Antibiotic infection prophylaxis in gallbladder surgery--a prospective randomized study

Antibiotic prophylaxis for patients undergoing elective laparoscopic cholecystectomy

BACKGROUND

Cholecystectomy is a common surgical procedure. In the open cholecystectomy area, antibiotic prophylaxis showed beneficial effects, but it is not known if its benefits and harms are similar in laparoscopic cholecystectomy. Some clinical trials suggest that antibiotic prophylaxis may not be necessary in laparoscopic cholecystectomy.

OBJECTIVES

To assess the beneficial and harmful effects of antibiotic prophylaxis versus placebo or no prophylaxis for patients undergoing elective laparoscopic cholecystectomy.

SEARCH STRATEGY

We searched the The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (Issue 3, 2010), MEDLINE (1985 to August 2010), EMBASE (1985 to August 2010), SCI-EXPANDED (1985 to August 2010), LILACS (1988 to August 2010) as well as reference lists of relevant articles.

SELECTION CRITERIA

Randomised clinical trials comparing antibiotic prophylaxis versus placebo or no prophylaxis in patients undergoing elective laparoscopic cholecystectomy.

DATA COLLECTION AND ANALYSIS

Our outcome measures were all-cause mortality, surgical site infections, extra-abdominal infections, adverse events, and quality of life. All outcome measures were confined to within hospitalisation or 30 days after discharge. We summarised the outcome measures by reporting odds ratios and 95% confidence intervals (CI), using both the fixed-effect and the random-effects models.

MAIN RESULTS

We included eleven randomised clinical trials with 1664 participants who were mostly at low anaesthetic risk, low frequency of co-morbidities, low risk of conversion to open surgery, and low risk of infectious complications. None of the trials had low risk of bias. We found no statistically significant differences between antibiotic prophylaxis and no prophylaxis in the proportion of surgical site infections (odds ratio (OR) 0.87, 95% CI 0.49 to 1.54) or extra-abdominal infections (OR 0.77, 95% CI 0.41 to 1.46). Heterogeneity was not statistically significant.

AUTHORS' CONCLUSIONS

This systematic review shows that there is not sufficient evidence to support or refute the use of antibiotic prophylaxis to reduce surgical site infection and global infections in patients with low risk of anaesthetic complications, co-morbidities, conversion to open surgery, and infectious complications, and undergoing elective laparoscopic cholecystectomy. Larger randomised clinical trials with intention-to-treat analysis and patients also at high risk of conversion to open surgery are needed.

Effectiveness of ceftriaxone versus cefoxitin in reducing chest and wound infections after upper abdominal operations

A controlled randomized trial with blind assessment of end results is described comparing the efficacy of 1 g of intravenous ceftriaxone at induction of anesthesia with 1 g of intravenous cefoxitin (three times) administered every 8 hours starting at induction in preventing pulmonary and wound infection after upper abdominal operations. There were 150 adults who underwent biliary or gastroduodenal operations who were randomized to each protocol. A total of 123 patients completed the protocol--59 received ceftriaxone and 64 cefoxitin. Chest infection was defined as pyrexia plus clinical and/or radiologic signs of consolidation or the production of purulent sputum. Wound infection was defined as purulent wound discharge. There was a significant reduction (19% versus 42%, P < 0.05) in chest complications and in wound infection (0% versus 8%, P < 0.05) in the ceftriaxone group compared with the cefoxitin group. It is concluded that for biliary and gastroduodenal operations, 1 g of ceftriaxone is superior to 1 g of cefoxitin (three times) administered every 8 hours and that this effect is likely to be due to the prolonged bactericidal blood levels produced by a single dose of ceftriaxone.

Prophylaxis against sepsis in patients undergoing major surgery

Postoperative infection in general surgical patients is discussed according to operation types. A selection of the huge literature on each group is reviewed, and details from the author's own work and ideas are presented. By discussing these points attempts are made to determine the best regimens for a given set of clinical circumstances. There is a small literature indicating that postoperative chest infection can be prevented by some antibacterial drug regimens, and this question has been addressed; it seems that in the past it has been largely ignored. Some nonantibacterial methods of reducing postoperative infection are also briefly discussed.

[Complications in pre- versus intraoperative one-time prophylaxis with cefuroxime after biliary surgery]

The trial was conducted with 66 patients undergoing cholecystectomy. At random, 33 patients received 1.5 g cefuroxime i.v. as a single bolus 20 minutes before surgical incision and 33 patients were injected 20 minutes after incision. The overall incidence of wound infections was 1.51%. In the preoperative group, there was the one wound infection and two patients developed urinary tract infections (incidence of infectious complications 9.1%). In the intraoperative group, one patient developed pneumonia and urinary tract infection and another had urinary tract infection. Wound infections did not occur in this group (incidence of infectious complications 6.1%). Patients with infectious complications had a longer operation time and a longer hospital stay. In conclusion, there was no statistically significant difference in infectious complications when cefuroxime prophylaxis was given preoperatively compared to intraoperative administration.

[Possibilities for the use of 2nd generation cephalosporins in perioperative antibiotic prophylaxis]

Perioperative antibiotic prophylaxis has proven to prevent infections in a variety of surgical interventions such as colorectal, biliary and vascular surgery. The antimicrobial spectrum of an antibiotic used for perioperative prophylaxis should include Staphylococcus spp., Streptococcus spp. and Escherichia coli which are among the most frequent pathogens isolated from surgical infections. Second generation cephalosporins provide appropriate activity against these microorganisms. In colorectal surgery, combination with an anti-anaerobic agent is mandatory. During the past few years no major resistance development has been observed against second generation cephalosporins which are used at a dosage of 1.5 to 2 g. A single dose may provide sufficient serum levels for approximately three hours. Prolonged surgical procedures need an additional dose. Single dose prophylaxis with a second generation cephalosporin appears to be an appropriate strategy for infection prevention in surgery with regard to efficiency, safety and costs.