Antibiotic prophylaxis in major surgery of the neck and head

Twenty-two patients undergoing major head and neck surgery were included in a randomized trial to value the efficacy and side effects of parenteral short-term antibiotic prophylaxis of post-operative infections. Two different antibiotic regimens were compared: group A, ceftazidime i.v. (2 g) in three doses (half an hour before surgery, 8 and 16 hours, from the first dose); group B, netilmicin (100 mg) plus clindamycin (600 mg i.v.), following the same chronological schedule. Overall infection rate was 18% (4/22): all post-operative infections occurred in group A patients, including one case of wound infection and 3 mixed infections (wound infection associated with lung infection), with a significant reduction of post-operative infection rate in group B patients (p = 0.045; Fisher's exact test).     

Single-dose v. short-term antibiotic therapy for prevention of wound infection in general surgery. A prospective, randomized double-blind trial

To investigate the effectiveness of a single-dose antibiotic regimen for preventing postoperative wound infection, a prospective, randomized double-blind trial was carried out in patients undergoing "clean-contaminated", "contaminated" or "clean" (vascular) surgery. Both elective and emergency operations were included. Single-dose (preoperative) prophylaxis was compared with short-term prophylaxis (1 dose preoperatively and 2 doses postoperatively). The antibiotics were penicillin, tobramycin and metronidazole in various combinations, and comparisons between single-dose and short-term prophylaxis were made with all the regimens. The incidence of wound infection was 5/277 (1.8%) in the short-term group and 9/287 (3.1%) in the single-dose group. The difference was not statistically significant. Nor was statistically significant difference found when the type of operation and the degree of contamination were considered. Single-dose antibiotic prophylaxis thus gave a low incidence of postoperative wound infection, even in "clean-contaminated" or "contaminated" cases.     

Antibiotic prophylaxis in hip fracture surgery: a metaanalysis

A metaanalysis was done to identify the most effective prophylactic antibiotic regimen in hip fracture surgery. Specific comparisons addressed were antibiotics at any dose versus placebo, multiple doses (>24 hours coverage) versus one dose of antibiotics, and multiple doses versus 24 hours antibiotic coverage. Outcomes measured included overall wound infections, deep wound infection, superficial wound infection, urinary tract infection, and mortality. A computer search of the Medline and EMBASE databases (English language literature from 1966 to 2000 and 1988 to 2000, respectively) retrieved 15 randomized controlled trials which addressed the specific aims. Most studies evaluated antibiotics from the cephalosporin group. Antibiotic prophylaxis significantly reduced overall wound infections when compared with placebo and was equally effective for deep and superficial infections. One dose of intravenous antibiotics seemed no different than multiple doses. Antibiotic use also was associated with a significant reduction in the incidence of urinary tract infection but had no significant effect on mortality.     

Antibiotic prophylaxis in cerebrospinal fluid shunting: a prospective randomized trial in 129 patients

The efficacy of a single dose of cefotiam, a cephalosporin of the second generation, as prophylaxis for postoperative infection was analyzed in a prospective randomized study of 129 patients undergoing cerebrospinal fluid shunting. The main focus of interest was the rate of shunt infection requiring operative shunt removal. Data were evaluated in the total group and subgroups formed for normal and high risk patients, respectively. The overall rate of shunt infection was 7.5% in the cefotiam group and 12.9% in the control group. In the high risk subgroup infection rate was 14.3% with and 26.3% without cefotiam as opposed to 4.3% and 6.9%, respectively, in the normal risk subgroup. Although our results do not reach statistical significance, there is a noticeable difference of infection rate between those patients who receive the antibiotic and those who do not. Therefore, we favor single dose antibiotic prophylaxis in shunting procedures.     

手部深层组织严重感染的治疗

目的：探讨手部深层组织严重感染的治疗方法。方法：对378例手部深层组织严重感染患者，术前创面严格抗感染治疗，术中创面彻底清创，在清洁创面上覆盖血运丰富的游离肌皮瓣。术后创面用敏感抗生素溶液冲洗治疗。结果：378块肌皮瓣中，337块全部存活，一次手术治愈率为89．1％；另41例皮瓣远端部分坏死，第2次清创后用局部皮瓣修复。结论：手部深层组织严重感染者，在彻底清创的基础上用吻合血管的肌皮瓣移植，是一种有效的治疗方法。     

Cefuroxime in total joint arthroplasty. Intravenous or in bone cement

A prospective randomized clinical trial was performed in two centers to compare the effect of systemic cefuroxime and cefuroxime in bone cement in the prophylaxis of infection after total joint arthroplasty. In two comparable groups comprising 200 and 201 patients, there was no statistically significant difference in the incidence of superficial wound infection. The early deep infection rate was 1%, with no difference detected between the group that received antibiotic in bone cement and the group that received systemic antibiotic. There were no late deep infections. It is concluded that cefuroxime given systemically or in bone cement is an effective antibiotic in the prophylaxis of infection after total joint arthroplasty.     

Identification and antibiotic prophylaxis of high-risk patients in biliary tract surgery]

A prospective randomized trial has compared 3 policies of antibiotic prophylaxis in biliary surgery. Patients considered to be high-risked against postoperative infection were randomly allocated to 2 groups: in group CTM-H, patients were given cefotiam; in group CMX-H, patients were given cefmenoxime. Patients free of risk factors (group CTM-L) were all given cefotiam. The high-risk factors adopted in this trial were; emergency surgery, presence of jaundice or cirrhosis, malignant disease, diabetes mellitus, age over 70, recent biliary tract infection, choledocholithiasis, and previous biliary surgery. Postoperative infection occurred in 2.1% (4/190) in the CTM-L group, which was lower compared to 15.5% (11/71) of the CMT-H group (p less than 0.01), and 11.3% (8/71) of the CTM-H group (p less than 0.01). The rates of bacterial isolation from intraoperative bile culture and wound swab were significantly high in the two high-risk groups compared to the low-risk group, but is was not different within the two high-risk groups. These findings suggest that while cefotiam is appropriate for prophylaxis for the low-risk patients, the utmost care should be taken in the high-risk patients to prevent intraoperative contamination along with prophylactic antibiotic therapy which covers the bacteria isolated from the bile.     

Perioperative Antibiotikaprophylaxe bei transperitonealer Tumornephrektomie

This monocentric prospective randomized study was designed to determine the efficacy of single-shot perioperative antibiotic prophylaxis with 1 g ceftriaxone i.v. in transperitoneal tumor nephrectomy. Eighty-three patients were randomized either into a prophylaxis or a control group: 39 patients received 1 g ceftriaxone i.v. 30 min preoperatively and 44 no study medication. Characteristics of the two groups showed no statistical differences. Postoperative overall infection rates were 7.7% and 27.3% (p=0.007), respectively. Postoperative assessment revealed overall 0 (0%)/7 (15.9%) wound infections, 0 (0%)/2 (4.5%) deep wound infections, 1 (2.6%)/2 (4.5%) pneumoniae, and 2 (5.2%)/3 (6.8%) significant urinary tract infections. In 4 (10.3%)/4 (9.1%) patients, postoperative antibiosis was started without detection of an infectious focus. Overall antibiotic treatment was carried out in 7 (17.9%)/12 (27.3%) patients postoperatively. Costs of antibiotic prophylaxis and/or treatment resulted in 23.60/30.10ZZZ;EUR per patient. Perioperative prophylaxis with 1 g ceftriaxone i.v. decreases postoperative infection rates. Although not all infections have to be treated with antibiotics, there are pharmacoeconomic advantages of such prophylaxis.     

Cefazolin versus cefamandole for prophylaxis during total joint arthroplasty

A prospective, randomized, double-blind comparison of cefazolin versus cefamandole was carried out to evaluate safety and efficacy and to determine bone and serum antibiotic concentrations in patients undergoing total joint arthroplasty. Dosages were 1 g of cefazolin before surgery followed by 500 mg every eight hours for six doses, versus 2 g of cefamandole before surgery followed by 1 g every eight hours for six doses. Intraoperative doses were given during prolonged procedures. No significant adverse drug reactions were clearly attributable to either drug. Among 48 patients receiving cefazolin there was one postoperative wound infection and one distant site infection. Among 49 patients receiving cefamandole, there were two postoperative wound infections and two distant site infections. No deep wound infections occurred in either group during at least 48 months of follow-up study. In hip specimens removed at surgery, the mean antibiotic concentrations were 1.6 +/- 1.4 micrograms/g for cefazolin recipients, compared with 5.7 +/- 5.9 micrograms/g for cefamandole recipients (p less than .001). In knee specimens, the mean antibiotic concentrations were 0.64 +/- 0.57 microgram/g for cefazolin recipients compared to 3.8 +/- 3.4 micrograms/g for cefamandole recipients (p = .004). Cefazolin given at one-half the dose of cefamandole appeared to be equally safe and effective but resulted in lower bone concentrations of antibiotic.     

Intraoperative antibiotic wound lavage: an attempt to eliminate postoperative infection in arterial and clean general surgical procedures.

Intraoperative antibiotic wound lavage has been used in all arterial reconstructive procedures for the past 7 years and reduced the incidence of early and late postoperative infections from 1.5% in 400 operations prior to 1969 to 0.23% (one post-hospital) in 434 patients operated since that date. In 226 consecutive clean major general surgical procedures since June 1971 there has been no early or late wound infections following intraoperative antibiotic wound lavage in contrast to an infection rate of 1.5% in 185 operations prior to that date. A double blind study of 200 patients undergoing operations for varicose veins was carried out as follows: The wounds of alternate patients were irrigated either with normal saline or with antibiotic solution. There were no gross (grade II) postoperative wound infections. Minor skin changes were noted in 93 of 632 incisions in the saline group and only 49 of 608 incisions irrigated with antibiotic solution (P less than 0.001). In clean operations without antibiotic wound lavage there was a 0.73% rate of in-hospital wound infections in 685 patients in contrast to a zero rate in 760 patients wherein intraoperative wound lavage was carried out throughout the operative procedure.     

Sternal wound infections in patients undergoing open heart surgery: randomized study comparing intracutaneous and transcutaneous suture techniques.

BACKGROUND: Intracutaneous suture technique has been our standard method for closing sternal wounds in cardiac surgery, mainly for cosmetic reasons. However, an increased rate of postoperative infections has been reported in cosmetic surgery with this method compared with the percutanous or transcutaneous closure technique. A comparison of these two techniques in cardiac surgery is presented. METHODS: In a randomized study, 300 patients were selected to intracutaneous suture (n = 150) or percutanous suture (n = 150). The endpoints were superficial and deep sternal wound infections within 6 weeks postoperatively. RESULTS: The total infection rate was lower in the percutanous group compared with the intracutaneous group (3% versus 8%) (p = 0.007). The superficial infection rate was lower in the percutaneous group (2.3% versus 6.7%) (p = 0.01), whereas there was no statistically significant difference in the deep infection rate between the groups. CONCLUSIONS: The percutaneous suture technique reduces the incidence of superficial wound infections, but not the deep infection rate in open heart surgery. There was no difference in the cosmetic results on a visual scale, assessed by the patients.     

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.     

Single dose prophylaxis in elective cholecystectomy. A prospective, double-blind randomized study

We tested the effectiveness of a single dose of prophylactic antibiotic (gentamicin) in elective cholecystectomy in a double-blind, controlled randomized study. All patients recognized preoperatively as being at risk were excluded. The treatment group comprised of 102 patients received a single dose of gentamicin and the 74 patients in the control group received a placebo. Of the patients who received gentamicin, wound infection developed in 4.9 percent versus 13.5 percent in the control group. Among 45 patients who had positive bile cultures, the wound infection rate for those in the treatment group was 14 percent versus 44 percent for those in the control group. Of 17 patients who underwent unexpected exploration of the choledochus, none of those in the treatment group had development of wound infection. The rate of wound infection in the control group was 50 percent. As 30 percent of the patients undergoing elective cholecystectomy were found to have risk factors for the development of wound infection which could not be identified preoperatively, we recommend single dose prophylaxis for all patients undergoing cholecystectomy.     

Perioperative antibiotic prophylaxis for prevention of postoperative neurosurgical infections. A randomized clinical trial

The authors report the results of a randomized, prospective study to assess the effectiveness of perioperative antibiotic prophylaxis in preventing postoperative infections following clean neurosurgical operations. The study group comprised 846 patients treated between October, 1979, and June, 1984. Antibiotics, including cefazolin and gentamicin, were administered only in the immediate preoperative and intraoperative periods. Sixteen patients, none of whom developed infections, were excluded from final statistical analysis because they had inadvertently been entered into the study while failing to meet entry criteria. Fifteen wound infections (3.64%) developed in the group of 412 patients who did not receive antibiotics, whereas only four infections (0.96%) were identified among the 418 patients who received antibiotics. The difference is statistically significant (p = 0.008) and represents a 74% reduction in infection rate with antibiotics. An analysis of subgroups of surgical procedures revealed a dramatic decrease in craniotomy infections from 6.77% to 0% (p = 0.003). Of the four infections that occurred among the antibiotic-treated patients, three were in cases where foreign bodies had been implanted. No complications of antibiotic usage were identified. The rates of infection in areas of the body other than the surgical wound were no different in the antibiotic-treated and nontreated groups. All wound infections in both antibiotic-treated and nontreated patients involved similar types of Gram-positive organisms, suggesting that antibiotic prophylaxis did not produce infections with resistant or unusual organisms. This study, combined with other recently published analyses, suggests that routine perioperative antibiotic prophylaxis can significantly reduce the incidence of postoperative neurosurgical infections.     

Comparison between antibiotic irrigation and mobilization of pectoral muscle flaps in treatment of deep sternal infections

Between January of 1978 and December of 1983, 41 patients developed deep sternal infections with mediastinitis after cardiac operations. Between January of 1978 and December of 1981, 19 of these patients were treated with débridement, primary wound closure, and mediastinal antibiotic irrigation (Group I). Between January of 1982 and December of 1983, 22 patients were treated with débridement, open "clean" packing, and delayed wound closure by the technique of pectoral muscle flap mobilization, which preserves the thoracoacromial pedicles and the pectoral humeral attachments (Group II). The purpose of this study was to compare the results of the treatment of deep sternal infections after cardiac operations with these two techniques. The perioperative hemodynamic, operation, functional, and pathological profiles of both groups of patients were the same. The cosmetic and functional results were the same in both groups as were shoulder girdle and torso mobility. We conclude that either technique is equally effective in the management of patients in whom the serious complication of deep sternal infection with mediastinitis develops after cardiac operation, and we now recommend débridement and pectoral muscle flap closure in one stage.     

The use of prophylactic flucloxacillin in treatment of open fractures of the distal phalanx within an accident and emergency department: a double-blind randomized placebo-controlled trial

Open fractures of the distal phalanx commonly present to the Accident and Emergency Department. Controversy surrounds the use of prophylactic antibiotics in treating this injury. A double-blind, prospective, randomized placebo-controlled study was undertaken comparing the use of prophylactic flucloxacillin to placebo in addition to meticulous wound toilet. One hundred and ninety-three adult patients with an open fracture of the distal phalanx were studied. Seven patients developed superficial infections, an overall infection rate of 4%. No patient developed osteitis or a deep wound infection. There were three cases of infection in the 98 patients (3%) in the antibiotic group and four cases of infection in the 95 patients (4%) in the placebo group. A difference of proportion test confirmed no significant difference. It is concluded that the addition of prophylactic flucloxacillin to thorough wound toilet and careful soft-tissue repair of open fracture of the distal phalanx confers no benefit.     

Cefamandole in gastroduodenal surgery: a controlled, prospective, randomized, double-blind study

Acceptance of the value of antibiotic prophylaxis in gastroduodenal surgery is growing, but only one controlled, double-blind study justifying this is available. In this second, controlled, randomized, double-blind study 60 patients underwent urgent and elective gastroduodenal operations. Among 32 patients receiving cefamandole perioperatively for prophylaxis, only 1 subsequently had a wound infection, but wound infections occurred in 8 of the 28 patients who received a placebo (P less than 0.01). Infection rates were higher in contaminated wounds and in urgent operations than in clean-contaminated wounds and elective surgery. The results confirm the value of antibiotic prophylaxis in this setting.     

The use of an iodophor-impregnated plastic incise drape in abdominal surgery--a controlled clinical trial

A prospective randomized clinical trial comparing the use of a new iodophor-impregnated incise drape with a standard skin preparation technique in 1102 patients undergoing abdominal surgical procedures is reported. The effect of the incise drape on wound bacterial contamination and subsequent wound infections is compared. The iodophor-impregnated plastic incise drape reduced the contamination of the wound. In particular, isolates of normal skin organisms were less frequent when the drape was used in clean and clean contaminated procedures. However, no difference was found between the wound infection rates for the patients on whom the iodophor drape was used and those patients on whom the drape was not used.     

The role of antibiotic prophylaxis in prevention of wound infection after Lichtenstein open mesh repair of primary inguinal hernia: a multicenter double-blind randomized controlled trial

OBJECTIVE: To determine whether the use of prophylactic antibiotics is effective in the prevention of postoperative wound infection after Lichtenstein open mesh inguinal hernia repair. SUMMARY BACKGROUND DATA: A recent Cochrane meta-analysis (2003) concluded that "antibiotic prophylaxis for elective inguinal hernia repair cannot be firmly recommended or discarded." METHODS: Patients with a primary inguinal hernia scheduled for Lichtenstein repair were randomized to a preoperative single dose of 1.5 g intravenous cephalosporin or a placebo. Patients with recurrent hernias, immunosuppressive diseases, or allergies for the given antibiotic were excluded. Infection was defined using the Centers for Disease Control and Prevention criteria. RESULTS: We included 1040 patients in the study between November 1998 and May 2003. According to the intention-to-treat principle, 1008 patients were analyzed. There were 8 infections (1.6%) in the antibiotic prophylaxis group and 9 (1.8%) in the placebo group (P = 0.82). There was 1 deep infection in the antibiotic prophylaxis group and 2 in the placebo group (P = 0.57). Statistical analysis showed an absolute risk reduction of 0.19% (95% confidence interval, -1.78%-1.40%) and a number needed to treat of 520 for the total number of infections. For deep infection, the absolute risk reduction is 0.20% (95% confidence interval, -0.87%-0.48%) with a number needed to treat of 508. CONCLUSIONS: A low percentage (1.7%) of wound infection after Lichtenstein open mesh inguinal (primary) hernia repair was found, and there was no difference between the antibiotic prophylaxis or placebo group. The results show that, in Lichtenstein inguinal primary hernia repair, antibiotic prophylaxis is not indicated in low-risk patients.     

Postoperative deep wound infection in adults after posterior lumbosacral spine fusion with instrumentation: incidence and management

The authors reviewed 817 instrumented lumbosacral fusions in adults and found an incidence of 3.2% deep wound infections. The primary focus of this study was the management of these infections, with particular attention to whether the implants needed to be removed. A consulting infectious disease specialist indicated that an acute infection of a low back fusion wound could not be healed without removal of the metallic implants. This opinion was in contrast to the authors' daily experience and prompted this study. The authors identified and reviewed 817 cases of instrumented posterior lumbosacral arthrodeses in adults. A detailed analysis of any case with a deep wound infection was performed and yielded and infection rate of 3.2% (26 patients). Of these, 24 achieved a clean, closed wound without removal of instrumentation through a protocol of aggressive debridement and secondary closure. Instrumentation removal is not necessary to obtain a clean, closed wound using an aggressive approach with early diagnosis, vigorous debridement in the operative room under general anesthesia, delayed primary or secondary closure, and appropriate antibiotic coverage.