Antibiotics prophylaxis is given only when indicated

ROJoson’s Medical Anecdotal Report

Date of Observation: September 16, 2017

Dolores C, a 64-year-old female, followed up with me one week after her operation (excision of a submanbibular mass).  The histopath showed chronic sialoadenitis.

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She commented: “galing galing ninyo doc. walang antibiotics. No infection.”  (You are so good, doctor.  I was not prescribed / I did not take antibiotics. No infection.)

I answered her back that antibiotics was not needed as the operation is considered a clean operation.  The incidence of wound infection is about 1-2% only.  I give antibiotics only when indicated.

Insight:

Because of the rampant practice of surgeons giving antibiotics even when not indicated, the public expect they would have to take antibiotics after every operation.

We have to educate the public that antibiotics are given only when indicated.

Surgical wounds are classified into clean, clean-contaminated, contaminated and dirty.

“Clean — an incision in which no inflammation is encountered in a surgical procedure, without a break in sterile technique, and during which the respiratory, alimentary and genitourinary tracts are not entered.

Clean-contaminated — an incision through which the respiratory, alimentary or genitourinary tract is entered under controlled conditions but with no contamination encountered.

Contaminated — an incision undertaken during an operation in which there is a major break in sterile technique or gross spillage from the gastrointestinal tract, or an incision in which acute, non-purulent inflammation is encountered.

Dirty or infected — an incision undertaken during an operation in which the viscera are perforated or when acute inflammation with pus is encountered during the operation (for example, emergency surgery for faecal peritonitis), and there is faecal contamination or devitalised tissue present”

https://www.ncbi.nlm.nih.gov/books/NBK174534

Before the routine use of prophylactic antibiotics, infection rates were:

1-2% or less for clean wounds

6-9% for clean-contaminated wounds

13-20% for contaminated wounds

about 40% for dirty wounds

Reference: Cruse PJ, Foord R. The epidemiology of wound infection. A 10-year prospective study of 62,939 wounds. Surg Clin North Am 1980; 60(1): 27-40.

Since the introduction of routine prophylactic antibiotic use, infection rates in US National Nosocomial Infection Surveillance (NNIS) system hospitals were reported to be:

2.1 % for clean wounds

3.3% for clean-contaminated wounds

6.4% for contaminated wounds

7.1% for dirty wounds

Reference: Culver DH, Horan TC, Gaynes RP, Martone WJ, Jarvis WR, Emori TG, et al. Surgical wound infection rates by wound class, operative procedure, and patient risk index. National Nosocomial Infections Surveillance System. Am J Med 1991; 91(3B): 152S-157S.

The following table summarizes the data above:

antibiotics-in-colorectal-surgery-23-728

https: // www. slideshare. net  / sanoopzac / antibiotics in colorectal surgery

One can see from above data that incidence of infection in clean surgical wounds is only about 1-2% and with use of prophylactic antibiotics, the incidence is the same and not lower.

Thus, as a rule, no prophylactic antibiotics is required for clean surgical wounds such as after a clean excision of breast mass, clean excision of skin and soft tissue mass, clean thyroidectomy, clean mastectomy and clean herniorrhaphy.  Those with contaminated and dirty surgical wounds definitely will need antibiotic prophylaxis.  Those with clean-contaminated surgical wounds may or may not need prophylactic antibiotics depending on the circumstances. (Note: above case may strictly be considered as a clean-contaminated surgical wound as the salivary duct is cut.  However, she did not receive antibiotics and did not develop infection.)

ROJ-TPOR@17sept17

 

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