Using preoperative colon preparation to prevent surgical site infection
15/11/10 | Acute wounds, Complex wounds, Infection | Donald E Fry
When it comes to the efficacy of oral antibiotic bowel preparation and the appropriate use of systemic antibiotics there are many unanswered questions. For example, is there a role for the intraoperative application of antibiotics or antiseptics to the surgical site? Can intraoperative pulsed-lavage reduce the microbial burden on the wound interface before closure? Could closed suction drains within a closed surgical incision reduce infection rates, especially in patients with a large body mass index (BMI)? What is the role of delayed primary closure or secondary closure in the wound where obvious contamination has occurred, or in the circumstance of emergent colonic resection where considerable contamination is encountered from pre-existent perforation? And are immediate negative pressure wound dressings appropriate in the open contaminated wound?
These and many other questions still continue to confront clinicians involved in colorectal surgery. In this author's opinion, considerable evidence supports the routine use of oral antibiotic bowel preparation in conjunction with effective mechanical preparation and this regimen deserves a broader application in practice.
Donald E Fry is Adjunct Professor of Surgery, Northwestern University, Feinberg School of Medicine, Chicago, Illinois and Emeritus Professor of Surgery, University of New Mexico School of Medicine, Albuquerque, New Mexico.
- Poth EJ. Historical development of intestinal antisepsis. World J Surg 1982; 6: 153-9.
- Polk HC Jr, Lopez-Mayor JF. Postoperative wound infection: a prospective study of determinant factors and prevention. Surgery 1969; 66: 97-103.
- Baum ML, Anish DS, Chalmers TC, et al. A survey of clinical trials of antibiotic prophylaxis in colon surgery: evidence against further use of no-treatment controls. N Engl J Med 1981; 305: 795-9.
- Milsom JW, Smith DL, Corman ML, et al. Double-blind comparison of single-dose alatrofloxacin and cefotetan as prophylaxis of infection following elective colorectal surgery. Am J Surg 1998; 176(Suppl 6A): 46S-52S.
- Itani KMF, Wilson SE, Awad SS, et al. Ertapenem versus cefotetan prophylaxis in elective colorectal surgery. N Engl J Med 2006; 355: 2640-51.
- Smith RL, Bohl JK, McElearney ST, et al. Wound infection after elective colorectal resection. Ann Surg 2004; 239: 599-607.
- Ahmed S, Macfarlane GT, Fite A, et al. Mucosa-associated bacterial density in relation to human terminal ileum and colonic biopsy samples. Appl Environ Microbiol 2007; 73: 7435-42.
- Garlock JH, Seley GP. The use of sulfanilamide in surgery of the colon and rectum. Preliminary report. Surgery 1939; 5: 787.
- Firor WM, Jonas AF. The use of sulfanilylguanidine in surgical patients. Ann Surg 1941; 114: 19.
- Firor WM, Poth EJ. Intestinal antisepsis with special reference to sulfanilylguanidine. Ann Surg 1941; 114: 663-71.
- Zhu QD, Zhang QY, Zeng QQ, et al. Efficacy of mechanical bowel preparation with polyethylene glycol in prevention of postoperative complications in elective colorectal surgery: a meta analysis. Int J Colorectal Dis 2010; 25: 267-75.
- Poth EJ, Ross CA. The clinical use of phthalylsulfathiazole. J Lab Clin Med 1944; 29: 785-808.
- Cohn I Jr. Kanamycin for bowel sterilization. Ann NY Acad Sci 1958; 76: 212-7.
- Washington JA II, Dearing WH, Judd ES, Elveback LR. Effect of preoperative antibiotic regimen on development of infection after intestinal surgery: prospective, randomized, double-blind study. Ann Surg 1974; 180: 567-71.
- Clarke JS, Condon RE, Bartlett JG, et al. Preoperative oral antibiotics reduce septic complications of colon operations: results of prospective, randomized, double-blind clinical study. Ann Surg 1977; 186: 251-9.
- Nichols RL, Smith JW, Garcia RY, et al. Current Practices of Preoperative Bowel Preparation Among North American Colorectal Surgeons. Clin Infect Dis 1997; 24: 609-19.
- Lewis RT. Oral versus systemic antibiotic prophylaxis in elective colon surgery: a randomized study and meta-analysis send a message from the 1990s. Can J Surg 2002; 45:173-80.
- Bucher P, Gervaz P, Soravia C, et al. Randomized clinical trial of mechanical bowel preparation versus no preparation before elective left-sided colorectal surgery. Br J Surg 2005; 92: 409-14.
- Nichols RL, Briodo P, Condon RE, et al. Effect of preoperative neomycin-erythromycin intestinal preparation on the incidence of infectious complications following colon surgery. Ann Surg 1973; 178: 453-9.
- Lewis RT, Goodall RG, Marien M, et al. Is neomycin necessary for bowel preparation in surgery of the colon? Oral neomycin plus erythromycin versus erythromycin-metronidazole. Can J Surg 1989; 32: 265-78.
- Itani KMF, Wilson SE, Awad SS, et al. Polyethylene glycol versus sodium phosphate mechanical bowel preparation in elective colorectal surgery. Am J Surg 2007; 193: 190-94.
- Ezri T, Lerner E, Muggia-Sullam M, et al. Phosphate salt bowel preparation regimens alter perioperative acid-base and electrolyte balance. Can J Anesth 2006; 53:153-8.
- Long J, Zaborina O, Holbrook C, et al. Depletion of intestinal phosphate after operative injury activates the virulence of P aeruginosa causing lethal gut-derived sepsis. Surgery 2008; 144: 189-97.
- Wren SM, Ahmed N, Jamal A, Safadi BY. Preoperative oral antibiotics in colorectal surgery increase the rate of Clostridium difficile colitis. Arch Surg 2005; 140: 752-56.
- It is still unclear which oral antibiotic regimen is the most effective
- Combined oral antibiotic bowel preparation and systemic antibiotics disrupt the normal colonic ecosystem
- Research is needed into whether postoperative probiotics and prebiotics help to restore the colonic microflora