Selective cefuroxime prophylaxis following colorectal surgery based on intra-operative dipslide culture

Abstract

The concept of a very limited effective period for prophylactic antibiotic action was challenged in a prospective, controlled and randomized study featuring a simplified method for assessing the degree of contamination in the operative field during colorectal surgery. The 226 patients were given 1 g metronidazole IV on induction of anaesthesia and 12 h postoperatively. Following standardized saline irrigation of the abdominal cavity, a uriculture dipslide was dipped in the residual fluid just before abdominal closure. The dipslide was incubated for 18 h, and colony counts of coliforms and Staphylococcus aureus were made. The number of colony-forming units (CFU) was classified as 0, 1-4 or greater than or equal to 5 (n = 123, 33 and 70). The patients with CFU greater than or equal to 5 were randomized to receive cefuroxime (1.5 g IV/8 h for 2 days) or no more antibiotics. In the patients given only metronidazole, the incidence of postoperative infections rose with the colony counts (5.7, 9.1 and 41.2 per cent with CFU 0, 1-4 and greater than or equal to 5). Addition of cefuroxime reduced the 41.2 per cent infection rate to 8.3 per cent (P = 0.003). The method thus identified a high-risk group in which a short postoperative course of cefuroxime significantly lowered the rate of sepsis.

Antimicrobial prophylaxis in colorectal surgery: a systematic review of randomised controlled trials.

“…In the RCTs reported in this review, cefuroxime was almost always combined with metronidazole ( Table 9). Cefuroxime plus metronidazole was more efficacious than metronidazole alone, 35,39,63,101 piperacillin alone, 131 and co-amoxiclav. 116 Three trials compared cefuroxime plus metronidazole with mezlocillin alone.…”

“…It seems that metronidazole alone was inadequate in the prevention of SWI in colorectal surgery when compared with other antibiotics (Table 13). Metronidazole alone was significantly less efficacious than metronidazole plus ampicillin, 56 metronidazole plus doxycycline (p = 0.056), 133 metronidazole plus cefuroxime or netilmicin, 35,63 metronidazole plus fosfomycin, 86 cephazolin plus neomycin and erythromycin. 76 Six other trials did not find a significant difference between metronidazole alone and other antibiotics such as doxycycline alone, 13 oral neomycin plus erythromycin, 21 metronidazole plus nalidixic acid, 79 or gentamicin plus metronidazole.…”

“…For example, bacteria isolated from wound infections were predominantly aerobic bacteria when prophylactic metronidazole had been administered. 35 One trial found that anaerobes were isolated from only one of 15 wound infections in the metronidazole group but from three of six wound infections in patients receiving cephozolin plus oral neomycin plus erythromycin. 76 A regimen of antibiotic prophylaxis in surgery may become ineffective if antibiotic-resistant bacteria develop.…”

Antimicrobial Prophylaxis for Abdominal Surgery: Is There a Need for Metronidazole?

“…The results reported here underline the importance of the widely accepted recommendation that metronidazole, or else clindamycin, should be used in perioperative antibiotic prophylaxis in order to reduce anaerobic intestinal flora 2 . The discrepancy that exists between this recommendation and everyday hospital practice may be attributable to earlier reports according to which addition of metronidazole brought no 12 , or only a minor and statistically insignificant, benefit 8,[13][14][15][16][17][18] .…”