CEPHALORIDINE PROPHYLAXIS IN LARGE;BOWEL
RESECTION
HUGHES ET ALll
CEPHALORIDINE PROPHYLAXIS IN RESECTION OF THE LARGE INTESTINE E. S. R . HUGHES, F. T. MCDERMOTT, A. WHITEAND J. P. MASTERTON Department of Surgery, Monash University, Alfred Hospital, Prahran A controlled prospective clinical trial of cephaloridine chemoprophylaxis in resection of the large intestine was undertaken between 1974 and 1978. Data were available on 159 of 177 unselected patients. All were operated on by one surgeon. Three groups were studied: intraabdominal resection and anastomosis (102 patients); pullthrough resection and anastomosis (30 patients): and resection, with colostomy or ileostomy, without anastomosis (27 patients). I n the total patient series cephaloridine reduced wound infection from 38.3% to 15.4% (P< 0.003). There was no significant decrease in intraabdominal infection. In the group of patients undergoing intraabdominal resection and anastomosis the wound infection rate was reduced from 40.0% to 14.9% (P< 0.01). Cephaloridine reduced wound infection from 50.0% to 21.4% (P = 0.05) in those patients in whom drainage tubes were inserted. A decrease in the incidence of faecal fistula from 10.9% to 4.3% was not significant. Wound infections were not reduced significantly after pullthrough excisions or resections without anastomosis. The results support the routine prophylactic use of cephalosporins in patients undergoing intraabdominal resection of the large intestine with anastomosis. THERE,is a heavy concentration of potentially pathogenic organisms in the large intestine. Consequently, the control of postoperative infection after resection of large intestine presents a special challenge. Previous prospective clinical trials with which one of the authors (E.S.R.H.) was associated, led to the following conclusions in regard to wound infection. (1) When no antibiotics are used, but careful wound protection is practised, the infection rate is approximately 50%. Most of these wound infections are localized, superficial and trivial, and do not delay convalescence. (2) The preoperative use of neomycin or kanamycin produces a slight improvement in the infection rate, viz., 38% (Rubbo et alii, 1965; Hughes, 1967). (3)
Topical useof polybactrin (neomycin sulphate, bacitracin, polymixin B sulphate) reduces the
Reprints. Professor Sir Edward Hughes, Department of Surgery, Monash University, Alfred Hospital. Prahran. Victoria 3181.
434
incidence to 17% (Rubbo et alii, 1965; Hughes 1967). (4) Intravenously administered crystalline penicillin (10 million units) given at the time of induction of anaesthesia reduces the infection rate to 9% (Hughes et alii, 1970). (5) Gentamicin does not significantly reduce the wound infection rate, but there is a lower incidence of intraperitoneal infection (Burton et alii, 1975). (6) Mechanical bowel preparation does not influence the incidence of infection (Hughes, 1972). (7) Effective prophylaxis requires a h i g h concentration of the antibiotic in the tissues at the time of operative contamination. This is achieved by administering theantibiotic ashort time before operative contamination (Rubbo et alii, 1965). This paper presents the results of a controlled prospective clinical trial wirh cephaloridine. AUST. N.Z. J. SURF. VOL. 49-No.
4 AUGUST
CEPHALORIOINE PROPHYLAXIS IN
HUGHES ET ALll
LARGE-BOWEL RESECTION
RESULTS (A) Total Series In the 81 patients not receiving cephaloridine, 31 (38.3%) operations were complicated by a wound infection. Wound infection occurred in 12 (15.4%) of the 78 patients receiving cephaloridine ( x = 9.43 ; P < 0.003) (Table 1). Seven of the patients not receiving cephaloridine and four of those receiving it developed concurrent intraabdominal abscesses ( X * = 0.31; not significant) (Table 2).
PROTOCOL OF TRIAL Cephaloridine (Ceporan 1 9)' was administered intramuscularly at the time of premedication and was followed by two subsequent injections, 4 hours and 10 hours post-operatively. The regimen selected for the patients, i.e., cephaloridine or no cephaloridine, followed instructions issued in sealed plain envelopes which were opened at the time of premedication. All patients were operated on by one surgeon (E.R.S.H.). The surgeon was not aware if the patient had received cephaloridine. Details of postoperative infection were recorded by the registrar without reference to the surgeon. Every effort was made to reduce the degree of contamination by aseptic technique (Hughes, 1972), although mechanical bowel preparation was not used. A drainage tube was placed down to the anastomosis if contamination was more than average, if haemostatis seemed incomplete, or i f the anastomosis was technically less satisfactory than usual. The drain tubewas broughtthrough the lower end of the main wound and drainagecollected into a plastic bag. Three types of intestinal resection were performed: (i) intraabdominal resection and anastomosis (102 patients); (ii) pullthrough resection and anastomosis (30 patients); and (iii) resection with colostomy or ileostomy but without anastomosis (27 patients). The wound was classified as infected if a purulent discharge was present. The formation of an
No cephaloridine Cephaloridine
TABLE1
No cephaloridine Cephaloridine
Incidence of Wound Infection
No cephaloridine Cephaloridine Total
%
81 78
31 12
38 3% 15 4%
159
43
27 0%
'18 patients excluded from trial (see text)
X 2 = 9 4 2 P
RESECTION
HUGHES ET ALll
CEPHALORIDINE PROPHYLAXIS IN RESECTION OF THE LARGE INTESTINE E. S. R . HUGHES, F. T. MCDERMOTT, A. WHITEAND J. P. MASTERTON Department of Surgery, Monash University, Alfred Hospital, Prahran A controlled prospective clinical trial of cephaloridine chemoprophylaxis in resection of the large intestine was undertaken between 1974 and 1978. Data were available on 159 of 177 unselected patients. All were operated on by one surgeon. Three groups were studied: intraabdominal resection and anastomosis (102 patients); pullthrough resection and anastomosis (30 patients): and resection, with colostomy or ileostomy, without anastomosis (27 patients). I n the total patient series cephaloridine reduced wound infection from 38.3% to 15.4% (P< 0.003). There was no significant decrease in intraabdominal infection. In the group of patients undergoing intraabdominal resection and anastomosis the wound infection rate was reduced from 40.0% to 14.9% (P< 0.01). Cephaloridine reduced wound infection from 50.0% to 21.4% (P = 0.05) in those patients in whom drainage tubes were inserted. A decrease in the incidence of faecal fistula from 10.9% to 4.3% was not significant. Wound infections were not reduced significantly after pullthrough excisions or resections without anastomosis. The results support the routine prophylactic use of cephalosporins in patients undergoing intraabdominal resection of the large intestine with anastomosis. THERE,is a heavy concentration of potentially pathogenic organisms in the large intestine. Consequently, the control of postoperative infection after resection of large intestine presents a special challenge. Previous prospective clinical trials with which one of the authors (E.S.R.H.) was associated, led to the following conclusions in regard to wound infection. (1) When no antibiotics are used, but careful wound protection is practised, the infection rate is approximately 50%. Most of these wound infections are localized, superficial and trivial, and do not delay convalescence. (2) The preoperative use of neomycin or kanamycin produces a slight improvement in the infection rate, viz., 38% (Rubbo et alii, 1965; Hughes, 1967). (3)
Topical useof polybactrin (neomycin sulphate, bacitracin, polymixin B sulphate) reduces the
Reprints. Professor Sir Edward Hughes, Department of Surgery, Monash University, Alfred Hospital. Prahran. Victoria 3181.
434
incidence to 17% (Rubbo et alii, 1965; Hughes 1967). (4) Intravenously administered crystalline penicillin (10 million units) given at the time of induction of anaesthesia reduces the infection rate to 9% (Hughes et alii, 1970). (5) Gentamicin does not significantly reduce the wound infection rate, but there is a lower incidence of intraperitoneal infection (Burton et alii, 1975). (6) Mechanical bowel preparation does not influence the incidence of infection (Hughes, 1972). (7) Effective prophylaxis requires a h i g h concentration of the antibiotic in the tissues at the time of operative contamination. This is achieved by administering theantibiotic ashort time before operative contamination (Rubbo et alii, 1965). This paper presents the results of a controlled prospective clinical trial wirh cephaloridine. AUST. N.Z. J. SURF. VOL. 49-No.
4 AUGUST
CEPHALORIOINE PROPHYLAXIS IN
HUGHES ET ALll
LARGE-BOWEL RESECTION
RESULTS (A) Total Series In the 81 patients not receiving cephaloridine, 31 (38.3%) operations were complicated by a wound infection. Wound infection occurred in 12 (15.4%) of the 78 patients receiving cephaloridine ( x = 9.43 ; P < 0.003) (Table 1). Seven of the patients not receiving cephaloridine and four of those receiving it developed concurrent intraabdominal abscesses ( X * = 0.31; not significant) (Table 2).
PROTOCOL OF TRIAL Cephaloridine (Ceporan 1 9)' was administered intramuscularly at the time of premedication and was followed by two subsequent injections, 4 hours and 10 hours post-operatively. The regimen selected for the patients, i.e., cephaloridine or no cephaloridine, followed instructions issued in sealed plain envelopes which were opened at the time of premedication. All patients were operated on by one surgeon (E.R.S.H.). The surgeon was not aware if the patient had received cephaloridine. Details of postoperative infection were recorded by the registrar without reference to the surgeon. Every effort was made to reduce the degree of contamination by aseptic technique (Hughes, 1972), although mechanical bowel preparation was not used. A drainage tube was placed down to the anastomosis if contamination was more than average, if haemostatis seemed incomplete, or i f the anastomosis was technically less satisfactory than usual. The drain tubewas broughtthrough the lower end of the main wound and drainagecollected into a plastic bag. Three types of intestinal resection were performed: (i) intraabdominal resection and anastomosis (102 patients); (ii) pullthrough resection and anastomosis (30 patients); and (iii) resection with colostomy or ileostomy but without anastomosis (27 patients). The wound was classified as infected if a purulent discharge was present. The formation of an
No cephaloridine Cephaloridine
TABLE1
No cephaloridine Cephaloridine
Incidence of Wound Infection
No cephaloridine Cephaloridine Total
%
81 78
31 12
38 3% 15 4%
159
43
27 0%
'18 patients excluded from trial (see text)
X 2 = 9 4 2 P
