Wound sepsis following gastrointestinal surgery: a comparison of topical and two-dose systemic cephradine.

A prospective study of the effect of the route of administration of prophylactic antibiotic on the wound infection rate following gastrointestinal surgery was performed. Patients were randomly allocated to one of three groups: group 1 received no form of antibiotic prophylaxis; group 2 received 1 g of cephradine applied topically to the wound at closure; group 3 received 1 g of cephradine intravenously at induction of anaesthesia and a further intravenous dose of 500 mg 4 h later. Wound infections occurred in 12 of 83 patients in the control group (14.5 per cent), in 6 of the 83 patients in the group who received topical antibiotic (7.2 per cent) and in 3 of the 82 patients who received systemic antibiotics (3.6 per cent). Only the group who received systemic antibiotic showed a statistically significant reduction in the incidence of wound infections compared with the control group (P = 0.03).     

Combined topical povidone-iodine and systemic antibiotics in postappendicectomy wound sepsis

Three hundred and fifteen patients with appendicitis were randomized into two groups. One group received pre-operative systemic gentamicin and metronidazole while the other group received 1 per cent topical povidone-iodine solution in addition to the antibiotics. For early appendicitis including normal and acutely inflamed appendices, only one dose of antibiotics was used. The postoperative wound sepsis was very low in both groups of patients and there was no statistical difference between them. For late appendicitis including gangrenous and perforated appendices, the antibiotics were continued for 7 days. Eight out of 51 patients who had the topical agent developed wound sepsis compared with one out of 52 patients who received no topical agent. This difference is statistically significant (P = 0.03). All wound infections presented within 2 weeks of operation and were deep. Povidone-iodine, 1 per cent, adversely affects the wound infection rate in late appendicitis and should not be used.     

Effects of antibiotics on prevention of infection in contaminated abdominal operations.

A prospective study was undertaken on 102 patients with massice intraperitoneal contamination from traumatic or spontaneous perforation of intestinal or pancreaticobiliary tract to determine the effects of combined systemic and intraperitoneal antibiotic administration on the prevention of the postoperative sepsis, intra-abdominal abscess formation and wound infection. Large doses of gentamicin and clindamycin were given parenterally before, during, and after the operation for five days. In addition, the peritoneal cavity and the abdominal incision were irrigated intraoperatively with antibiotic solution containing the same antibiotics. The drugs were given so as to provide a potent level of antibiotics during the operation and in the immediate postoperative period. The postoperative wound infection rate was 4 per cent, intra-abdominal abscess 2.9 per cent, sepsis 1 per cent, resulting in a total infectious complication rate of 7.9 per cent. This is a marked reduction in the incidence of infectious complications and compares favorably with the results from either parenteral or intraperitoneal therapy alone. Furthermore, no complications were encountered due to this method of therapy. These results do not indicate that antimicrobial drugs be given prophylactically to all surgical patients, but they strongly suggest the advantages of combined systemic and intraperitoneal antibiotics in the management of patients with massive intraperitoneal contamination.     

Metronidazole and Augmentin in the prevention of sepsis after appendicectomy

Two hundred and fifty patients were admitted to a prospective randomized trial to compare the efficacy of Augmentin with metronidazole in the prevention of sepsis after appendicectomy. Pre-operatively they received either 500 mg metronidazole or 1.2g Augmentin intravenously. Those patients with gangrenous or perforated appendices received eight additional doses of the trial drug at 8 hourly intervals. Overall there were 13 wound infections in the Augmentin group (11 per cent) and 21 in the metronidazole group (18 per cent). The 90 per cent confidence limits for the overall 7 per cent difference in infection rates were +/- 8.5 per cent. There were high rates of wound infection in the gangrenous group (Augmentin 8 per cent versus metronidazole 19 per cent) and especially in the perforated group (Augmentin 33 per cent versus metronidazole 63 per cent). There was no statistically significant difference between the infection rates with the two antibiotics but our study suggests that Augmentin, which is active against both aerobes and anaerobes, may be more effective than metronidazole in reducing wound sepsis after appendicectomy.     

A prospective trial of prophylactic antibiotics in hand lacerations.

A series of 368 patients with hand lacerations which required suturing were randomly allocated to one of three treatment groups. The incidence of infected and of imperfectly healed wounds was noted 7 days after suturing. As well as the influence of antibiotics on healing, sixteen other factors which it was considered might affect healing were analysed. The overall infection rate was 9-8 per cent, and there was no significant difference between the three groups. The imperfect healing rate (which includes the infected cases) was 24-6 per cent. There was a lower rate (P less than 0-05) of imperfect healing in the Triplopen group (15 per cent) than in either the flucloxacillin group (29-5 per cent) or the group who received no antibiotics (29-0 per cent). Other factors associated with imperfect healing found to be significant at the 1 per cent level, were wound contamination, pain and the presence of a wet or changed dressing at the second examination.     

Parietal wound drainage in abdominal surgery

A prospective randomized study of wound drainage in 250 surgical abdominal wounds was undertaken to determine (a) what effect wound drains had on clean surgical wounds; (b) whether wound drains reduced infection in potentially contaminated wounds; (c) whether wound drainage was an acceptable alternative to the use of topical antibiotics in frankly contaminated wounds. Ten per cent of clean wounds which had been drained became infected, compared with 2 per cent of control wounds in the same group (P less than 0.002). Infection was also more common in potentially and frankly contaminated wounds in the presence of a drain. Skin organisms were grown from 8 drained and 2 nondrained wounds in this group (P less than 0.005), suggesting contamination by the drains. Drains were, however, associated with a lower infection rate in 23 obese patients with frankly contaminated wounds.     

The place of antibiotics in preventing wound infection after clean operations in an Indian hospital: a prospective, randomised, controlled clinical trial.

Two hundred patients in a major Indian hospital who were undergoing clean operations participated in a prospective, randomised, controlled clinical trial of the effectiveness of systemic antibiotics in preventing wound infectious. Of the patients on antibiotics 12.6% developed wound infections and of those not on antibiotics 13.3% did--a difference of no significance. Other factors analysed which included age, duration of operation, place on the operating list and length of the incision did not appear to effect the incidence of infection. Wound infection delayed the discharge of the patient from hospital by seven days. Avoiding antibiotic prophylaxis in these operations would have saved our hospital 12,500 pounds a year. We suggest that prophylactic antibiotics are ineffective in preventing wound infection after clean operations in India. Their use is wasteful and should be discouraged.     

Morbidity and mortality in renal transplant patients after incidental surgery.

Sixty-five further surgical procedures were carried out in 39 renal transplant patients without mortality and with low morbidity. There was a 9 per cent incidence of clean wound infection, and minor chest infection occurred in another 9 per cent. Stay in hospital for these procedures was not prolonged. The function of the transplanted kidney showed no deterioration after these further surgical procedures. The successfully transplanted patients is thus a good candidate for further surgery despite the previous renal failure and the continuing immunosuppressive therapy.     

Preoperative prophylactic cephalothin fails to control septic complications of colorectal operations: results of controlled clinical trial. A Veterans Administration cooperative study.

Data obtained from a survey of the membership of the Society for Surgery of the Alimentary Tract and the American Society of Colon and Rectal Surgeons indicated that concomitant administration of oral neomycin-erythromycin base and systemic cephalothin, together with mechanical colon cleansing, was the most popular method of colon preparation. We designed a prospective double blind clinical trial to compare administration of intravenous cephalothin, oral neomycin-erythromycin base, and the combination of both the intravenous and oral antibiotics. Intake of patients to the intravenous cephalothin group was stopped because the data indicated that this method of prophylaxis resulted in significantly higher numbers of septic complications. The incidence of wound infection was 30 per cent and the overall incidence of septic complications was 39 per cent in patients receiving only intravenous cephalothin combined with mechanical colon cleansing. The incidence of wound infection and the overall incidence of septic complications was only 6 per cent in the comparison group, and the differences are highly significant.     

Prophylactic antibiotics in elective colorectal surgery

A randomized prospective study was conducted on 194 patients who underwent elective colorectal surgery for carcinoma. All patients received the same mechanical bowel preparation. In addition, patients in group A received oral neomycin and erythromycin base; patients in group B received systemic metronidazole and gentamicin, while patients in group C received both oral and systemic antibiotics. Postoperative septic complications related to colorectal surgery occurred in 27.4 per cent, 11.9 per cent and 12.3 per cent respectively in groups A, B and C (chi 2 = 7; P less than 0.05). The incidence of sepsis in groups B and C was almost identical. Patients who received oral antibiotics alone (group A) had significantly higher risks of postoperative sepsis when compared with patients in either group B or group C (P less than 0.05). As there is no additional advantage of combining oral and systemic antibiotics, we recommend systemic metronidazole and gentamicin to be used with mechanical bowel preparation in elective colorectal surgery.     

One-dose antibiotic prophylaxis against wound infection after appendicectomy: a randomized trial of clindamycin, cefazolin sodium and a placebo.

Two hundred and fifty patients were admitted to a prospective randomized trial of single dosage prophylaxis against wound infection after appendicectomy. There were 12 exclusions, 72 patients received placebo, 81 received 600 mg i.m. clindamycin phosphate and 85 received 1 1 g i.m. cefazolin sodium, the agent being given in the anaesthetic room. Clindamycin produced a significant reduction in the overall rate of wound infection from 33 per cent in the controls to 17 per cent. In cases with a gangrenous or perforated appendix the infection rate in controls was 78 per cent; this was reduced to 44 per cent by a single dose of clindamycin. Cefazolin significantly reduced the number of aerobic organisms isolated from wound infections, but did not significantly reduce the incidence of wound infection. We conclude that anaerobic organisms are more important than faecal aerobic organisms in the pathogenesis of wound infection after appendicectomy.     

The importance of positive bacterial cultures of specimens obtained during clean orthopaedic operations

Microbiological cultures of specimens of tissue and of fluids from the wound in forty patients who had had consecutive clean, elective orthopaedic operations (excluding total joint replacements) and had not received antibiotics preoperatively were analyzed. Of the forty patients, twenty-three (58 per cent) had a positive culture on at least one of the media that were used and seventeen (43 per cent) had negative cultures. Of the forty specimens that were obtained from swabbing of the wound, eight (20 per cent) were positive on culture, compared with twenty (50 per cent) that were obtained from biopsy of tissue. Of these twenty-eight positive cultures, thirteen (46 per cent) were on routine blood-agar plates and fifteen (54 per cent), in broth only. Of the thirty-three bacterial organisms that were identified in the twenty-eight positive cultures of the wound, nineteen (58 per cent) were coagulase-negative Staphylococcus; eight (24 per cent), Propionibacterium acnes; two (6 per cent), Peptostreptococcus; and four (12 per cent), miscellaneous organisms. In all of the positive cultures on the blood-agar plates, except in those showing Propionibacterium acnes, there were five colonies or fewer. One patient had a clinical infection with Staphylococcus aureus that developed later, but the initial cultures of the wound had been positive for Staphylococcus epidermidis only. None of the bacteria that grew on culture were Staphylococcus aureus or the less common pathogenic gram-negative bacteria, such as Escherichia coli, Pseudomonas, or Klebsiella.(ABSTRACT TRUNCATED AT 250 WORDS)     

Topical perioperative antibiotic prophylaxis for minor clean inguinal surgery

BACKGROUND: In minor clean procedures, such as inguinal hernia repair and varicocelectomy, the efficacy of systemic perioperative antibiotic prophylaxis is not well established. To determine the efficacy of topical antibiotic prophylaxis alone in preventing postoperative wound infection in a minor urologic clean procedure, we retrospectively reviewed the medical records of 1,654 patients who had undergone microsurgical varicocelectomy. STUDY DESIGN: From September 1985 until December 2000, 1,654 men underwent 2,554 microsurgical varicocelectomies (900 bilateral) by a single surgeon (MG). The skin was shaved and then prepped with standard Betadine gel (Purdue Frederick) that was wiped away with 70% ethanol. No systemic antibiotics were used. The wound was irrigated with 1% neomycin at the moment the incision was made, and then every few minutes until the completion of the procedure, which averaged 45 minutes per side. No postoperative antibiotics were used. RESULTS: No wound infections occurred. No patient developed an adverse reaction to topical application of neomycin. One can conclude that the infection rate in this study is no higher than 0.2% with 95% confidence. CONCLUSIONS: Our review of a large series of consecutive clean urologic procedures indicates that by combining a skin preparation of Betadine gel and 70% ethanol with perioperative topical neomycin irrigation at the moment of skin incision, the risk of postoperative wound infection when performing microsurgical varicocelectomy can be effectively reduced to less than 0.2%.     

Acute appendicitis: efficacy of prophylactic preoperative antibiotics in the reduction of septic morbidity

The course of 200 patients who recently underwent appendectomy at UCLA for acute appendicitis has been reviewed to determine the efficacy of preoperative systemic antibiotic prophylaxis in reducing septic morbidity after surgery. Among those with nonperforated appendicitis who were given gentamycin and clindamycin preoperatively, a reduction of infection rate from 10.2 to 5.3 per cent was found when compared with patients who received no antibiotics.     

Antibiotics in elective colon surgery. A randomized trial of oral, systemic, and oral/systemic antibiotics for prophylaxis

A prospective, randomized double-blind study was undertaken to compare the efficacy of three prophylactic regimens (oral neomycin and erythromycin, intravenous cefoxitin, and a combination of both oral and intravenous antibiotics) in patients undergoing elective colorectal surgery. One hundred sixty-nine patients were randomized and 146 patients were evaluable. Septic complications occurred in 11.4 per cent of patients receiving oral antibiotics only, in 11.7 per cent of patients receiving intravenous cefoxitin alone, and in 7.8 per cent of patients receiving both oral and intravenous antibiotics. These differences were not statistically different. The greatest number of septic complications occurred in those patients with anastomotic disruptions. Two patients died (1.3%), both of whom had major anastomotic failures. There was no advantage between any of the groups in the incidence of wound infection (3.9-6.8%). Thus, no advantage could be identified in this study in the combination of oral and intravenous antibiotics in elective colorectal surgery.     

The continuing challenge of acute and perforated appendicitis.

A two year review of 216 patients with a preoperative diagnosis of appendicitis is used to help clarify the continuing points of controversy concerning appendicitis. Morbidity of perforated appendicitis by far exceeds that of nonperforated cases. Twenty-nine per cent of patients had perforation with a postoperative complication rate of 33 per cent. Rate of wound infection after perforation was 15 per cent despite antibiotics and delayed wound closure. Pediatric patients in this study did not experience a higher incidence of perforation or complication. A decision tree for management of acute appendicitis is presented.     

Is antibiotic administration indicated after outpatient cystoscopy

The incidence of urinary tract infection was examined in 138 patients who underwent diagnostic cystoscopy in an outpatient clinical setting with preoperatively sterile urine. A prospective randomized trial was conducted to compare the incidence of infection in patients who received no antibiotic (controls, group 1) and those who received a postoperative course of oral antibiotics (group 2). The incidence of bacteriuria after cystoscopy was 2.8 per cent in group 1 (control) and 1.5 per cent in group 2, with an over-all incidence of 2.2 per cent. Only 1 patient presented with a symptomatic infection (0.7 per cent). This study has confirmed the safety of outpatient cystoscopy and has demonstrated that routine administration of postoperative antibiotics is not indicated.     

Fungal infection in burn patients: Results of using 5-fluorocytosine (flucytosine)

Fungal infection and use of 5-fluorocytosine were studied prospectively among burn patients receiving multiple antibiotics. From 22 out of 23 patients positive cultures for Candida were obtained. Cultures from the mouth and rectum became positive first. Averaging 6 days later, 16 patients had positive urine cultures. Candida in urine was the best way to detect systemic candidiasis.Nine patients received 5-fluorocytosine. Although this drug did not influence survival among patients with burns of less than 59 per cent of body surface area, it prevented death from disseminated Candida infection among patients with burns of greater than 60 per cent body surface area.Patients with large surface burns receiving multiple antibiotics should have prophylaxis against fungi. If Candida is detected in urine, systemic treatment should be given. 5-Fluorocytosine is a safe and effective systemic drug for this purpose.     

Acute nonperforating appendicitis. Efficacy of brief antibiotic prophylaxis

A prospective, randomized, double-blind clinical study was performed to determine the efficacy of perioperative systemic antibiotics in preventing infection after appendectomy for acute nonperforating appendicitis. One hundred three patients received three doses of either placebo (saline, n = 52) or cefoxitin sodium (n = 51). The two groups were similar with regard to age distribution, sex ratio, duration of operation, pathologic condition of appendix, and hospital stay. Postoperative wound infections were detected in 9.6% of the placebo-treated patients, whereas none occurred in the cefoxitin group. All but one infection appeared after discharge. Cost analysis identified a net savings of $ 84 per patient with the use of prophylactic antibiotics. Septic morbidity after appendectomy for nonperforating appendicitis is significantly reduced by systemic antibiotics, and brief administration of a single broad-spectrum agent (cefoxitin) is effective prophylaxis.     

Failure of topically applied antibiotics, added to systemic prophylaxis, to reduce perineal wound infection in abdominoperineal excision of the rectum

In a prospective, randomized trial, prophylactic use of topical antibiotics in addition to systemic prophylaxis was studied in patients undergoing abdominoperineal amputation of the rectum. All patients received gentamicin 80 mg and metronidazole 500 mg intravenously at induction of anesthesia, followed by the same dose 8 hourly for 48 hours. In accordance with the randomization, half of the patients were additionally given gentamicin 160 mg + metronidazole 400 mg topically into the perineal wound at closure. Perineal wound infection appeared in 19 of the 41 patients who received both systemic and topical prophylaxis, and in 18 of the 38 with only systemic antibiotics. Cell-mediated immunity was preoperatively assessed with a skin test (Multitest) in all but three patients. Impairment of cell-mediated immunity was associated with significantly heightened rate of wound infection, and these patients did not benefit from topical antibiotics.