|Year : 2013 | Volume
| Issue : 4 | Page : 405-409
A study comparing preoperative intra-incisional antibiotic infiltration and prophylactic intravenous antibiotic administration for reducing surgical site infection
Bharat Bhushan Dogra, Sai Kalyan, Karan V. S. Rana, Sunil Panchabhai, Kundan Kharade, Siddarth Priyadarshi
Department of Surgery, Padmashree Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune, India
|Date of Web Publication||17-Sep-2013|
Bharat Bhushan Dogra
Department of Surgery, Padmashree Dr. D. Y. Patil Medical College, Hospital and Research Centre, Pimpri, Pune
Source of Support: None, Conflict of Interest: None
Introduction: Surgical site infection (SSI) continues to be a distressing problem since time immemorial, as it happens to be one of the major causes of post-operative morbidity and mortality. Many methods have been evolved to combat wound infection, but the rate of wound infection has been more or less static over the past few decades. The search for alternative modes of management is going on and one of the methods is intra-incisional infiltration of antibiotics. Aims and Objectives: To study the comparative efficacy of pre-operative intra-incisional antibiotic infiltration and prophylactic parenteral antibiotic therapy in reducing surgical site infection. Materials and Methods: This is a prospective randomized controlled study comprising of 120 patients divided in to three groups i.e. 40 in each group. Group A comprising 40 patients were subjected to local infiltration of 1 gram of Cefotaxime around the site of incision, 20 min before the induction of anesthesia. Group B comprising of 40 patients were administered a single dose of 1 gram of Cefotaxime intravenously 20 minutes before the surgical incision and Group C comprising of 40 patients were administered local infiltration of 1 gram of Cefotaxime as well as intravenous administration of 1 gram of Cefotaxime, 20 minutes before surgical incision. Inclusion criteria were patients in age group of 20-60 yrs, procedures that lasted for less than 2 hours, clean and clean contaminated surgical procedures. The exclusion criteria were patients with diabetes mellitus and those on steroid therapy. Incidence of SSI, type of organisms cultured in case of infection were studied. Results: Overall incidence of SSI in Group A was 10%, in Group B 18%, and Group C 2.5%. Frequency of infection due to gram positive bacteria was more as compared to gram negative in the cases that developed SSI. The commonest organism isolated was Methicillin Sensitive Staphylococcus aureus (MSSA). Conclusion: The incidence of SSI was lower in the group of patients who were subjected to intra-incisional antibiotic infiltration as compared to the group who received prophylactic intravenous (IV) antibiotic. There was significant reduction in incidence of SSI in the group, which received both Intra-incisional as well as IV antibiotics. There was no definite correlation between the duration of surgery to the development of SSI in this study.
Keywords: Intra-incisional antibiotic, prophylactic antibiotic, surgical site infection
|How to cite this article:|
Dogra BB, Kalyan S, Rana KV, Panchabhai S, Kharade K, Priyadarshi S. A study comparing preoperative intra-incisional antibiotic infiltration and prophylactic intravenous antibiotic administration for reducing surgical site infection. Med J DY Patil Univ 2013;6:405-9
|How to cite this URL:|
Dogra BB, Kalyan S, Rana KV, Panchabhai S, Kharade K, Priyadarshi S. A study comparing preoperative intra-incisional antibiotic infiltration and prophylactic intravenous antibiotic administration for reducing surgical site infection. Med J DY Patil Univ [serial online] 2013 [cited 2022 Jan 17];6:405-9. Available from: https://www.mjdrdypu.org/text.asp?2013/6/4/405/118290
| Introduction|| |
Surgical site infection (SSI) continues to be a baffling problem since time immemorial. It is one of the major causes for postoperative morbidity and mortality. Over the years, reasonable success has been achieved in this direction by taking various aseptic measures, which were initiated by Joseph Lister (1827-1912) in 1860.  Initially, the antibiotics were only administered post-operatively for treatment of already established surgical site infection.  Later, the concept of antibiotic prophylaxis was introduced. After administration of intravenous (IV) antibiotic, there is distribution of antibiotics, initially in the systemic pool and then in the peripheral pool, which results in a low concentration of the antibiotic at the site where it is needed the most.  Therefore, the search for alternative modes of administration of prophylactic antibiotics was started so as to affect a further decrease in the rate of wound infection. One such method is the intra-incisional infiltration of prophylactic antibiotics. This mode ensures a high concentration of antibiotic at the incision site and it has been proven to provide systemic cover by the absorption of the antibiotic from the incision site. This is primarily because the antibiotic gets fixed to the tissues along the incision and thus the antibiotic is present in a high concentration during time of maximum contamination of incision.  This study is done to evaluate the role of pre-operative antibiotic infiltration in prevention of SSI.
| Materials and Methods|| |
It is a prospective randomized controlled study, conducted at Department of General Surgery, of a medical College during 2009-2011. The criteria for inclusion were clean cases (inguinal hernioplasty, thyroidectomy), clean contaminated surgical procedures, (open cholecystectomy, interval appendectomy), surgical procedures lasting for not more than 2 hours and patients aged between 20-60 years were included in this study. Patients, who were immunocompromised, on prolonged steroid therapy, or suffering from diabetes mellitus, were excluded from this study. First case was selected on lottery basis and subsequent cases were selected alternatively. Detailed case history of the patient was taken to assess if the patient falls under inclusion criteria or not. Sample size was 120 cases (40 in each group) and was assigned to one among the following groups, alternatively.
Group A: Prophylaxis by preoperative intra incisional infiltration of the antibiotic. One gram of Cefotaxime diluted in 10 ml of distilled water was infiltrated along the skin and the sub cutaneous tissue in the proposed line of incision, 20 minutes before surgical incision.
Group B: A single dose of 1 gram of Cefotaxime was administered intravenously 20 minutes before the surgical incision at the time of induction of anesthesia.
Group C: Prophylaxis by both systemic and intra-incisional infiltration of the antibiotic (1 gram of Cefotaxime was administered intravenously and 1 gram of Cefotaxime diluted in 10 ml of distilled water was infiltrated along the site of proposed incision 20 minutes before incision).
However, cases which developed signs of infection (edema, redness, discharge, and fever) empirical antibiotic cover with Inj cefotaxime was continued and change of antibiotic was carried out based on culture sensitivity report. In each group of 40 patients, we assigned 15 cases for Inguinal hernioplasty, five cases for thyroidectomy, 10 cases for open cholecystectomy, and 10 cases for interval appendectomy. Mesh plasty was carried out for repair of inguinal hernia in all cases.
One day prior to the surgery, test dose of antibiotic was given intra-dermally to exclude hypersensitivity reactions. Part was shaved in the morning of the surgery before the patient had bath with soap and water. In operation theatre, after induction of anesthesia, the part was prepared with povidone iodine scrub (Betascrub) followed by methylated spirit. The antibiotic was infiltrated along the incisional site 20 min before the surgery. Standardization of incision was done for all the cases (Appendectomy-7.5 cm, Herniorrhaphy-7.5 cm, Subtotal Thyroidectomy-10 cm, Cholecystectomy-10 cm).
The dose of antibiotic used for infiltration was 1 gram of Cefotaxime dissolved in 10 ml of distilled water and it was infiltrated uniformly 1 cm circumferentially around all the margins of the planned incision with a disposable syringe and 16 G needle in subcutaneous tissue plane. Operation site was covered by occlusive dressings for 48 hours, when first inspection of the suture site was carried out. The suture site was left open thereafter to inspect daily except in patients who developed infection. Cases where surgical site infection was suspected, occlusive dressing was resorted to daily with povidone iodine. Wound complications were documented as per Centers for Disease Control and Prevention (CDC) guidelines. Patients developing any discharge from the surgical wound were investigated by pus swabs for culture and appropriate antibiotics were administered as per culture sensitivity report. Sutures were removed on 10 th post op day and patients were discharged by 14 th post op day. Subsequently, all cases were followed up in the General Surgery Out Patient Department (OPD) initially at 2 weekly intervals for 1 month, followed by monthly review till 6 months. The statistical analysis was done based on EPI INFO software.
| Results|| |
Incidence of SSI in Various Groups
On comparison of incidence of SSI in Groups A and B, it was found that four out of 40 (10%) patients in Group A and seven out of 40 (18%) in Group B developed SSI. On statistical analysis, the difference between the Group A and the Group B was not significant, but the incidence of SSI was less in Group A [Table 1].
Comparing the incidence of SSI in Group A and C, it was found that four out of 40 (10%) patients in group A and one out of 40 (2.5%) in Group C developed SSI. The incidence of SSI was less in Group C [Table 2] as compared to Group A.
Comparing the incidence of SSI in Group B and C, it was found that seven out of 40 (18%) patients in Group B and one out of 40 (2.5%) in Group C developed SSI. On statistical analysis, the difference between the Group A and the Group B was significant [Table 3].
Duration of Surgery
Five out of 45 cases developed SSI, when the duration of surgery was between 1 and 2 hours whereas seven out of 75 cases developed SSI, when the duration of surgery was less than 1 hour. The incidence of infection was almost similar in both the groups.
Type of Organism Isolated
Among the cases who developed surgical site infection, the commonest organism isolated was Methicillin Sensitive Staphylococcus aureus (MSSA) followed by Escherichia More Details coli and Pseudomonas aeruginosa shown in [Table 4].
|Table 4: Prevalence of different type of organism isolated from culture |
Click here to view
Prevalence of SSI
Four out of 40 in Group A, seven out of 40 in Group B, and one out of 40 in Group C developed SSI with overall rate of 10%. Most of these cases belonged to superficial surgical site infection category in 92% and only one patient (8%) developed deep SSI in a case of inguinal hernia who had undergone mesh plasty and mesh got exposed following local wound infection.
| Discussion|| |
SSI is one of the commonest complications following surgery. SSI is reportedly the third most commonly reported nosocomial infection and accounts for 14-16% of all nosocomial infections.  Risk of SSI has been described to be around 2.6% in all operations and SSI rates are likely to be greater than reported since all surgical wounds are contaminated by atmospheric bacteria but only a few actually develop clinical infection.  A study was carried out in Italy to find out the incidence of SSI in general surgery, where 3,066 surgical procedures were carried out in 2,972 patients and 154 (5%) of them developed SSI.  SSI also affects 2.6% of patients undergoing thyroid surgery.  Bickel studied 210 patients who underwent open surgery for acute appendicitis and reported SSI in 5.6% cases.  Velezquez studied 80 patients who underwent open cholecystectomy and found SSI in 11.25% cases.  SSI has been brought down considerably by employing various aseptic measures in addition to the use of prophylactic systemic antibiotics. However the rate has been static over the past few decades. The drawbacks associated with the use of prophylactic systemic antibiotics have been lesser concentration of antibiotic at the incision site, fibrin matrix formed at the incision site, and improper timing of administration of the antibiotics.
This prompted newer modes of administering prophylactic antibiotics, one of which is the intra-incisional infiltration of the antibiotic to ensure a higher concentration of the antibiotic at the incision site.
Data from the National Nosocomial Infections Surveillance System reveals that the most common SSI pathogens are Staphylococcus aureus, Enterococcus, coagulase negative Staphylococcus, Enterobacteriaceae, Pseudomonas species.  .
In our study, among the cases who developed SSI, there was a predominance of gram positive organism (83.33%) as compared to gram negative (16.66%). Among the individual organism cultured, commonest was MSSA (83.33%) followed by E. coli (8.33%), and Pseudomonas aeruginosa (8.33%).
In the study carried out by Taylor TV et al., the effect of preoperative intraparietal (intra-incisional) injection of Cefoxitin along the site of the intended incision on the incidence of wound infection has been investigated by a randomized prospective study of 181 consecutive patients undergoing abdominal surgery. A significant reduction in wound infection was evident in the Cefoxitin-treated group (8.4%) when compared with controls (16.7%) (chi square = 6; P = 0.02). Administration of antibiotic by this route did not delay wound healing or produce any undesirable side effects.  In our study, the group which received only intra incisional antibiotic 4 out of 40 patients (10%) developed SSI.
In our study, the group which received only one dose of prophylactic intravenous antibiotic, SSI was observed in seven out of 40 patients (18%) as compared to the group which received only intra incisional antibiotic, where 10% of the patients developed SSI. This shows that intra incisional mode of administration may be more effective than I.V antibiotic. This compares favorably with the study carried out by Pollock AV et al.,  where, a total of 624 consecutive eligible patients undergoing abdominal operations received a single preoperative dose of amoxycillin/clavulanic acid (1.2 g Augmentin) for the prophylaxis of surgical wound infection. They were randomized to have the antibiotic injected intravenously at induction of anesthesia (n = 328) or infiltrated subcutaneously along the line of the proposed incision (n = 296). The incidence of wound infections was considerably lower in the group, who were given the antibiotic into the abdominal wall (8.4% compared with 15.9%; chi square = 7.90, P = 0.005). It is concluded that pre-incisional intra-parietal injection is more effective than intravenous injection of amoxycillin/clavulanic acid for the prophylaxis of surgical wound infection. 
The study carried out by Greenall et al.,  where the effect of intravenous and intra-incisional Cephaloridine was compared, both modes were found to be equally efficacious. Four hundred and five consecutive patients undergoing emergency or elective abdominal operations under the care of one surgeon were randomly allocated to receive prophylaxis against SSI by means of a single dose of 1 gram Cephaloridine given either intravenously or into the incision at the beginning of the operation. The rates of SSI were not significantly different between the two groups i,e 3.5% and 2.1%, respectively, for major wound sepsis and minor wound sepsis was present in 12.4% and I5.5% of the cases, respectively. But the rate of infection was less in the group which received intra incisional Cephaloridine. 
In another study, carried out by Dixon and Armstrong,  where 205 patients who underwent elective and emergency operations upon the gastrointestinal tract and considered to be at risk of SSI, were randomized prospectively into three groups, the control group not receiving any antibiotics, and in the two test groups one receiving 1 gram of Cephamandole intravenously and the other intra-incisionally. They have also shown that the intra-incisional infiltration is more efficacious than IV administration.
The study carried out in India by Bhaskar et al.,  in which both, intra venous as well as intra-incisional antibiotic administration was employed pre operatively, it was found to be more effective and statistically significant. (χ2 = 10.414, P < 0.01) in reducing the incidence of SSI. In our study also the combination of intravenous and intra-incisional administration of antibiotic pre operatively has shown statistically significant value comparing favorably with the above study.
| Conclusion|| |
The aims of this study were to find the mode of administration of antibiotic to reduce the incidence of SSI. The commonest organism isolated in our study was MSSA. The incidence of SSI in the group which received intra-incisional antibiotic was less than the group of patients, which received IV antibiotics. There was significant reduction in incidence of SSI in the group, which received both Intra incisional and IV antibiotics preoperatively than the other two groups. There was no definite correlation between the duration of surgery with incidence of SSI in our study. Preoperative intra incisional antibiotics significantly reduces the rate of SSI because of the higher concentration achieved at the incision site and theoretically makes it a better mode of administration. But, this can be established in a larger study where factors like concentration of the antibiotic in the blood and at incisional site at various intervals, affinity of the antibiotic to adipose tissue are also studied.
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[Table 1], [Table 2], [Table 3], [Table 4]