Antimicrobial prophylaxis for surgery

Indications of antibiotic prophylaxis in dental practice- review

Antibiotics are frequently used in dental practice. Clinical and bacteriological epidemiological factors determine the indications of antibiotics in dentistry. Antibiotics are used in addition to appropriate treatment to aid the host defences in the elimination of remaining bacteria. It is indicated when there is evidence of clinical sign involvement and spread of infection. Antibiotics are prescribed in dental practice for treating odontoge nic infections, non-odontogenic infections, as prophylaxis against focal and local infection. Special care needs to be addressed to patients with organ transplants, poorly controlled diabetes and pregnancy. Antibiotics should be used only as an adjunct to dental treatment and never alone as the first line of care. The present paper reviews the indications of antibiotics in dental practice.

A Pilot Study to Determine the Effectiveness of Different Amoxicillin Regimens in Implant Surgery

The aim of this study was to attempt to determine the minimum effective regimen of amoxicillin antibiotic prophylaxis for dental implant surgery. One hundred patients were randomly allocated to 4 different antibiotic prophylactic treatment groups. At second-stage surgery, only 2 implants failed in the nonantibiotic group. No statistically significant differences were found in the 4 groups, probably because of the limited number of the samples. Until a study with a larger population may definitely rule on the role of antibiotics in oral implant surgery, in may be prudent for the practitioner to adopt the single preoperative antibiotic dose as the minimal effective regimen.

Antimicrobial use in the surgical patient

Antimicrobials are often used in the surgical patient in an effort to prevent infection (prophylactic) or to treat established infection (therapeutic). To be effective, prophylactic antimicrobials at appropriate concentrations must be present in tissues at the surgical site at the time of contamination to prevent bacterial growth and subsequent infection. Therapeutic antimicrobials are used to treat established localized or systemic infection. Selection of antimicrobial agents for prophylactic or therapeutic use should be based on knowledge of expected flora, ability of the antimicrobial to reach the target tissue at appropriate concentrations, bacterial resistance patterns, drug pharmacokinetics, and culture and susceptibility testing results (therapeutic use). Failure of antimicrobial therapy to prevent or treat infection in the surgical patient may result from poor antimicrobial selection, inappropriate dosage or frequency, or inappropriate duration of therapy.

Antibiotic prophylaxis: problems in paradise

The age of antibiotic prophylaxis may be receding into its twilight years because the assumption upon which it was based has not proved generally true. Although antibiotics treat infections, limited benefit has been demonstrated in preventing infections. These are two entirely different biologic entities, a distinction which appears to have gone unappreciated by many for more than 50 years. If the principles of antibiotic prophylaxis established more than 40 years ago had been assiduously followed, many of its abuses could have been avoided. This may not have stopped our legal colleagues, but it would have been worth an effort on behalf of our patients. It is likely that the massive overuse of antibiotics as litigation prevention has contributed to the global epidemic of antibiotic-resistant micro-organisms and an unknown number of serious adverse effects to the antibiotics themselves. Even with this abuse, much money has still flowed from defendant to plaintiff. Substantial data exist that antibiotics do not prevent bacteremias. The absolute risk rate for bacterial endocarditis after dental treatment even in at-risk patients is very low. Antibiotic prophylaxis for surgical infections requires specific dosing schedules (perioperative surgical prophylaxis) to be successful. Hopefully the difficulties presented herein regarding antibiotic prophylaxis will lead to their more enlightened use in the future.

The identification of barriers preventing the successful implementation of a surgical prophylaxis protocol

AIM

The aim of this study was to introduce a protocol for the use of antimicrobials in surgical prophylaxis for the described procedures in Antrim Area Hospital.

METHOD

Historical data of antimicrobial use were obtained from retrospective analysis of patients' charts, for those patients identified as having one of the following 'clean/contaminated' surgical procedures over the previous six months; cholecystectomy or abdominal hysterectomy. These data were analysed, and a protocol was introduced providing guidelines for the choice of antimicrobial agent, its administration time, route, dose, duration and frequency of treatment.

MAIN OUTCOME MEASURE

The main outcome measure was the success of the uptake of the protocol following its implementation.

RESULTS

There was a total of 285 patients identified, 105 prior to and 180 post implementation. Overall, 68% of patients received some form of prophylaxis in the first cycle, and 72% in the second.

CONCLUSION

Although the introduction of the protocol led to slight improvements in compliance with standard prescribing procedures, with an increase in single-dose prophylaxis, and a reduction in prolonged prophylactic treatment, the improvements did not reach expectations. This paper attempts to identify the possible barriers to protocol implementation.

Antibiotic prophylaxis for endocarditis, prosthetic joints, and surgery

It would seem from a review of the evidence that the need for antibiotic prophylaxis in dentistry is overstated. In simple mathematic terms, the risk for providing coverage is greater than the outcomes that could arise if coverage is withheld. In addition, there is the increasing problem of the development of resistant strains and their impact on medicine and dentistry. Yet despite these observations, the profession continues to put their patients at this greater risk. Medico-legal issues do cloud judgments in this area and many dentists err on the side of caution. The profession does require clear, uniform guidelines that are evidence-based. At present, there is still significant debate as to who is at risk from dental-induced bacteremia and what procedures require chemoprophylaxis.

Is single-dose antibiotic prophylaxis sufficient for any surgical procedure?

The objective of perioperative prophylaxis is to prevent postoperative infections, which are the primary cause of morbidity and mortality in patients undergoing surgery today. One cannot predict with certainty when bacterial contamination at the operative site may occur during surgery. Furthermore, it has been suggested that the period of highest risk may actually be at the end, rather than at the beginning, of the operation. Therefore, the effect of antimicrobial prophylaxis ideally should cover the entire perioperative "period of risk". It should be remembered that the period of risk for postoperative infection may last substantially longer than the actual surgical procedure. The duration of the risk period also may vary based on a number of other factors, such as the age and general condition of the patient, presence of concomitant disease, amount of blood loss during surgery, and number of blood transfusions required. Antimicrobial prophylaxis that provides coverage throughout the entire perioperative period of risk will reduce not only the risk of wound infections but may also reduce the danger of other types of infectious complications. Numerous clinical studies have clearly shown that appropriately-timed "single shot" prophylaxis is as effective as multiple-dose prophylaxis. This paper considers the evolution of this therapeutic intervention and reviews the opportunities available for antibiotic prophylaxis in surgery, with particular attention to the long-acting cephalosporin, ceftriaxone.

Surveillance of antimicrobial prophylaxis for surgical procedures

OBJECTIVE

To assess the practice of antimicrobial prophylaxis for surgical procedures in eight surgical departments in a 550-bed teaching hospital.

METHODS

A list of all major procedures performed in our hospital, with recommendations for prophylaxis based upon the literature, has been distributed since 1993 and is updated periodically. The practice of surgical prophylaxis between January 1 and March 31, 1996, was examined by assessing four variables: (1) Did the particular procedure justify prophylaxis, and was it provided? (2) Was timing optimal, ie, within 1 hour prior to surgery? (3) Was the appropriate antimicrobial selected? (4) Was duration optimal, ie, < or =24 hours?

RESULTS

During the study period, 2,117 operations were performed, of which 1,631 (77%) were reviewed. Sixty-six percent were clean surgery, 28% clean-contaminated, and 6% contaminated; 72% of procedures were elective, 28% emergencies. Of 1,631 operations requiring prophylaxis, 1,142 (70%) received it, 489 (30%) did not. Of 1,631 patients, 1,392 (85%) received appropriate care: 929 (67%) appropriately received prophylaxis, and 463 (33%) appropriately did not receive prophylaxis. Of 955 patients who received prophylaxis, 26 (3%) did so inappropriately. Of 1,142 patients who should have received prophylaxis, 213 (19%) did not receive it. Female gender, clean surgery, elective operations, and infrequently performed procedures were all significant indicators of inappropriately withheld prophylaxis (P<.001). In addition, the rate of appropriately provided prophylaxis varied between departments from 71% to 97% (P<.001). Assessment of the 929 procedures for which prophylaxis was justified and given revealed that 100% of patients received it on time, the choice of antimicrobial was appropriate in 95% of cases, and duration was < or =24 hours in 91%.

CONCLUSIONS

Audits of surgical prophylaxis are expected to detect different errors in different institutions. Conducting audits of surgical prophylaxis probably should be part of the routine activity of infection control teams. Feeding the information back to surgeons could improve adherence to recommended guidelines and might contribute to reduced wound infection rates.

Cost reduction with successful implementation of an antibiotic prophylaxis program in a private hospital in Ribeirão Preto, Brazil

OBJECTIVE

To describe the implementation and results of a perioperative antibiotic prophylaxis (PAP) program.

DESIGN

A protocol for correct use of PAP was implemented in December 1994. For selected months we measured the PAP protocol compliance of a random sample of clean and clean-contaminated procedures and calculated the cost of incorrect use of PAP. SELLING: A 180-bed general hospital in Ribeirão Preto, Brazil.

RESULTS

The cost of unnecessary PAP in the obstetric and gynecologic, cardiothoracic, and orthopedic services dropped from $4,224.54 ($23.47/procedure) in November 1994 to $1,147.24 ($6.17/procedure, January 1995), $544.42 ($3.58/procedure, May 1995), $99.06 ($0.50/procedure, August 1995), and $30 ($0.12/procedure, March 1996). In November 1994, only 13.6% of all surgical procedures were done with correct use of PAP, compared to 59% in January 1995, 73% in August 1995, 78% in March 1996, 92% in November 1996, and 98% in May 1997.

CONCLUSIONS

Incorrect PAP use wastes resources, which is a particular problem in developing countries. Our program is simple and can be implemented without the use of computers and now is being adopted in other hospitals in our region. We credit the success of our program to the commitment of all participants and to the strong support of the hospital directors.

Complications of dental surgery

Both retrospective data and clinical experience indicate that complications of dental surgery are occasionally encountered and, to some extent, are inevitable. Many of the reported complications related to dental surgery such as incomplete removal of diseased teeth or removal of the wrong tooth can be avoided with sound preoperative planning and intraoperative technique. Diseased teeth should be properly identified prior to and during surgery. In addition, complete removal of the diseased tooth must be performed. Use of intraoperative radiographic examination to confirm the location of the diseased tooth and to document its removal cannot be overemphasized. Iatrogenic fracture of the maxillary or mandibular alveolar walls or palatine bone can be avoided by proper placement of the dental punch. The chances of developing incisional drainage or secondary sinusitis can be reduced by use of appropriate systemic antibiotics. These factors should guide the surgical approach to dental surgery to reduce the likelihood of developing common complications.

Single- versus multiple-dose antimicrobial prophylaxis for major surgery: a systematic review

BACKGROUND

Single-dose antimicrobial prophylaxis for major surgery is a widely accepted principle; recommendations have been based on laboratory studies and numerous clinical trials published in the last 25 years. In practice, single-dose prophylaxis has not been universally accepted and multiple-dose regimens are still used in some centres. Moreover, the principle has recently been challenged by the results of an Australian study of vascular surgery. The aim of this current systematic review is to determine the overall efficacy of single versus multiple-dose antimicrobial prophylaxis for major surgery and across surgical disciplines.

METHODS

Relevant studies were identified in the medical literature using the MEDLINE database and other search strategies. Trials included in the review were prospective and randomized, had the same antimicrobial in each treatment arm and were published in English. Rates of postoperative surgical site infections (SSI) were extracted, 2 x 2 tables prepared and odds ratios (OR) [with 95% confidence intervals (95% CI)] calculated. Data were then combined using fixed and random effects models to provide an overall figure. In this context, a high value for the combined OR, with 95% CI > 1.0, indicates superiority of multiple-dose regimens and a low OR, with 95% CI < 1.0, suggests the opposite. A combined OR close to 1.0, with narrow 95% CI straddling 1.0, indicates no clear advantage of one regimen over another. Further subgroup analyses were also performed.

RESULTS

Combined OR by both fixed (1.06, 95% CI, 0.89-1.25) and random effects (1.04, 95% CI, 0.86-1.25) models indicated no clear advantage of either single or multiple-dose regimens in preventing SSI. Likewise, subgroup analysis showed no statistically significant differences associated with type of antimicrobial used (beta-lactam vs other), blinded wound assessment, length of the multiple-dose arm (> 24 h vs 24 h or less) or type of surgery (obstetric and gynaecological vs other).

CONCLUSIONS

Continued use of single-dose antimicrobial prophylaxis for major surgery is recommended. Further studies are required, especially in previously neglected surgical disciplines.

Prophylactic antibiotics in cataract operations

The rationale for prophylactic antibiotics in cataract operations must be continually reevaluated in light of cost-effectiveness and adverse reactions. The principles learned from wound infections associated with general surgical procedures should be applied to the limited knowledge about the rare event of endophthalmitis. Herein the literature on experimental and clinical wound infections in general surgical procedures is reviewed, with analysis of microbial flora, pathophysiology of wound infections, and pharmacokinetics of antibiotics. Experimental and clinical studies on prophylactic antibiotics to prevent endophthalmitis are reviewed, including information on topically applied antibiotics, chemical antisepsis, and administration of subconjunctival, intracameral, and systemic antibiotics. In addition, the benefits, limitations, and risks of the various types of prophylactic antibiotics are discussed. Because of the limited data on prophylactic antibiotics in cataract operations, providing dogmatic statements is difficult. General recommendations are offered based on the currently available literature, and a stratified approach is suggested based on wound construction and number of anterior segment maneuvers.