R. Hughes and J.P. Masterton Department of Surgery, Monash University. Alfred Hospital, Melbourne
In the spectrum of surgical endeavour there is at one end the operation in a clean field performed by an able surgeon with the help of diligent assistants in a well run operating theatre. Mastectomy , thyroidectomy , inguinal hernia repair or meniscectomy are a few of these non-infective or clean operations. IJi these and many similar instances prophylactic antibiotics are absolutely unnecessary and indeed may be harmful. They are harmful to the community because of the change towards virulent organisms in a bacterial population, and they are harmful to the individual because of possible serious side-effects such as enterocolitis and pseudomembranous colitis. These can threaten life and linger long after the effects of the operation itself. In the management of these patients a rise in temperature in the first day or two post-operatively is not an absolute indication for the use of antibiotics and each problem should be treated on its merits. Due attention must be paid to the evidence that there is infection really present. Pus and isolation of an organism are criteria for treatment that are too often anticipated before they appear. Consequently, patients are treated unnecessarily or inappropriately with the wrong antibiotic. So much for the straight-forward case. In consideration of the role of systemic antibiotics, it is perhaps useful to focus on procedures within the peritoneal cavity. At the opposite end of the spectrum of operations there are those where tissues are already inflamed as a result of infection. Acute diverticulitis with a prarcolic abscess requiring drainage comes within this group. In these situations there are good theoretical reasons for giving prophylactic antibiotics. Even so, it is prudent to consider that these patients do well without antibiotics if attention is paid to the principles of adequate initial and continuing
Systemic Antibiotic Prophylaxis in Surgical Patients
334
effective drainage, rest and delayed wound closure. The latter is too often neglected with unfortunate consequences. Antibiotics do not replace these measures; they simple enhance them. If antibiotics are to be used they are best given in the pre- or peri-operative period . Between the two extremes of the spectrum there is a third group of surgical situations regarding which a genuine controversy exists and may well continue to exist. This is the group where contamination occurs during surgery and is to all intents and purposes unavoidable. If one continues to consider the specific area of abdominal surgery, a typical example of this is in a low anterior resection and anastomosis. It has been shown in prospective clinical trials [I] that in such circumstances wound infection can be reduced to a minimum by mechanical protection and meticulous attention to the detail of operative technique. If this is done antibiotics are not required as a preventive of wound infection. However, there is an inherent problem in this view and that is that the technique of mechanical protection requires a degree of care and discipline that 'cannot necessarily be reproduced with the same rigour by every surgical team. To be universally acceptable any technique should work across the board of surgical skill and practice, and this one should be no exception. That may in fact be its Achilles heel. It is because of this and in circumstances when it is impossible to prevent intra-peritoneal contamination that a strong case can be made supporting Burke's recommendation [2] that prophylactic antibiotics be used. It has been shown conclusively that pre- and intra-operative antibiotics are superior to those given post-operatively [3]. Accordingly, this should be the regimen followed. If antibiotics are to be used, the surgeon may have a clear concept of what he should do when pus is present and when there is obvious soiling. However, there are other mitigating factors for which we do not have a clear answer. Even in the clean case, is there a place for antibiotics when the surgery is prolonged, when the patient is old or undernourished, or when there is widespread cancer? There are imponderables which lead to decisions based on impressions rather than facts . The facts are lacking. The choice of antibiotics is too wide a subject for a brief editorial. It is axiomatic that wherever possible we must choose drugs that are effective yet safe from serious side-effects. On occasion, this can be difficult. It is known, for example, that the anaerobic Gram-negative bacilli, Bacteroides [4] , are an important cause of sepsis after colo-rectal surgery. Both lincomycin and its 7-cWoro derivative, clindamycin , are effective against Bacteroides. but both have been incriminated as a cause of non-specific or pseudomembranous colitis, although the precise relationship is still unclear. The question must arise whether it is justifiable to use such drugs when these risks exist? It should be pointed out that an acute colitis is by no means an inevitable consequence of the administration of either of these drugs.
Systemic Antibiotic Prophylaxis in Surgical Patients
335
As an alternative the cephalosporins can be used both pre- and intraoperatively but their activity may be less predictable, particularly against Bacteroides. It is evident that much has yet to be done in the area of identification of causative organisms and safe and effective antibiotics, whether these are used in prophylaxis or treatment.
References
2 3
Hughes, E.S.R.: Asepsis in large bowel surgery. Annals of Royal College of Surgeons of England 51: 347-356 (1972). Burke, J .F.: Use of preventive antibiotics in clinical surgery. American Journal of Surgery 39: 6-11 (1973) . Alexander, J.W. and Altemeier, W.A.: Penicillin
4
prophylaxis of experimental staphylococcal wound infections. Surgery, Gynecology and Obstetrics 120: 243-254 (1965) . Keighley, M.R.B.; Burdon, D.W.; Slaney, G.; Cooke, W.T. and Alexander-Williams, J .: Abstract of communication to British Society of Gastroenterology . Gut 16: 408 (1975) .
Authors' address: Dr E.S.R. Hughes and Professor J.P. Masterton, Department of Surgery, Alfred Hospital, Prahran, Victoria 3181 (Australia) .
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