5. Perioperative Antibiotics in Laparoscopic Surgery
Tracey D. Arnell, M.D.
I. Goals
a. Prevent surgical site infections.
i. Elimination of surgical site infections is impossible; there- fore, the goal of antibiotic usage is to reduce the incidence of surgical site infections.
1. A surgical site infection is not simply a failure of anti- biotic prophylaxis.
2. The use of laparoscopic methods may be associated with a reduction in the incidence of wound infections.
a. Decreased postoperative immunosuppression.
b. The role of carbon dioxide insufflation is unclear.
i. There are conflicting results regarding laparo- scopic appendectomy for appendicitis; some studies demonstrate an increase and some a decrease in surgical site infections.
ii. Appendicitis may serve as a peritonitis model.
b. Treat existing infections, i.e., diverticulitis, appendicitis, peri- tonitis, etc.
c. Avoid toxicity.
i. Allergic reactions.
ii. Antibiotic-related infections such as Clostridium difficile infection.
iii. Adverse interactions or reactions with other drugs.
iv. Bone marrow suppression (very rare reaction to rarely used antibiotics).
d. Avoid unnecessary use.
i. Drug resistance.
1. Increasing incidence of resistant strains of Staphylo- coccus, enterococci (VRE), and other bacteria; this may be related to the use of broad-spectrum antibiotics as well as excessive duration of therapy.
ii. Selection of pathogenic bacteria.
iii. Cost considerations.
iv. Noncompliance with antibiotic recommendations more than 50% and as high as 75%.
1. Despite multiple prospective studies and consensus state- ments regarding appropriate use of antibiotics, practi- tioners continue to deviate from recommendations.
2. Patients, at times, take antibiotics without obtaining the approval of a physician.
II. General considerations
a. Risk factors.
i. Patient factors.
1. Increased incidence of wound infection in the setting of:
a. Obesity.
b. Immunosuppression of whatever cause (diabetes, chemotherapy, steroid use, human immunodefi- ciency virus (HIV) infection, etc.).
c. Advanced age.
d. Malnutrition.
e. Established infection in the abdomen or abdomi- nal wall.
ii. Technical factors.
1. Duration of procedure in open surgery has been shown to be associated with an increased rate of infection.
a. Although advanced laparoscopic procedures usually take more time to complete, a higher rate of surgical site infection has not been demon- strated (when compared to open results).
2. Tissue factors.
a. Trauma, devascularization.
b. Inflammation.
c. Radiation-related damage.
3. Type of surgery: (Note: All data regarding expected rates of surgical site infection are from open surgery patients).
a. Clean cases are associated with less than 1%–2%
rate of surgical wound infection.
i. Laparoscopic exploration, solid organ biopsy.
b. Clean contaminated cases: less than 5% infection rate.
i. Violation of biliary tract, uninfected urinary tract, upper intestinal surgery in the absence of stasis or achlorhydria.
c. Contaminated cases: 10%–20% infection rate.
i. Colorectal surgery, upper intestinal surgery with stasis or achlorhydria, cholecystitis, biliary tract stasis.
d. Infected cases: 40% infection rate.
i. Active infection, abscess.
ii. Examples: acute diverticulitis, gangrenous cholecystitis, appendicitis, other intestinal perforation.
b. Appropriate antibiotic choice and duration (Table 5.1).
i. Appropriate spectrum for suspected source of contamination.
1. Skin flora in clean and clean contaminated cases.
a. Coverage may be different in hospitalized or immunosuppressed patients as well as those patients with a recent history of antibiotic usage.
2. Intestinal flora.
a. Gastric bacteria may include oral flora.
b. Colonic or upper intestinal with stasis.
i. Anaerobes and gram-negative coverage.
ii. Enterococcus coverage unnecessary unless infection documented in culture of infection (i.e., abscess).
c. Intraoperative cultures have not been found to be beneficial or necessary in guiding therapy in cases of established infection such as appendicitis.
Infections in immunosuppressed patients may be an exception.
3. Urinary tract with stasis or documented infection.
a. Based on preoperative cultures.
b. Expected organisms including gram-negative flora and enterococci (Table 5.1).
ii. Maintain high tissue levels of antibiotic for the duration of procedure.
Table 5.1. Prophylactic antibiotic recommendations for the intestine and biliary system.
Surgery Organism Antibiotic Penicillin allergic Gastroduodenal Gram-negative First- or second- Fluoroquinolones
(GN) bacilli, generation and flagyl streptococci, cephalosporin
oropharyngeal (e.g., cefazolin, anaerobes cefotetan)
Biliary GN bacilli Cefazolin + Fluoroquinolones
anaerobes flagyl and flagyl
Cefoxitin or Cefotetan
Colorectal and GN bacilli Cefazolin + flagyl Fluoroquinolones
appendix anaerobes Cefoxitin or and flagyl
Cefotetan
1. Based on the half-life of the antibiotic and duration of the procedure.
a. Goal is to attain sufficient plasma and tissue levels before breaching the skin (within 2 hours).
b. May require intraoperative dosing to maintain adequate levels throughout the operation depend- ing on the half-life of the antibiotic chosen.
c. A general recommendation is to repeat the dose of antibiotics if the surgery exceeds 4 hours.
iii. Course.
1. Prophylaxis (no established infection).
a. No evidence to support postoperative use. A single preoperative dose is as effective.
i. May have higher wound infection rates with increased duration of antibiotic therapy.
2. Contamination (intraoperative as well as trauma related):
a. No evidence to support increased duration of therapy (24 hours as effective as 5 days).
3. Infection. For established infection such as perforated appendicitis or diverticulitis.
a. Unclear if specific duration is appropriate. Tradi- tional recommendations are being evaluated.
i. May be based on clinical factors.
1. Presence of temperature and
leukocytosis.
2. CT or USG (ultrasonography) evidence for collection or abscess.
III. Adjuncts to Parenteral Antibiotics
a. Bowel preparation.
i. Common practice in cases of intestinal surgery, especially colon. Goal is to decrease the bacterial load of the colon.
1. Mechanical “gut lavage.”
a. Many agents available.
b. Recent data suggest it may be unnecessary and may increase infectious complication rates.
i. Present recommendation/standard of care remains to perform bowel preparation.
2. Oral antibiotics.
a. Administration.
i. Spectrum to include gram-negative and anaerobic organisms.
ii. Given after gut lavage to prevent being washed out.
iii. Generally given as three divided doses.
b. Effectiveness.
i. Studies conflicting as to necessity when par- enteral antibiotics are given. There appears to be a small advantage to administering both.
ii. High rate of intolerance and vomiting.
b. Antibiotic irrigation.
i. Intraperitoneal.
1. Very few data regarding outcomes. No evidence that there is a significant decrease in wound and intra- abdominal infections.
2. Increased rate of adhesion formation possibly.
ii. Wound.
1. Very few data.
2. May interfere with local wound inflammatory factors.
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