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April 1985, Volume 35, Issue 4

Original Article

Perioperative Single Dose Antibiotic Therapy in Elective Surgery

S.A.R. Gardezi  ( Department of Surgery, King Edward Medical College and Mayo Hospital, Lahore. )
Abdul Majeed Chaudhry  ( Department of Surgery, King Edward Medical College and Mayo Hospital, Lahore. )
Ghulam Akbar Khan Sial  ( Department of Surgery, King Edward Medical College and Mayo Hospital, Lahore. )
Khalid Mahmood  ( Department of Surgery, King Edward Medical College and Mayo Hospital, Lahore. )

Abstract

A placebo controlled study was undertaken to evaluate the role of antimicrobials as a single 24 hours cover peri-operatively. Patients matching in proposed surgery, age, sex, diagnosis and built were divided into three groups. Group ‘A’ was on placebo, group ‘B’ received full dose of antibiotics by con­ventional method and group ‘C’ received antibiotics as a single 24 hour cover pèrioperatively. The post operative incidence of complications was 27% in placebo, 13% in group B and 7% in group ‘C’. The comparatively more effective, safe and economical.perioperative use of antibiotics has been found to be (JPMA35: 112, 1985).

Introduction

Infection of a. surgical wound is always an undesirable problem, both for the patient and the doctor. Its effects may be particularly discouraging after major surgery where sometimes it may lead to fatality.1 Operative treatment was regarded safe only after the introduction of strict aseptic techniques. However, there is always a possibility, inspite of great care, of either wound contamination or bacteraemia in certain patients which may lead to infection. Further safety is achieved towards uneventful recovery by antibiotic and chemotherapeutic agents. Whereas these antibiotics have their advantages, unfortunately they are not free from side effects. Their haphazard and extended use may cause serious disturbances of body mechanisms and they have other toxic adverse effects.2
The present study was conducted on 180 patients admitted to North Surgical Unit, Mayo Hospital, Lahore with the purpose of evaluating the role of antibiotics when given before operation and during first 24 hours. This regimen was compared with placebo and the conventional methods of use of antibiotics.
The trial was carried out with the aims to determine the role of antibiotics when used perioperatively in clean surgical procedures, to find out the advantages and disadvantages of antibiotics administered for an extended period in elective surgical procedures and to determine if their use for this length of time was judicious, to do culture and sensitivity in infected cases with a view to choose an ideal periopertive drug, to pin point the source of infection in a clean surgical procedure.

Material and Methods

One hundred and eighty patients undergoing elective surgical procedures were included in this study. The trial extended over a period of one year (January 1983 to April 1984). Patients with obvious infection both local and systemic, and other generalized debilitating conditions like diabetes, uraemia, C.C.F., and liver diseases were excluded from the trial. Patients were assigned at random to one of three groups. Group ‘A’ where no antibiotics were used, group ‘B’ where antibiotics were used by conventional method and group ‘C’ when antibiotics were used perioperatively. Each group matched in diagnosis, age sex and built. A retrospective matching between two consecutive operations lists was done to overcome the difficulty of matching cases in a single list.
All the cases were operated by the same surgeon, Similar type of anaesthesia, skin preparation and suture material were used, Postoperatively all wounds were covered with polyurethane membrane, to facilitate frequent wound examination3
A daily record of general and local signs of inflammation was kept. Patients were enquired about any malaise and anorexia: Temperature was recorded 6 hourly. Wound were inspected daily for any redness, oedema, induration and discharge upto a period of 7 days. The findings were recorded by independent observers who were uninformed about the grouping. Pyrexia 100°F or.above was investigated for evidence of local or systemic infection. In case of wound infection culture and sensitivity studies were done and appropriate antibiotic was given.

Discussion

The idea of prophylactic use of antibiotics is not a new. As early as in 1930, penicillin was used for prophylaxis in pulmonary surgery.4 Since then there have been a number of reportes about antibiotic prophylaxis in different disciplines of surgery.5 Recently interest in this field has risen again. In 1973 the beneficial effects of cephaoridine in different general surgical and abdominal operations were reported.6  For patients in protective isolations, antibiotic prophylaxis was considered beneficial7 and its value in vascular surgery was proved in 19808. Single dose doxycycline as a prophylactic measure was found effective by peroperative bacteriological culture in elective colorectal surgery9 A single dose of arnoxicillin, cotrimoxazole or trime. thoprim, controlled urinary tract infection in 87.5% ot 90% patients.10 It was also observed that a change of antibiotic did not materially affect the results as long as the bacteria were sensitive.10 Three doses of cotrimoxazole in acute urinary tract infections, improved the results to 94%11 Its advantage in pulmonary surgery ortec12 A single dose Tinidazole and ycycline dine was effective in controlling wound hfection in elective surgery of colon and rectum.13
The purpose f this study was to evaluate the following hypothesis: the presence of antimicrobial agents in blood and tissues at the t’ when the tissues are challenged with patt micro-organisms and following 24 hreduce the frequency of infection”.
In this study four antimicrobials of different groups were used by two different regimens.
An attempt was made to compare the results under similar standardized conditions.
The results of this study show a higher incidence (21%) of local infection at the operative site when no antibiotic was given necessitating the use of an antimicrobial for better results. Frequancy of wound infection in colorectal surgery when no antibiotic was used varies from 25-60%14,15
In other trials it was as high as 50%1617 When antibiotics are combined in. the post operaüve management, the incidence of septic complications falls constderably.18 In this study when antibiotics were started after the operation and continued till the time of removal of stitches, the incidence of septic complications fell to 1 2%. When the antibiotic was administered for the first 24 hours, the incidence was even lower ie 7% This clearly shows that perioperative use of antibiotics gives better results than their conventional and extended use.
The important reduction of chemotherapeutic consumption offered by 24 hours dose schedule can save, the patient from a number of untoward reactions associated with specific drugs19. Antimicrobial agents will also decrease the incidence of staphylococcal enterocoli tis, pseudomembranous enterocolitis and infection due to opportunistic organisms which are well documented complications of their prolonged use.20 It will discourage the development of resistant strains as well21
It was therefore observed that the perioperative method of antibiotic administration is effective, economical and safe. Use of antibiotics in elective surgical procedures for an extended period of time is not judicious. The results of this trail show that any one of the broad spectrum antibiotics can be utilized as a perioperative drug. study also highlights the fact, that the most ent causative factor for operative site in-
on is the contamination at the time of uperation. If these micro-organisms are checked by a high (bactericidal) serum concentration before they start multiplying in the wound haernotorna, the incidence of septic complications will fall considerably.

Acknowledgement

The authors ire grateful for the help and assistance of Dr. Azam Yusuf, Dr. Masood Rashid and Dr. Javid Raza Gardezi of North Surgical Unit, Mayo Hospital, Lahore. Thanks are also due to Mr. Mohammad Nazir Naushahi, Mr. Abdul Ghaffar Naeern, Mr. Imtiaz Al! and Mr. Nayyar Salam for typing the article.

Results



Table 1 shows the age and sex of 180 cases, divided into three groups of 60 each.


One hundred and fourty four were males and 36 females, their ages varied between 12 and 62 years.
Twenty seven of 180 patients had varion local and general complications. They occurea m 21% and 7% in the treated groups B and C respectively (Table IV).



In majority of cases the causative organisms were mixed staphlococci and E.coli, with a small percentage of streptococci and pseudomonas. in group A appropriate antibiotics controlled the infection and subsequent healing proceeded normally. in group B and C it was noted that the isolated micro-organisms were resistant to the antibiotics which were being administered, or had been chosen for perioperative use.

References

1. Truesdale, R., D’ Alessandri, R., Manuuel, V., Daicoff. G., and Kluge, R.M. Anti-microbial vs placebo prophylaxis in non-cardiac thoracic surgery. JAMA., 1979; 241 : 1254.
2. Chodak, G.W., Plaut, M.E. Use of systemic antibiotics for prophylaxis in surgery. Arch. surg., 1977; 112: 326.
3. Gardezi, S.A.R., Chaudhry, A. M., Sial, G.A.K., Ahmed, I. and Rashid, M. Role of “Polyurethane membrane” in post operative wound management. JPMA 1983 ; 33 : 219.
4. Citron, K.M. Controlled trial of prophylactic penicillin in thoracic surgery Thorax, 1965; 20:18.
5. Campbell, P.C. Large doses of penicillin in the prevention of surgical wound infection. Lancet, 1965 ;2: 805.
6. Fvans, C. and Pollock, A.V. The reduction of suigical wound infections by prophylactic parenteral cephaloridine. Br. J. Surg., 1973; 60 434.
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10. Harborod, R.B. and Gruneberg, R.N., Treatment of urinary tract infection with a single dose of amoxy­dlllin, cotrimoxazole, or trimethoprim. Br. Med. J., 1981 ;283 :1301.
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13. Giercksky, K.E., Danielsen, S., Garberg, 0., Gruner, O.P.N., Holter, 0., Johnson, J.A., Nygaard, K., Ofstad, E., Stadaas, J. and viddal, K.O. A single dose tinidazole and doxycycline prophylaxis in elective surgery of dolon and rectum; a prospective controlled clinical multi-center study. Ann. Surg,, 1982 ; 195 : 227.
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16. Clarke, J.S., Condom, R.E., Bartlett J.G. et al. Preoperative oral antibiotics reduce septic complicat ions of colon operations, results of prospective, randomized double-blind clinical study. Ann. Surg., 1977 : 185, 251.
17. Hojer, H. and Watterfors, 1. Systemic prophylaxis with doxycycline in surgery of the colon and rectum. Ann. Surg., 1978; 187 : 362.
18. Matheson D.M., Arabi, Y., Baxter-smith, D., Alexander-williams, J. and Keighley, M.R.B. Randomized multicentrie trial of oral bowel preparation and antimicrobials for elective colorectal operations. Br. J. Surg., 1978; 65 597.
19. Giercksky, K.E., Fuglesang, I., Christiansen, E., et al. Short term chemotherapeutic prophylaxis in gastrointestinal operations. Surg. Gynecol. Obstet., 1980; 151 : 349.
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21. Halarz, N.A. Wound infection and topical antibiotics; the surgeons dilemma. Arch. Surg., 1977; 112: 1240.

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