Prophylaxis antibiotics in colorectal surgery

1
Prophylaxis antibiotics in colorectal surgery

• By
• Hanaa Tashkandi

2
introduction

• 25 of all nosocomial infections are wound
  infections and their costs are greater than one
  billion dollar per year in the United states.

3

• No (gold standard) regimen can be identified.
• contamination by bacteria from the content of
  the large bowel means that colorectal surgery is
  associated with a particularly high risk of
  surgical wound infection.

4

• If antimicrobial prophylaxis is not used ,about
  40 of patients will develop wound infection
  after colorectal surgery.
• This figure is reduced to around 11 when
  patients receive some form of antimicrobial
  prophylaxis.

5

• In colorectal surgery ,the prophylactic regimen
  should include broad spectrum cover for both
  aerobic and anaerobic organisms.
• To prevent post operative infections, it is
  crucial that the concentration of antibiotics in
  the tissue surrounding the surgical wound is
  sufficient at the time of bacterial contamination.

6

• A recent study done on the use of prophylactic
  antibiotics orally in colorectal surgery .
• (department of surgery hospital valle de
  hebron.University of Barcelona)
• -300 consequative colorectal resections were
  studied and all the patients received mechanical
  bowel preparation with intravenous antibiotics.

7

• -the intravenous antibiotics in the study was
  (cefoxitin).
• .one pre operative at the time
  of
• skin incision.
• .two post operative doses.

8

• three groups
• -1-three doses of (neomycin metronidazole)
• -2-one oral dose.
• -3-no oral dose.

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Conclusion of this study

• Addition of oral antibiotic in all patient
  prophylaxis is associated with lower patient
  tolerance in terms of increase nausea , vomiting
  and abdominal pain with no advantages in
  preventing of post operative complications.
• so the recommendation was not to give oral
  antibiotics.
• --------------------------------------------------
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• Int. J colorectal disease.2005 Nov 20(6)542-6

10

• A more recent survey of United Kingdom antibiotic
  policies demonstrated a similar pattern with
  Cefuroxime plus Metronidazol.
• -this combination is the most frequently
  recommended policy.

11

• -the BNF currently recommends either
• a single dose of Gentamycin plus
  metronidazole.
• or Cefuroxime plus Metronidazole given in
  two hours prior to surgery.

12
Timing of antibiotics prophylaxis

• Current recommendations are that the parental
  antibiotics used in prophylaxis should be given
  in sufficient dosage within 30 minutes preceding
  incision.
• (this is also depend on the half life of the
  antibiotics and the pharmacokinetics)

13
Factors associated with an increased risk of
surgical wound infection colorectal surgery

• duration of the operation.
• obesity.
• presence of drains.
• left sided colonic resection.
• inflammatory bowel disease.
• preoperative blood transfusion was also found
  to be associated with an increased risk of
  surgical wound infection in two trials.

14

• A study regarding the comparison of the
  prophylactic efficacy of Ceftriaxone and
  Ceferuxime in colorectal surgry.
• (John c woodfield , andre M van rij , Ross a
  pettigew , dome Bott)

15
y

• prospective , randomized ,double blind study of
  1013 patients undergoing abdominal surgery ,
• the prophylactic use of Ceftriaxone and
  Cefotaxime were compared .

16

• The result
• both antibiotics provide comparable wound
  prophylaxis as long as metronidazole is added for
  colorectal and appendeceal surgery.

17

• Ceftriaxone is having an additional apparent
  benefits of reducing other post operative
  infections , being less depandant on
  metronidazole as an adjuvant and providing a more
  effective prophylactic cover against
  staphylococcus aureus.

18

• ((2000 J chemother))
• A multicenter randomized trial of prophylaxis
  with intravenous
• -cefepine metronidazole . Or
• -ceftriaxone metronidazole .
• In colorectal surgery.

19

• The two prophylactic antimicrobial regimens in
  615 patients undergoing elective colorectal
  surgical procedures.
• -patients ranged in age from 19 92 years
• (median 66 year ).

20

• All patients underwent mechanical bowel
  preparation.
• -patients were randomized to receive preoperative
  infusions of 2 grams cefepime or 2 grams
  ceftriaxone , followed by 500 mg metronidazole .
• -patients were followed for up to 6 weeks after
  surgery.

21

• -antimicrobial prophylaxis was successful in
  preventing primary site infection 92.8 of
  patients in the cefepine metronidazole group.
• And
• 92.9 of patients in the ceftriaxone
  metronidazole group.

22
ha

• So
• A single dose of cefepime metronidazole
• Seems to be a very useful alternative to other
  regimens for prophylaxis in patients undergoing
  colorectal surgery.

23
h

• There was another American study , its goal was
  based on if single dose prophylaxis given just
  before the start of surgery is as effective as
  multiple doses in preventing surgical wound
  infection and is also associated with less
  toxicity ,fewer adverse events and lower costs.

24

• This study involved 414 patients.
• -one group had no post surgical prophylaxis.
• -one group had antibiotics continued for up to 24
  hours
• -one group had antibiotics usage for up to 48
  hours.
• -one group had antibiotics usage exceed 48 hours
  after surgery.

25

• and there was essentially no change.

26

• (song and glenny performe an extensive systemic
  review and meta-analysis on colorectal
  antibiotics prophylaxis.
• -their analysis of 147 randomized clinical trials
  concluded that

27

• Single dose antibiotic regimens were effective
  preventing surgical wound infection except for
  the possible inadequacy of the antibiotics ,
  example
• Doxycycline , pipracillin , or metronidazole
  used alone.

28

• The meta analysis demonstrated that single dose
  regimen were as effective as regimens with post
  operative doses and \ or multiple drug regimens.