A comparative trial between cefotetan and cephazolin for wound sepsis prophylaxis during elective upper gastrointestinal surgery with an investigation of cefotetan penetration into the obstructed biliary tree

Prospective Control Study of Clinical Effectiveness of Prophylactic Antibiotics in Laparoscopic Cholecystectomy on Infection Rate

PURPOSE

This study evaluated the effectiveness of prophylactic antibiotics in elective laparoscopic cholecystectomy (LCC) for the reduction of postoperative infection rate.

MATERIALS AND METHODS

Elective LCC was performed on 529 patients at Jeonbuk National University Hospital between April 2015 and August 2017. A total of 509 patients were enrolled based on the inclusion criteria. This prospective study compared the results for antibiotic group (AG) (n=249, cefotetan 1 g, 1 dose/prophylactic) and non-antibiotic group (NAG) (n=260).

RESULTS

There were no significant differences in clinical characteristics between the two groups: AG and NAG (p=0.580, 0.782, and 0.325, respectively). Levels of C-reactive protein were higher in NAG compared to AG at postoperative day 2 (16.6±24.2 vs. 24.2±40.6; p=0.033). There were no significant differences in white blood cell counts and erythrocyte sedimentation rate. Fever ≥38℃ on postoperative day 2 occurred in 3 (1.2%) and 9 (3%) patients in AG and NAG, respectively. One patient in each group had subhepatic fluid collection by abdominal computed tomography, but there was no evidence of infection. Two patients in NAG (3%) had serous wound drainage on postoperative day 14.

CONCLUSION

Our results showed no significant differences in patients receiving or not receiving prophylactic antibiotics during LCC. Therefore, it is not necessary to use prophylactic antibiotics during elective LCC in patients who meet the inclusion criteria.

The impact of prophylactic antibiotics on postoperative infection complication in elective laparoscopic cholecystectomy: a prospective randomized study

BACKGROUND

The aim of this prospective randomized study was to investigate the necessity and impact of prophylactic antibiotics on postoperative infection complications in elective laparoscopic cholecystectomy.

METHODS

At the time of induction of anesthesia, group A patients (n = 141) received 1 g cefazolin, and group B patients (control; n = 136) received 10 mL isotonic sodium chloride solution. Patients' characteristics and general operative outcomes were compared and analyzed.

RESULTS

The overall rate of infection was 1.1% for total 277 patients (0.7% for group A patients and 1.5% for group B patients). No significant difference in infection complications was found between these 2 groups. Also any risk factors contributing to infection complications could not be found.

CONCLUSIONS

We do not recommend the use of prophylactic antibiotics in elective laparoscopic cholecystectomy because they will not decrease the already-low rate of postoperative infectious complications.

Double-blind comparison of cefazolin and ceftizoxime for prophylaxis against infections following elective biliary tract surgery

Antibiotics have been shown to reduce the incidence of wound infections after elective biliary tract procedures. Cefazolin and cefoxitin are among the agents most commonly promoted for this purpose. Cefoxitin has been substituted with ceftizoxime in many institutions; however, the role of ceftizoxime as a prophylactic agent in this setting has not been determined. To assess the comparative prophylactic efficacies of cefazolin and ceftizoxime in biliary tract surgery, we conducted a double-blind, randomized prospective clinical trial in a tertiary-care teaching hospital. Adult patients were randomized to one of two treatment groups and received a 30-min preoperative dose of study drug and as many as two postoperative doses at 12 and 24 h, depending on hospitalization status. Cefazolin and ceftizoxime were given as 1,000-mg doses. Patients with infections, those receiving prior antibiotics, or those with beta-lactam allergies were excluded. Over the 19-month study tenure, 167 patients were enrolled. Seventeen patients were excluded from analysis because of protocol violations. Of the 150 evaluable patients (72 and 78 receiving cefazolin and ceftizoxime doses, respectively), there was no significant difference among groups regarding sex, age, weight, preoperative Apache II score, baseline chemistry, and hematological parameters. Groups were also equivalent regarding the surgeon, type of procedure, characteristics (blood loss, drains, organ injury, and complications), and duration of hospital stay (mean, 5.6 versus 4.3 days [P = 0.31]). No clinical evidence of infection (7-day hospital stay and 30-day follow-up) was identified in 93% of cefazolin and 92% of ceftizoxime patients (P = 1.0). Microbiological confirmation was found in only 18% of primary-site infections. In conclusion, cefazolin and ceftizoxime appear to be equivalent for the prevention of infection in biliary tract surgery with the dosage regimens studied.

Clinical pharmacokinetics of cefotetan

Cefotetan is a 7-alpha-methoxy beta-lactam. A long serum half-life and resistance to beta-lactamase hydrolysis have made cefotetan an attractive chemotherapeutic agent, and the results of clinical trials worldwide have demonstrated its efficacy in a wide variety of clinical situations. Cefotetan can be administered intravenously (bolus or infusion) or intramuscularly with lidocaine (lignocaine) 0.5%. Mean peak plasma concentrations are almost linearly related to dose. The volume of distribution is between 8 and 13L and is not different from other cephalosporins. No accumulation is seen after repeated doses and no metabolite has been detected in either plasma or urine. Total body clearance is 1.8 to 2.9 L/h. Renal clearance accounts for about 64 to 84% of a dose, and 75% of a dose is excreted in the urine within 24 hours. The plasma elimination half-life is between 3 and 4 hours after intravenous and intramuscular doses. Half-life is considerably prolonged in patients with renal impairment (up to 10 hours). Cefotetan concentrations are likely to be active against susceptible bacteria in most tissues and body fluids. Breast milk and cerebrospinal fluid concentrations are low. The recommended dosage is 1g every 12 hours, increasing to 2g in severe infections and 3g in life-threatening infections. In surgical prophylaxis, a single dose of 2g is given with the induction of anaesthesia; an additional dose of 2g may be administered 12 hours later. In children over 6 months, the recommended dosage is 30 mg/kg given 12-hourly. In patients with a creatinine clearance of 10 to 40 ml/min (0.6 to 2.4 L/h), the dose is halved or the dosage interval is doubled. When creatinine clearance is less than 10 ml/min (0.6 L/h), the dose is quartered or the dosage interval quadrupled.

[Antibiotic prophylaxis in gastroduodenal surgery]

The incidence of postoperative wound infections is increased up to 35% after gastroduodenal surgery, when gastric motility and acidity are decreased, as in case of gastric ulcer or cancer, obstruction, bleeding, antacid therapy. The endogenous flora contaminating the operative-site consists of organisms of the oropharynx and the jejunum and includes anaerobes like bacteroides, aerobes like streptococci, staphylococci, E. coli. Antimicrobial prophylaxis is therefore indicated in these high risk patients. All groups of antibiotics have been used, however 1st and 2nd generation cephalosporins are the most effective. A single dose given intravenously just before anaesthesia is recommended, a second dose is advisable intraoperatively when surgery is prolonged or massive blood loss occurs. Antibiotic prophylaxis is also recommended in gastric bypass surgery for obesity, but remains controversial for percutaneous endoscopic gastrotomy.

Overview of cephalosporin prophylaxis

After an uncertain and highly controversial beginning, the use of antimicrobials for prophylaxis of surgical wound infection has evolved to represent state-of-the-art management of the surgical patient. Although a truly ideal prophylactic antimicrobial does not exist, the cephalosporins, particularly those of the first generation, have emerged as the mainstay of prophylaxis in surgery. However, new pathogens and newly recognized problems have necessitated a comparative evaluation of a wide variety of antibiotic regimens. The choice of an appropriate antibiotic is complicated by the lack of an adequate experimental model of infection in clean and clean-contaminated surgical procedures. Moreover, clinical trials have proved to be an inefficient method of comparing antibiotic regimens, as important variations in risk factors for infection cannot be reliably controlled. Significant differences exist among cephalosporins and between the cephalosporins and other classes of antimicrobials in several clinically important parameters: antimicrobial spectrum, serum half-life, ease of administration, tissue penetrability, cost, and incidence of allergy and toxicity. New generations of cephalosporins and new classes of antibiotics have demonstrated the potential to out-perform the first-generation cephalosporins in many of these areas. Although the first-generation cephalosporins were essential in establishing the efficacy of antibiotic prophylaxis in surgery, there are no guarantees that this class of cephalosporin, or that any cephalosporin, for that matter, will continue to dominate the prophylactic arena.