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COMMENTARY
Year : 2013  |  Volume : 6  |  Issue : 4  |  Page : 409-410  

Antibiotic prophylaxis for preventing surgical site infection


Department of Surgery, Government Medical College, Chandigarh, India

Date of Web Publication17-Sep-2013

Correspondence Address:
Ashok Kumar Attri
Department of Surgery, Government Medical College, Sector 32, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


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How to cite this article:
Attri AK. Antibiotic prophylaxis for preventing surgical site infection. Med J DY Patil Univ 2013;6:409-10

How to cite this URL:
Attri AK. Antibiotic prophylaxis for preventing surgical site infection. Med J DY Patil Univ [serial online] 2013 [cited 2019 Jul 23];6:409-10. Available from: http://www.mjdrdypu.org/text.asp?2013/6/4/409/118292

Wound infection is one of the most commonly occurring surgical complication and affects up to 5% of all surgical procedures. They are denoted as surgical site infection (SSI) and represent a quarter of all nosocomial infections. SSI adds to the morbidity in terms of hospital stay, pain, reintervention, and cost.[1] Several risk factors have been identified, which contribute to SSI-intrinsic (patient related) or extrinsic (procedure related). Many of the patient related factors are non-modifiable such as age, medical comordities (diabetes, chronic renal failure etc.), but extrinsic issues can certainly be influenced. These procedure related factors include antibiotic prophylaxis, fluid management, and skin disinfection.[1],[2]

Use of prophylactic antibiotic is a common practice to avoid SSIs; however, indiscriminate use of antibiotics can lead to problems including an increase in costs and the emergence of resistant micro-organisms. The benefits of antibiotic prophylaxis either in clean-contaminated, contaminated and dirty surgery are universally accepted. Antibiotic prophylaxis is also accepted for clean surgeries were prosthetic material is used and where the presence of infection poses a threat, but controversy remains regarding certain clean surgeries.

A Cochrane meta-analysis on prophylactic use of antibiotics for elective hernia repair was published in 2012.[3] The total number of patients included in this meta-analysis was 7,843 from 17 studies (prophylaxis group: 4,703, control group: 3,140). The overall infection rates were 3.1% in the prophylaxis group, and 4.5% in the control group (Odd Ratio0.64, 95% confidence interval [CI] 0.5-0.82). Based on the results of this systematic review, the administration of antibiotic prophylaxis for elective inguinal hernia repair cannot be universally recommended. Neither can the administration be recommended against when high rates of wound infection are observed.

In a similar Cochrane mete-analysis (2010)[4] for a commonly performed procedure that is laparoscopic cholecystectomy, which included 11 studies having 1664 patients observed that the number of SSIs was similar in the two groups: 24 of 900 (2.7%) patients in the prophylaxis group had a SSI against 25 of 764 (3.3%) in the no-prophylaxis group. This meta-analysis could not find sufficient evidence to support or refute the use of antibiotic prophylaxis to reduce SSI or global infections in patients with the low anesthetic risk, low co-morbidities, and low-risk of conversion to open surgery, and undergoing elective laparoscopic cholecystectomy.

Another meta-analysis including a total of nine studies (2,260 participants) evaluated pre-operative antibiotic compared to no antibiotic or placebo for breast surgery. The review concluded that prophylactic antibiotics administered pre-operatively significantly reduce the incidence of SSI for patients undergoing breast cancer surgery without reconstruction (pooled risk ratio 0.71, 95% CI 0.53-0.94).[5]

Several guidelines have been recommended based on the evidence in the literature regarding strategies to prevent SSI, but evidence based medicine and clinical practice is often wide.

National Institute for Health and Clinical guidelines guidelines, 2008 for preventing and treating SSI emphasizing on pre-, intra- and post-operative care.[6] In particular, regarding the antibiotic prophylaxis, it recommended:

  • Give antibiotic prophylaxis to patients before:

    1. Clean surgery involving the placement of a prosthesis or implant
    2. Clean-contaminated surgery
    3. Contaminated surgery


  • Do not use antibiotic prophylaxis routinely for clean non-prosthetic uncomplicated surgery
  • Use the local antibiotic formulary and always consider potential adverse effects when choosing specific antibiotics for prophylaxis
  • Consider giving a single dose of antibiotic prophylaxis intravenously on starting anesthesia. However, give prophylaxis earlier for operations in which a tourniquet is used.


Surgical Care Improvement Project (SCIP) was developed jointly by several surgical and other organizations to reduce rates of infectious and non-infectious complications developing after surgical procedures.[7] Three components Surgical Care Improvement Project were related to prophylactic antibiotics and are as follows:

SCIP INF 1: Prophylactic antibiotics were administered within 1 h before making surgical incision (2 h if using vancomycin or a flouroquinolone).

SCIF INF 2: Prophylactic antibiotic used were agents recommended for a specific procedure.

SCIP INF 3: Prophylactic antibiotic were discontinued within 24 h of the surgery end time (48 h for cardiac surgical procedure).

The goal of SCIP INF measures is to decrease perioperative infections, chiefly SSI, but strict compliance to the same is required to achieve desired results. In a large data based study reported by Stulberg et al. on 405,720 patients from 398 hospitals found that the reduction of post-operative infection reached significance when the SCIP INF 1, 2, and 3 were strictly followed.[8]

Thus, the non-compliance of accepted guidelines entails worse outcome, which is worrying. The efforts should be focused to improve compliance at individual, institutional, and national level to reduce the incidence of SSI.

 
  References Top

1.Schwulst SJ, Mazuski JE. Surgical prophylaxis and other complication avoidance care bundles. Surg Clin North Am 2012;92:285-305.   Back to cited text no. 1
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2.Diana M, Hübner M, Eisenring MC, Zanetti G, Troillet N, Demartines N. Measures to prevent surgical site infections: What surgeons (should) do. World J Surg 2011;35:280-8.   Back to cited text no. 2
    
3.Sanchez-Manuel FJ, Lozano-García J, Seco-Gil JL. Antibiotic prophylaxis for hernia repair. Cochrane Database Syst Rev 2012;2:CD003769.   Back to cited text no. 3
    
4.Sanabria A, Dominguez LC, Valdivieso E, Gomez G. Antibiotic prophylaxis for patients undergoing elective laparoscopic cholecystectomy. Cochrane Database Syst Rev 2010;12:CD005265.   Back to cited text no. 4
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5.Bunn F, Jones DJ, Bell-Syer S. Prophylactic antibiotics to prevent surgical site infection after breast cancer surgery. Cochrane Database Syst Rev 2012;1:CD005360.   Back to cited text no. 5
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6.Leaper D, Burman-Roy S, Palanca A, Cullen K, Worster D, Gautam-Aitken E, et al. Prevention and treatment of surgical site infection: Summary of NICE guidance. BMJ 2008;337:a1924.   Back to cited text no. 6
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7.Rosenberger LH, Politano AD, Sawyer RG. The surgical care improvement project and prevention of post-operative infection, including surgical site infection. Surg Infect (Larchmt) 2011;12:163-8.   Back to cited text no. 7
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8.Stulberg JJ, Delaney CP, Neuhauser DV, Aron DC, Fu P, Koroukian SM. Adherence to surgical care improvement project measures and the association with postoperative infections. JAMA 2010;303:2479-85.  Back to cited text no. 8
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