Antibiotic prophylaxis

Local wound infections (superficial or deep-sided), urinary tract infections (caused by a bladder catheter inserted for surgery), and pneumonia (due to impaired breathing/coughing, caused by sedation and analgesics during the first few hours of recovery) may endanger the health of patients after surgery. Visibly worse are postoperative bacterial infections at the site of implanted foreign bodies (sutures, ostheosynthetic material, joint replacements, pacemaker implants, etc.) Often, the outcome of the procedure may be put into question and the life of the patient may even be put at risk.

Worldwide experience with antimicrobial prophylaxis in surgery has proven to be effective and cost-efficient, both avoiding severe patient suffering while saving lives (provided the appropriate antibiotics have been carefully chosen and used to the best of current medical knowledge).

A proper regimen of antibiotics for perioperative prophylaxis of septic complications decreases the total amount of antimicrobials needed and eases the burden on hospitals. The choice of antibiotics should be made according to data on pharmacology, microbiology, clinical experience and economy. Drugs should be selected with a reasonable spectrum of activity against pathogens likely to be encountered, and antibiotics should be chosen with kinetics that will ensure adequate serum and tissue levels throughout the risk period.

For prophylaxis in surgery, only antibiotics with good tolerability should be used. Cephalosporins remain the preferred drugs for perioperative prophylaxis due to their low toxicity. Parenteral systemic antibiotics seem to be more appropriate than oral or topical antibiotics because the chosen antibiotics must reach high concentrations at all sites of danger. It is well recognized that broad-spectrum antibiotics are more likely to prevent gram-negative sepsis. New data demonstrate that third generation cephalosporins are more effective than first and second generation cephalosporins if all perioperative infectious complications are taken into consideration. Dermatologic surgeons commonly use antibiotic prophylaxis to prevent bacterial endocarditis. Based on previous studies, though, the risk of endocarditis following cutaneous surgery is low and thus the use of antibiotic prophylaxis is controversial. Although this practice is appropriate for high-risk patients when skin is contaminated, it is not recommended for noneroded, noninfected skin.[6] There are many factors that affect physicians’ compliance with guideline recommendations, including cultural factors, educational background, training, nurse and pharmacist influences, medication supply, and logistics.[3]

For dental procedures, the American protocol in 2017 called for the prescription of amoxicillin or ampicillin.[3]

Long-acting, broad-spectrum antibiotics offer the following advantages by comparison to short-acting antimicrobials in perioperative prophylaxis:

• A single dose covers the whole perioperative risk period - even if the operation is delayed or long-lasting - and with regard to respiratory and urinary tract infections
• Repeat administrations for prophylaxis are not necessary, so that additional doses are less likely to be forgotten (an advantage of practical value in a busy working situation such as a hospital)
• Less risk of development of resistance and less side effects
• Increased compliance and reduced errors of administration
• Possibly better-effectiveness (less material and labor cost, less septic perioperative complications)

There are many factors that affect physicians’ compliance with guideline recommendations, including cultural factors, educational background, training, nurse and pharmacist influences, medication supply, and logistics.

The American Heart Association (AHA) now recommends antibiotic prophylaxis for very few patients since only a small number of cases of endocarditis might be prevented by this procedure.[7]