Extended Post-Operative Antibiotics

To detect an 8% difference in surgical site infections between patients receiving single- or multiple-dose antibiotics with gastric surgery

All patients received IV cefazolin immediately after induction. After surgery, patients randomly were assigned to receive no additional antibiotics or five additional doses every 12 hours. Patients were stratified according to type of surgery and were followed for 30 days after surgery.

• N = 325  
• MEAN AGE = 68 years
• AGE RANGE = 33–91 years
• MALES: 72%, FEMALES: 28%
• KEY DISEASE CHARACTERISTICS: All had gastric cancer; 97% had total gastrectomy; 38 patients had laparoscopic procedures.

• SITE: Single site 
• SETTING TYPE: Inpatient 
• LOCATION: Japan

• PHASE OF CARE: Active antitumor treatment
• APPLICATIONS: Elder care

• RCT

• Centers for Disease Control and Prevention definitions of surgical infections were followed.

Overall surgical site infection incidence was 9.1% in the single-dose group and 6.2% in the multiple-dose group. This difference was not statistically significant. Analysis showed that risk of infection was higher in cases with greater blood loss, body mass index of 25 kg/m² or higher, and older age.

No significant difference was seen in post-operative infection rates between those who received single- versus multiple-dose antibiotic prophylaxis.

• Risk of bias (no blinding)

This study showed no statistically significant difference in surgical site infections with single- versus multiple-dose antibiotic prophylaxis. However, this may be questioned—particularly in high-risk patients—if the approximate 3% difference is clinically meaningful. Further research regarding optimal prophylaxis in the highest-risk populations would be helpful.

The purpose of the study was compare surgical site infection rates between intraoperative antibiotic therapy alone versus intraoperative and postoperative antibiotic administration in patients undergoing distal gastrectomy surgery for potentially curable gastric cancer.

Participants were randomly assigned to receive either intraoperative antimicrobial prophylaxis alone or intraoperative antimicrobial prophylaxis plus extended use of prophylactic antibiotic administration for two days postoperatively. Patients were monitored for surgical site infections for 30 days postoperatively.

• The total sample size was 355 with an average age of 65.5 years (range = 35–84)
• Males made up 68% of the sample; females made up 32%
• A key disease characteristic was gastric adenocarcinoma considered curable with distal gastrectomy.

Multiple inpatient settings in Japan

Active antitumor treatment

Randomized, controlled trial (non-blinded)

The Centers for Disease Control and Prevention's National Nosocomial Infection Surveillance System

The group that received intraoperative antibiotics only had a lower rate of surgical site infections (5%) than the group that received intraoperative and extended antibiotic prophylaxis (9%). This indicates statistically significant non-inferiority (p < 0.0001). The authors also studied subgroups of patient characteristics, including length of surgery, body mass index, and prognostic nutritional index. None of these subgroups showed benefit from extended antimicrobial administration.

Interestingly, those patients who got more doses of antibiotic had nearly double the rate of surgical site infection as those who received intraoperative antibiotic prophylaxis only. Additional study is warranted to determine if limited antimicrobial prophylaxis is superior in preventing infection.

Risk of bias (no blinding)

Because elimination of postoperative antibiotic prophylaxis did not negatively affect surgical wound infection rates, this intervention is not recommended. Elimination of the unnecessary treatment will reduce expense, free up pharmacy and nursing time (further reducing expense), and reduce the potential for antibiotic resistance.

To investigate the effects of single-dose versus multiple-dose antimicrobial prophylaxis on surgical site infections (SSI) in patients undergoing elective surgery for rectal cancer

All patients received a preoperative bowel cleansing, kanamycin and erythromycin orally within 24 hours prior to surgery, and 1 g of a second-generation cephalosporin IV perioperatively. After surgery, patients were randomized to receive either single-dose prophylaxis one hour after surgery or an additional five doses over two consecutive days. Wounds were inspected daily in the hospital and in the clinic 30 days after surgery. The trial was designed to detect a 10% difference in the incidence of SSIs between groups.

• N = 279  
• MEAN AGE = 65 years (range = 33–91 years)
• MALES: 64.5%, FEMALES: 35.5%
• KEY DISEASE CHARACTERISTICS: All patients had rectal cancer; the majority had anterior resections
• OTHER KEY SAMPLE CHARACTERISTICS: None of the patients had preoperative chemotherapy or radiation therapy.

• SITE: Single-site    
• SETTING TYPE: Multiple settings    
• LOCATION: Japan

• PHASE OF CARE: Active antitumor treatment

Noninferiority randomized, controlled trial

• SSIs were recorded according to Centers for Disease Control (CDC) definitions for incision site and organ/space infections

The incidence of incision site infections was 5% in the single-dose group and 7.1% in the multiple-dose group. Organ/space infections were 10.8% in the single-dose group and 8.6% in the multiple-dose group. Several organ/space infections were related to anastomotic dehiscence. Overall, the incidence of SSIs was 13.7% with single-dose prophylaxis and 13.6% with multiple-dose prophylaxis. Subgroup analysis by specific surgical procedure did not show any significant differences between groups.

Single-dose, postoperative, intravenous, antimicrobial prophylaxis demonstrated similar results to that of multiple-dose prophylaxis. Multiple antimicrobial doses did not show improved benefit for the prevention of surgical site infections

• Risk of bias (no blinding)

A single dose of IV antibiotic prophylaxis after rectal surgery for cancer had similar outcomes to that of multiple postoperative antibiotic doses. These findings show there is no benefit to more doses of prophylactic postoperative antibiotics for the prevention of SSIs.

To evaluate the feasibility of intraoperative antimicrobial prophylaxis compared to conventional prophylaxis in patients undergoing elective open gastrectomy

Procedures for prophylaxis were conducted in two stages during six months. In the first stage, patients received four IV doses of cebazolin 1 g at 12-hour intervals beginning 30 minutes before surgery. In the second cohort, patients received the same agent at three-hour intervals beginning 30 minutes before surgery until the end of surgery. Perioperative care was conducted in a standard approach in both cohorts.

• N = 423   
• MEAN AGE = 63.5 years
• AGE RANGE = 27–88 years
• MALES: 65.2%, FEMALES: 34.8%
• CURRENT TREATMENT: Other
• KEY DISEASE CHARACTERISTICS: All were undergoing gastrectomy for gastric cancer. Ninety-eight percent had a ASA score of 1 or 2.
• OTHER KEY SAMPLE CHARACTERISTICS: Median operation time was four hours.

• SITE: Single site   
• SETTING TYPE: Inpatient    
• LOCATION: Japan

PHASE OF CARE: Active antitumor treatment

Cohort comparison—prospective

The definition of surgical site infection (SSI) was based on the Centers for Disease Control and Prevention surveillance system.

The overall SSI rate was 9.2%, and all were treated successfully with antibiotics. No statistically significant difference existed between cohorts.

Provision of antimicrobial prophylaxis immediately before and during the operative procedure appears to be feasible and sufficient for the prevention of SSI in patients undergoing gastrectomy.

• Risk of bias (no blinding)
• Risk of bias (no random assignment)

Provision of antibiotic prophylaxis to reduce SSI 30 minutes before and during the surgical procedure may be sufficient. This study is limited by its design. Additional research is needed to determine the most effective timing and duration of antibiotic prophylaxis for SSI prevention in patients undergoing various types of surgical procedures.