No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
Abstract
Sixty-four consecutive patients appendicectomized for perforated appendicitis were studied retrospectively to assess the effect of peroperative metronidazolee on postoperative infections. All patients were given antibiotics against aerobic organism. The infection rate in patients receiving metronidazol peroperative was 3%. It is concluded that the effect of peroperative administrated metronidazole in prevention of postoperative infections after perforated appendicitis is as good as previously demonstrated for preoperative administrated. Consequently metronidazole treatment can be restricted to peroperative proven high risk patients with perforated and perhaps gangrenous appendicitis.
Die Zahl der jährlich neu erscheinenden Publikationen zum Thema „Behandlung der diffusen Peritonitis“ steigt ständig. Immer wieder werden neue Antibiotika mit breiterem Spektrum und besserer Wirksamkeit für die Therapie der diffusen Peritonitis empfohlen. So fällt es dem Chirurgen immer schwerer, seine Wahl zu treffen. Gewisse Faktoren machen die diffuse Bauchfellentzündung hinsichtlich der Therapie und der Prognose zu einer schwer abwägbaren Erkrankung:
Unterschiedliche Ursachen der Peritonitis,
verschiedene Grade der Beteiligung von Keimen,
das Resistenzverhalten der Keime,
das Vorhandensein von Mischinfektionen,
unterschiedliche Zeiträume bis zum Beginn der Therapie,
die patienteneigene Abwehrlage.
Patients with gangrenous nonperforated appendicitis have a high risk of developing postsurgical infectious complications. The present prospective randomized multicenter study was performed to ascertain whether a single, intraoperative high dose (4 g) cefoxitin given intravenously effectively reduces infectious complications in these patients. The postsurgical infection rate in the treated group was 13.3% as compared to 41.9% in nontreated control patients. This reduction is statistically significant (p < 0.025). Cefoxitin given as a single dose of 4 g is a simple and safe treatment that effectively decreases postsurgical infectious complications in patients with nonperforated gangrenous appendicitis.
Summary The treatment of infected wounds follows the well-known principles of septic surgery: incision, drainage and perhaps irrigation. The prevention of infection is particularly important: a short clinical stay in preparation for the operation, observing the rules of hygiene, and an atraumatic surgical technique. Prophylactic antibiotics are indicated in surgery of the colon. In manifest peritonitis the source of infection must be eliminated. Drainage of the free abdominal cavity as well as intra- and postoperative peritoneal irrigation are of questionable value.
In a prospective, randomized double-blind trial, the efficacy of whole gut irrigation as preoperative bowel preparation for elective colorectal surgery was evaluated alone and in combination with two antimicrobial agents in 148 patients. The antimicrobial regimens were metronidazole alone or metronidazole and ampicillin administered systemically preoperatively and continued for 3 days. Whole gut irrigation was completed without any discomfort in 87 percent of the patients. In 3 percent, the irrigation was stopped and the patients were excluded from the study. Abdominal wound infection developed in 32 percent of the patients after whole gut irrigation, and the addition of metronidazole decreased this incidence to 22 percent (not significant). The incidence in wound infections in the group receiving metronidazole as well as ampicillin was 2 percent, and this difference was highly significant compared with both other groups. No significant difference was found for the incidence of intraabdominal abscesses (p = 0.06), infection of the perineal wound, or anastomotic leakage. No difference in the postoperative infection rate was found between a bowel containing fecal fluid or fecal masses, but when a bowel was clean, significantly fewer infectious complications were found. Whole gut irrigation is a rapid, well-tolerated, easily performed, and safe form of preoperative bowel preparation in elective colorectal surgery if combined with systemic antimicrobial prophylaxis consisting of antimicrobial agents effective against anaerobic and aerobic organisms.
Surgery for perforated appendicitis was used to estimate the infective dose of aerobic and anaerobic bacteria in postoperative wound sepsis. The wound sepsis rates were 22.6% (7/31) after treatment with intravenous ampicillin sodium and metronidazole and 23.5% (8/34) after penicillin G sodium, streptomycin, and metronidazole, a nonsignificant difference. Intraoperative sampling by velvet pads demonstrated that the density of aerobes did not differ significantly from that of anaerobes, either on the surface of the appendix, in peritoneal exudate (aspirated), or in the wound before closure. The predominant pathogens were Escherichia coli and Bacteroides fragilis. In 15 patients who developed wound sepsis, the density of aerobes and anaerobes was significantly higher at all sampling sites than in 50 noninfected patients. The median infective dose of aerobes and anaerobes together was 4.6 X 10(5) colony forming units.cm-2 in the operative wound. There was a significantly high correlation between the densities of bacteria during operation and subsequent wound sepsis.
The effect of antibiotic prophylaxis initiated one hour prior to contamination or at the time of contamination was evaluated in a randomized blind study using a guinea pig model of surgical wound infection. Would infection, defined as accumulation of pus draining spontaneously or after opening of the wound, developed in 135 guinea pigs after intraincisional contamination before wound closure with 10(7) Escherichia coli plus 10(8) Bacteroides fragilis. Antibiotic prophylaxis with gentamicin plus clindamycin significantly reduced the wound sepsis rate from 82% in the control group of 61 animals to 19% in the two treated groups of 68 and 67 animals (p less than 0.001). However, the timing of antibiotic prophylaxis did not influence wound sepsis rates, rectal temperature during the postoperative period, or bacterial recovery from wound infections.
Our double blind prospective randomized trial comparing intravenous cefoxitin with rectal metronidazole in appendicectomy reveals both groups to be similar regarding basic data, with no significant difference in the results between the two drugs. Nearly all the wound infections occurred after the patient went home. Most were minor infections and the overall infection rate was 6%. The intravenous route was the more certain but the more expensive. Bacteriology suggests that the same flora were present in the appendiceal wall of normal and acute non-perforated appendices. This would suggest bacteriologically that the same risks exist with non-inflamed appendicectomy as occurs with inflamed non-perforated appendices. These findings support the use of short course prophylaxis in appendicectomy.
Antimicrobial prophylaxis for surgical procedures is an area that is recognized as being subject to individual clinical variations. This review gives practitioners some basic principles of rational prophylaxis as defined by the medical literature. In addition, this literature is evaluated and condensed to provide clinicians with guidelines for particular procedures: obstetric, gynecologic, gastric, biliary, colonic, urologic, cardiac, thoracic, vascular, orthopedic and head and neck. Each section concludes with recommendations for the clinically most accepted prophylactic regimens. Antibiotics discussed include not only the older agents, but where good information exists, the newer cephalosporins. The suggested regimens consider efficacy, safety and cost as determinants in rational prescribing. Although research into even shorter, and perhaps more cost-effective, regimens continues, this compilation lists state-of-the-art recommendations.
Infection commonly follows removal of the gangrenous or perforated appendix. However, if the appendix is normal or simply acutely inflamed, the rate of infection is low. The organisms most frequently isolated from the wound after appendectomy are Bacteroides (especiallyB. fragilis) andEscherichia coli. A combination of chemoprophylaxis effective against these 2 groups of organisms is the most rational choice of antimicrobial cover. Such antimicrobial cover should be given to all patients with a gangrenous or perforated appendix and to all other patients with appendicitis who have compromised immune systems. Prophylaxis is probably unnecessary in patients with a normal immune system who present with uncomplicated appendicitis.
The treatment of infected wounds follows the well-known principles of septic surgery: incision, drainage and perhaps irrigation. The prevention of infection is particularly important: a short clinical stay in preparation for the operation, observing the rules of hygiene, and an atraumatic surgical technique. Prophylactic antibiotics are indicated in surgery of the colon. In manifest peritonitis the source of infection must be eliminated. Drainage of the free abdominal cavity as well as intra- and postoperative peritoneal irrigation are of questionable value.
ResearchGate has not been able to resolve any references for this publication.