Perioperative Antibiotic Selection and Surgical Site Infection in Elective Colon Surgery

Abstract

Objectives The highest rates of surgical site infections (SSIs) are associated with colorectal operations (up to 30%). A sentinel paper showed that the use of intravenous (IV) cefazolin and metronidazole was associated with decreased rates of SSI compared with cefoxitin (6% vs 13%). We reviewed the association of SSI with prophylactic antibiotic choice. We specifically investigated the regimens of ceftriaxone and metronidazole IV, cefoxitin IV, or ertapenem. Methods We conducted a retrospective review of 532 colon surgeries between 2016 and 2018. Inclusion criteria were patients 18-89 years of age undergoing elective colon surgery who received ceftriaxone/metronidazole, cefoxitin, or ertapenem for prophylaxis. All emergent cases were excluded. This resulted in 241 elective colon cases for review. The primary endpoint was to determine if the use of ceftriaxone/metronidazole decreased the rate of SSI. Results In total, there were 241 elective colon cases with 21 SSI. We compared SSI rates in the ceftriaxone/metronidazole group to those patients receiving either cefoxitin or ertapenem (4.5% vs 12.2%; P = .035). We then compared SSI in ceftriaxone/metronidazole to SSI in cefoxitin (4.5% vs 10%; P = .13). Finally, we compared SSI in the ceftriaxone/metronidazole group to SSI in the ertapenem group (4.5% vs 14%; P = .03). Comorbidities and underlying factors were similar across all antibiotic groups. Conclusion In our experience, the use of ceftriaxone/metronidazole is associated with a decreased SSI rate. Furthermore, ceftriaxone/metronidazole use is superior to the use of ertapenem, with a trend toward superiority over cefoxitin. Based on this study, we recommend ceftriaxone/metronidazole as antibiotic prophylaxis for elective colon surgery.

Hospital Antibiotic Prescribing Pattern in General Surgery Specialty: Analysis Based on the WHO Access, Watch and Reserve (AWaRe) Classification

“…Many studies reported varying number of drugs with more than one antibiotic per encounter [17,34]. In addition to this, the use of a combination of ceftriaxone and metronidazole in the prophylaxis for elective colon surgery is associated with a decreased SSI rate [36]. Indeed, many factors in the patient's surgical journey contribute to the risk of SSI.…”

Six Long-Standing Questions about Antibiotic Prophylaxis in Surgery

“…The antibiotics used most commonly for SAP are first-and second-generation cephalosporins, such as cefazolin, cefuroxime, cefoxitin, or the combination of cefazolin plus metronidazole [47]. However, owing to decreasing activity against anaerobic and aerobic gram-negative bacilli and a short half-life, cefoxitin-an intravenous second-generation cephalosporin-is now discouraged for prophylaxis of elective colorectal surgery compared to cefazolin plus metronidazole [48][49][50][51]. Cefazolin, for most procedures, is the drug of choice for SAP [33].…”