Preoperative Antibiotics

To assess the effectiveness of prophylactic antibiotics on prevention of surgical site infection (SSI) and the cost of this effectiveness, as compared to a control without prophylaxis antibiotics in early breast cancer surgery in overweight or obese women

Women randomly were assigned to receive IV infusion of 1 g ampicillin-sulbactam at the start of anesthesia or no prophylactic antibiotics. Patients were followed for 30 days. Outcomes also were compared to a group of women who had a body mass index (BMI) lower than 25 and who did not receive antibiotic prophylaxis.

• N = 369 (187 in the prophylaxis group, 182 in the control group)
• AGE = 58 years
• FEMALES: 100%
• KEY DISEASE CHARACTERISTICS: BMI of 25 or higher; all had nonrecurrent, operable breast cancer

• SITE: Single site 
• SETTING TYPE: Inpatient 
• LOCATION: Tertiary university hospital in Turkey

• PHASE OF CARE: Multiple phases of care

• Phase IV, randomized, controlled, parallel-group

• SSI was defined as infection within 30 days post-operation with one of the following.
  • Purulent drainage from incision
  • Organisms isolated from incision cultures
  • Localized pain
  • Tenderness
  • Swelling
  • Redness of an incision deliberately opened by the surgeon
• ASA class

Nine SSIs developed in the prophylaxis group, versus 25 in the control group (p = .002). Patients were matched well according to age, BMI, history of smoking, ASA class, interval between tissue biopsy and randomization, clinical cancer stage, type of breast and axillary surgery, operation time, hospital stay, and post-operation complications. All SSIs were discovered within post-operation week one after discharge, except one. The control group had significantly more SSIs compared to those in the normal-weight comparison group (p = .0007) and higher SSI treatment costs than the prophylaxis group (p = .007). Patients in the control group had more open surgical biopsies than those in the prophylaxis group (p = .004)

The administration of antibiotics at the time of induction for surgery was associated with reduced incidence of SSI among obese women undergoing breast cancer surgery. Costs were lower among those receiving prophylactic antibiotics.

• Risk of bias (no blinding)
• Risk of bias(sample characteristics)
• Other limitations/explanation: The control group underwent more biopsies prior to surgery; mastectomy is more common in Turkish culture.

Reminding physicians to prescribe pre-operation antibiotics is important. Administration of a dose of IV antibiotics at the time of induction is a current U.S. standard of care and recommendation for SSI prevention. Careful hand washing and clean dressing changes are imperative. These findings also point to the increased risk of infection associated with obesity. Nurses can educate patients regarding risks associated with obesity and assist patients with weight management.

To estimate the prevalence of pneumonia after tracheotomy in patients with head and neck cancer, and to evaluate the effect of prophylactic antibiotics

Data on patients who underwent tracheotomy were obtained from health records, and patients were grouped according to whether they had been given prophylactic antibiotics. In all cases, tracheotomy was the primary operation. The comparison of ventilator-associated pneumonia was analyzed.

• N = 88  
• MEAN AGE = 68.3 years (SD = 9.9)
• MALES: 69%, FEMALES: 31%
• KEY DISEASE CHARACTERISTICS: All had head and neck cancer, and 71% had prior radiation therapy.
• OTHER KEY SAMPLE CHARACTERISTICS: Of the patients, 88% had underwent a because of stridor. The median time from radiation to the procedure was 160 days.

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

• PHASE OF CARE: Transition phase after active treatment

• Retrospective

Pneumonia was defined as the clinical suspicion of pneumonia or the postoperative administration of antibiotics.

More patients who did not receive prophylaxis received antibiotics postoperatively (p = 0.04). The hospital stays of those given prophylactic antibiotics were seven days shorter (p < 0.01).

Prophylactic antibiotic administration for patients undergoing tracheotomy may reduce the risk of postprocedure ventilator-associated pneumonia.

• Small sample (< 100)
• Risk of bias (no blinding)
• Risk of bias (no random assignment)
• Measurement/methods not well described
• Measurement validity/reliability questionable
• No standard and objective measure of pneumonia

Prophylactic antibiotic use in patients undergoing surgical procedures has been shown to reduce postoperative infections. The findings from this study add to that body of evidence, suggesting that this approach prior to tracheostomy provides a similar benefit in preventing ventilator-associated pneumonia.

To compare the effectiveness of standard fluoroquinolone prophylaxis with fluoroquinolone plus ceftriaxone in the prevention of infection post prostate biopsy

Patients received one of three prophylaxis regimens: (a) 500 mg fluoroquinolone by mouth twice a day for three days, (b) 500 mg fluoroquinolone by mouth twice a day for three days plus 2 g IV ceftriaxone once before biopsy, or (c) 500 mg fluoroquinolone by mouth twice a day for more than seven days plus 2 grams IV ceftriaxone once before biopsy.

• N = 5,577   
• MEAN AGE = 64 years
• AGE RANGE = 18–92 years
• MALES: 100%
• CURRENT TREATMENT: Immunotherapy
• KEY DISEASE CHARACTERISTICS: None described
• OTHER KEY SAMPLE CHARACTERISTICS: N/A

• SITE: Single site   
• SETTING TYPE: Outpatient    
• LOCATION: South Korea

• PHASE OF CARE: Diagnostic

• Retrospective case review

Infection post prostate biopsy was defined as any of the following: a temperature greater than 38 degrees Celsius, a white blood cell count greater than 12,000/mm³, a urinary tract infection, or acute prostatitis.

A significant decrease of infections was observed post prostate biopsy for patients that received prophylaxis with fluoroquinolone plus ceftriaxone (p < 0.001). One percent of patients who received fluoroquinolone prophylaxis had infectious complications compared to 0.3% of patients who received fluoroquinolone plus ceftriaxone. Patients who received fluoroquinolone prophylaxis for more than seven days had no added reduction of infection compared to patients who received fluoroquinolone prophylaxis for three days.

Infection prophylaxis with fluoroquinolone alone after prostate biopsy may be insufficient because of increasing resistance among pathogens, including Escherichia coli. The addition of 2 grams IV ceftriaxone before prostate biopsy was correlated with a significant reduction in infectious complications at one hospital in South Korea.

• Risk of bias (no random assignment)
• Unintended interventions or applicable interventions not described that would influence results
• Findings not generalizable
• The time frame of the retrospective comparison groups differed by several years (group 1: 2005–2009 versus groups 2 and 3: 2010–2012); thus, other clinical practice variations may have affected the results.
• Patient adherence to oral fluoroquinolone was not assessed.
• For infectious cases to be identified, patients with complications needed to return to the participating hospital. Patients with complications may have gone to other hospitals, affecting results.
• Groups were not assessed for risk factors, so comparison between groups is limited.
• The study was conducted at one hospital, limiting generalizability to other hospitals.
• Observation/reporting time frame for infectious complications after prostate biopsy not defined

Adequate patient education on potential infectious complications is necessary post prostate biopsies. To tailor infection prophylaxis, nurses should consider assessing for individual risk factors for infection (e.g., diabetes, history of organ transplant, etc.) and collect rectal swabs to identify quinolone-resistance organisms.

To determine comparative effectiveness of oral antibiotics and probiotics as bowel preparation in the prevention of surgical site infection (SSI)

Patients were randomized to one of three groups. The probiotic group took bifidobacteria tablets orally after each meal three times daily for seven days preoperatively, and postoperatively for 10 days. The oral antibiotic group took 0.5 g kanamycin sulfate and 0.5 g metronidazole orally three times on the day before surgery. The control group did not receive any bowel preparation beyond standard care. All patients underwent mechanical bowel prep with sodium picosulfate two days before surgery and polyethylene glycol in the morning of the day of surgery. All patients received a single preoperative 1 g dose of flomoxef IV one hour prior to incision. The same procedures for surgical site disinfection, intraperitoneal irrigation, and suture closures were done. Operative wounds were assessed daily during the hospital stay and in an outpatient clinic four weeks after surgery.

• N = 294
• MEAN AGE = 66.5 years
• MALES: 53.1%, FEMALES: 46.9%
• KEY DISEASE CHARACTERISTICS: All had colon cancer. Patients who had resection of adjacent organs were excluded. Seventy-three percent had open procedures, and the rest had laparoscopic procedures.

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

• PHASE OF CARE: Active antitumor treatment

• RCT
  • Three-group
  • Single-blind

• SSI was classified as incisional or organ/space SSI.
• Stool samples were collected prior to surgery and on postoperative days 7 and 14 for analysis of fecal flora and Clostridium difficile (CD) toxin.

Rates of postoperative infections, including incisional infections, organ/space SSIs, and remote infections, were 24% in the probiotic group, 11.1% in the oral antibiotic group, and 25% in the control group. Group comparisons showed that the difference in infection rate was significantly lower in the oral antibiotic group than in either other group (p < .03). Incidence of incisional SSI was lower in the oral antibiotic group (p = .014). The oral antibiotic group also had a significantly lower rate of leakage (p = .004). SSI-causing pathogens were analyzed in all patients, and most of the bacteria detected were not covered by the spectrum of flomoxef. No significant differences were observed in CD toxin detection between groups.

Findings suggest that bowel preparation with oral antibiotics is helpful in preventing postoperative infections in patients with colon cancer undergoing elective colon surgery. No benefit was shown with the use of preoperative probiotics.

• Measurement/methods not well described
• Other limitations/explanation: Definition of SSI was described minimally.

Findings show that rates of postoperative infections among patients undergoing surgery for colon cancer can be reduced by the addition of oral antibiotics as part of bowel preparation. Probiotic use was not effective. Nurses can advocate for consideration of use of preoperative oral antibiotics as examined in this study and advocate for further research to confirm these findings. CD risk was not shown to be different across groups in this study, but this risk remains a consideration, particularly if oral antibiotic use is prolonged.