Alternative antimicrobial prophylaxis associated with higher rates of SSI
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Patients treated with alternative antimicrobial prophylaxis for elective colorectal surgery faced higher rates of surgical site infections than patients who received IV beta lactam-based prophylaxis, researchers found.
The effect disproportionately impacted patients who claim to have penicillin allergy, who often receive recommended alternative antimicrobial prophylaxis (AAP), according to the researchers.
Based on “robust" evidence that shows beta-lactam-based antimicrobial prophylaxis (BLP) reduces the risk for surgical site infection (SSI), “Guidelines recommend cefazolin with metronidazole as first line prophylaxis for clean-contaminated, elective colorectal surgery procedures,” Alisha R. Fernandes MD, MPH, FRCSC, advanced gastrointestinal minimally invasive surgery fellow at Dalhousie University, and colleagues wrote.
“The equivalent efficacy of guideline-recommended antibiotic prophylaxis in colorectal surgery has not been proven, despite local antibiograms suggesting their efficacies may differ in preventing surgical site infection,” Fernandes told Healio.
To determine whether the odds of SSI differ between adult elective colorectal surgery patients receiving IV BLP and AAP, Fernandes and colleagues performed a retrospective cohort study that reviewed elective colorectal surgeries between October 2009 and April 2016 in a tertiary-care hospital setting in Ontario, Canada.
Eligible procedures included elective clean-contaminated colorectal surgeries with traceable 30-day follow-up, and administration of guideline-recommended preoperative IV antimicrobial prophylaxis performed on patients aged 18 years and older.
In total, 966 adult, clean-contaminated, elective colorectal surgeries involving guideline-
recommended IV antimicrobial prophylaxis were included in the study. Among these, cefazolin and metronidazole were used as BLP, whereas patients who took AAP received metronidazole plus ciprofloxacin (86.5%) or gentamicin (13.5%). Vancomycin was also used in 3.6% of patients.
SSIs occurred in 163 patients, with 77 having superficial SSIs, 75 having abscess or anastomotic leak and 11 having wound dehiscence. Overall, the researchers detected no differences in clinically relevant covariates among patients receiving BLP and AAP, aside from penicillin allergy status. SSIs, however, were more commonly reported among patients who received AAP.
According to the study, AAP was associated with higher odds of SSI than BLP (adjusted
OR = 2.15; 95% CI, 1.33-3.5). Among the patients who developed SSIs, most manifested as superficial incisional SSIs (47.2%). These patients also had a longer postoperative length of stay in the hospital (8 vs 6 days; P = .003) and required more post-discharge physician assessments, outpatient nursing care, readmissions and reoperations (P < .001).
Researchers said that regardless of SSI status, AAP was associated with significantly more post-discharge physician assessments (P = .028), outpatient nursing care (P = .001) and readmissions (P = .049).
“SSI rates in elective colorectal surgery differ based on which guideline-recommended antimicrobial prophylaxis they receive, so prophylaxis decisions should be made based on guidelines alongside consideration of local antibiograms, in order to confer the greatest benefit of prophylaxis to patients,” Fernandes concluded.
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