Antibiotic survey

The following assessment of your responses will be based on:
 
1. the
recommendations of the Surgical Infection Society (SIS) which
distinguishes between CONTAMINATION (which requires no therapeutic
postoperative antibiotics) and INFECTION (which requires a
course). Bohnen et al Arch Surg  1992;127:83-89
 
2. My understanding of the topic as published previously:
 
Schein et al. Minimal antibiotic therapy...British Journal of Surgery
1994;81:989-991
 
Schein & Wittmann. Antibiotics in abdominal surgery: less is bettr.  Eur
J Surg  1993;159:451-453
 
Schein et al.  Current attitudes concerning the duration of antibiotic
therapy... Theoretical Surg 1994;9:160-164
 
RESULTS:
 
Case 1: Gunshot injury to the colon operated within 3 hours.
 
Spectrum of your responses: Minimal-Tom Gilas: no postoperative antibiotics.
Maximal: Errico from Italy & and Thomas Zweng from ? who recommended 7 days.
 
An early diagnosed and managed bowel injury represent CONTAMINATION ,
not INFECTION. In requires peri-operative antibiotic prophylaxis but
not postop therapy.  Therefore, to the best of my knowledge,1 pre-op dose
is adequate. If the op is > 3 hours, another intra-op dose may be given.
 
Many of you suggest that the duration of treatment depends on the degree
of CONTAMINATION. Contamination is treated by surgery- not with
antibiotics. All studies which comapared short vs long duration of AB
for this indication did not show any advantage for the longer courses.
 
Steven Johnson mentioned shock as a reason to continue postop AB. Shock
certainly affects the pharmacodynamics of the drug and there is evidence
that shocked patients require LARGER doses but not longer.
 
Gregory Beilman suggest treatment until the patient is afebrile and his
WBC are normal. Fever and WBC response are triggered by the inflammatory
-cytokine mediated response to injury and operation. Using these crude ,
unproven guidelines you will treat most of your patients unnecesarily.
 
My recommendation: NO POSTOP AB, irrespective of degree of contamination,
fever or WBC count.
 
Case 2-Perforated peptic ulcer operated within 8 hours.
Spectrum of responses: minimal: no antbiotics-Tom Gilas,  Asher
Hirshberg from Tel Aviv & marcelo from Brazil. maximal: Errico from Rome-
7 days.
 
Again this case represent CONTAMINATION and not INFECTION. In peptic
perforations (no previous drug therapy) most cultures are negative, and
even if positive contamination is dealt by surgery.
 
All comments about case 1 relavant to this case,
 
My recommendations: NO postop antibiotcs.
 
Case 3.  appendicectomy for gangrenous appendicits.
 
Spectrum of your results: minimal-Tom Gilas-no therapy.  Maximal-Errico
from Italy, 7 days, followed by Marcelo from Brazil (5-7 days).
 
My recommendation:  maximum 24 hours therapy. In this condition infection
is confined within the wall of the appendix; you remove it-you remove
the problem. The few bacteria around are dealt with by the peritoneal
defense mechanisms and the peri-op antibiotics.
 
Gangrenous cholecystitis-similar!
 
Case 4.  Appendicectomy for perforated appendicitis; a few ml of pus
around.
 
Your responses: minimal- Thomas Zweng -2 doses, Jeff Punch- 1day, Asher
Hirshberg-
1day ("depending on how dramatic is the resident's description of the
findings...")
maximal: as usual Errico- 7 days and marcelo 5-7 days.
 
The responses of those of you who go according 'fever and WBC' will be
discuss at the end.
 
Interestingly, the hitherto  "minimalist" (Tom) recommeds a few days for
medicolegal reasons only").
 
My recommendations: 1 day- 2 days- more than adequate.
 
 
Case 5: Bowel Ischemia; resection of bowel (bowel, not perforated).
Your respons: minimal- Tom Gilas -no therapy, maximal-Errico who loves
his 7 days.
 
My recommendation-no postop AB. You resect the dead bowel; suck out the
"dark" fluid, peri-op AB deal with the few bacteria which have translocated
through the wall.
 
Case 6: Percutaneous CT-guided drainage of postoperative abdomianl abscess.
 
Your responses: Minimal- Nathan Coates from Houston-3-5 days.
                Maxima;- Steven Johnson from Kentucky- 14 days.
 
Most of you recommended extended duration therapy of at least few day, or
until afebrile + WBC normal.
 
My recommendations: this is a problematic case with no guidelines in the
literature. When you conventionally drain an abdominal abscess
(open drainage) no antibiotics are necessary. (the management of an
abscess is its drainage).  The PC "semiblind: drainage involves, however,
a sense of uncertainty: did we drain all the pus?, is any infected fluid
left? is the tube obstructed?  Hence the tendency to administer prolonged
AB to steriliz the tissues adjacent to the cavity.
 
I cannot make objective recommendations but  I usually go for 24-48
hours and than stop.
if the temperature is still elevated I would suspect an inadequate
drainage. I perform a CT; if no residual collection is visible I remove
the tube and usually the elevated temperature subsides.
(you remove a FB; you remove the source of inflammation and temperature..)
 
General comments.
 
The common practice to continue AB until fever and WBC are normal is
based on NOTHING. Studies have shown that persisting fever and high WBC
count are associated with a persistig or recurrent sites of infection. But
no study has shown that continuation of AB therapy would abort these
infections.  Conversly, high fever and WBC usually reflect undrained
(subcutaneous, subfascial or intra-abdominal pus), or an extra-abdominal
infection(lung, urine). Dogmatic continuation of AB's only masks and
delays the correct diagnosis and its treatment.
 
Thus, postop high temp and WBC are a marker of inflammation but not
an indication for AB.
 
Interesting observations:
 
Frank Lloyd recommends a few days"of AB for all conditions but than adds:
"I think all the above could be treated with three doses of antibiotics
with little change in infection rates".  He is absolutely right, but
gives AB , probably because "everybody does".
 
Asher Hirshberg agrees that no postop Ab are needed for case 1 but when
"massive contamination" exists he would give 24 hours "to treat the
surgoen's anxieties rather than the patient..." .
 
And finally our Italian friend Errico who prefers the "satisfying
surgical knife"on PC drainage and cries "why PC drainage for subphrenic
abscess with a lot of AB if open darinage needs  only a few doses?".
 
Well, Errico, we all love the knife but if you would have a subphrenic
abscess; what
would you prefer? an open (painful) drainage or a simple PC procedure?.
 
Errico also writes that probably no one of the discussed situation needs
antibiotics but than asks whether  there is any surgeon willing to deny a
full week AB course... and blames it on the lawyers...
 
Awards:  minimalist: Tom Gilas & Jeff Punch.
         maximalist: Errico (7 days for all) & Greory Beilman who goes only
according to
         temperature and WBC count..
 
 
Conclusions:
 
Again, this survey reflects the antibiotic overkill in daily clinical
use, common dogmatic and non scientific approach  and the lack of uniform
practice.