Effect of Body Mass Index and Ertapenem versus Cefotetan Prophylaxis on Surgical Site Infection in Elective Colorectal Surgery

Department of Surgery, Veterans Affairs Boston Health Care System, West Roxbury, MA 02132, USA.
Surgical Infections (Impact Factor: 1.45). 04/2008; 9(2):131-7. DOI: 10.1089/sur.2007.034
Source: PubMed


The effectiveness of prophylactic antibiotics in the prevention of surgical site infection (SSI) after elective colorectal surgery is dependent on many factors, including the body mass index (BMI) of the patient. In this study, the association of BMI and type of antibiotic prophylaxis with SSI was evaluated in patients undergoing elective colorectal surgery.
A post-hoc analysis was performed using data obtained from a multicenter randomized, double-blind study of 1,002 patients undergoing elective colorectal surgery who received prophylactic administration of ertapenem (1 g) or cefotetan (2 g). Among 650 evaluable patients, the effect of BMI and type of antibiotic prophylaxis on SSI rates was assessed four weeks after surgery. Mechanical bowel preparation was standardized, and no patient received oral antibiotics; intravenous antibiotics were not repeated during or after surgery.
The majority of patients had a BMI between 18.5 and 39.9 kg/m2. Regardless of the type of prophylaxis, SSI rates were significantly higher in patients with a BMI > or = 30 kg/m2 than in those with a BMI < 30 kg/m2. However, failure, defined as SSI, was significantly less common after ertapenem than after cefotetan prophylaxis at both BMI < 30 kg/m2 (12.7% vs. 26.4%, respectively; difference -13.7; 95% confidence interval [CI] -21.0, -6.5) and BMI > or = 30 kg/m2 (26.7% vs. 41.9%, respectively; difference -15.3; 95% CI -28.2, -2.0). The most prevalent type of SSI was superficial incisional infection, which was more common with both treatments in patients with a BMI > or = 30 kg/m2; however, the incidence of superficial SSI was lower after ertapenem than cefotetan prophylaxis.
In patients undergoing elective colorectal surgery, the incidence of SSI, specifically superficial incisional SSI, was higher in patients with a BMI > or = 30 kg/m2, regardless of the prophylactic antibiotic given. Ertapenem prophylaxis was more effective than cefotetan in the prevention of SSI at any BMI.

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    • "As for the high rate of superficial-site infection observed in the study by Itani and colleagues (22.4% in cefotetan group and 13.1% in ertapenem group), it should be noted that 28.9% of the patients evaluated had a body mass index (BMI) ±30 kg/m2, which is much higher of the rates of obese patients usually included in other studies.82,83,86 Furthermore, in a post-hoc analysis performed using the data from the study by Itani and colleagues, the incidence of SSIs, and specifically of superficial incisional SSIs, was found to be higher in patients with a BMI ± 30 kg/m2 regardless of the prophylactic antibiotic (ertapenem or cefotetan) given.87 Indeed, failure of antibiotic surgical prophylaxis in obese patients may be related both to technical factors, such as an inadequate obliteration of “dead spaces,” and to low drug levels in serum and tissues, especially at the end of an operation and during surgery.88 "
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    ABSTRACT: Despite improvement in infection control measures and surgical practice, surgical site infections (SSIs) remain a major cause of morbidity and mortality. In colorectal surgery, perioperative administration of a suitable antimicrobial regimen that covers both anaerobic and aerobic bacteria is universally accepted. In a prospective, double-blind, randomized study ertapenem was recently found to be more effective than cefotetan, a parenteral cephalosporin so broadly used as to be considered as gold standard in the prevention of SSIs following colorectal surgery. In this adequate and well controlled study, the superiority of ertapenem over cefotetan was clearly demonstrated from the clinical and bacteriological points of view. However, data that directly compares ertapenem with other antimicrobial regimen effective in preventing SSIs following colorectal surgery are lacking; furthermore, the possible risk of promotion of carbapenem resistance associated with widespread use of ertapenem prophylaxis as well as the ertapenem effects on the intestinal gut flora are of concern. Further comparative studies of ertapenem versus other widely used prophylactic regimens for colorectal surgery in patients submitted to mechanical bowel preparation versus no preparation as well as further research on adverse events of antibiotic prophylaxis, including emergence of resistance and Clostridium difficile infection, seem warranted.
    Preview · Article · Nov 2009 · Therapeutics and Clinical Risk Management
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    • "In particular, cefuroxime, a secondgeneration cephalosporin, has been successfully used in surgery units [4]. However, it has been shown that obese patients are at a higher risk of developing SSI compared with normal weight subjects [7] [8]. Due to the high prevalence of obesity (at least 400 million adults worldwide [9]), free, active antibiotic concentrations at the site of infection following a standard dose should be evaluated in this population. "
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    ABSTRACT: Antibiotic prophylaxis is intended to prevent postoperative wound infections, a major source of morbidity and mortality in surgical patients. Cefuroxime is a well-established second-generation cephalosporin that is given preoperatively in surgery units at a standard dose of 1.5 g. It is therefore important to determine whether cefuroxime distributes to the interstitial space fluid (ISF) of subcutaneous (s.c.) soft tissues, especially in obese patients who are at a higher risk of surgical site infections. In a single centre, prospective, open-label study, six morbidly obese patients [body mass index (BMI)> or =40] undergoing abdominal surgery received a single intravenous dose of 1.5 g cefuroxime within 1h of incision. Blood and microdialysis samples from the ISF of skeletal muscle and s.c. adipose tissue were collected before, throughout and after surgery for up to 6h post-dosing. Cefuroxime concentrations were determined by high-performance liquid chromatography-ultraviolet (HPLC-UV). Total peak concentrations in plasma (C(max)) (66.8+/-18.9 microg/mL) were higher than free C(max) levels in the ISF of muscle (60.1+/-15.2 microg/mL) and s.c. adipose tissue (39.2+/-26.4 microg/mL). Mean area under the free concentration-time curve ratios of muscle/total plasma (1.0+/-0.2) or s.c. adipose tissue/total plasma (0.6+/-0.5) indicate that cefuroxime distributes into the ISF of these tissues. In conclusion, the findings of this pilot study indicate that cefuroxime distributes into the ISF of muscle and s.c. adipose tissue of morbidly obese patients undergoing abdominal surgery. Concentrations in the ISF of soft tissues following a single 1.5 g dose may be high enough to prevent infections with Gram-positive organisms but may be insufficient to prevent infections with Gram-negative organisms.
    Full-text · Article · Jun 2009 · International journal of antimicrobial agents
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    ABSTRACT: Postoperative Wundinfektionen stellen ernste Komplikationen bei chirurgischen und orthopädischen Eingriffen dar und führen zu einer Verlängerung der Verweildauer im Krankenhaus, verursachen zusätzliche Kosten und gehen mit einer erhöhten Morbidität und Mortalität einher. Deshalb ist die Vermeidung von postoperativen Wundinfektionen essentiell und stellt eine Herausforderung im Gesundheitswesen dar. Strategien zur Vermeidung werden präsentiert und erörtert. Eine aktive Surveillance postoperativer Wundinfektionen, die Einführung einer Checkliste, Compliancebeobachtungen und Schulungen/Training von medizinischem Personal sowie Staphylococcus-aureus-/MRSA-Screening, Clipping anstelle der Rasur, die korrekte Einhaltung der perioperativen Antibiotikaprophylaxe, die intraoperative Aufrechterhaltung einer Normothermie und die Blutglukosekontrolle sind essentiell für ein umfassendes Bündel an Infektionspräventionsmaßnahmen, um postoperative Wundinfektionen zu vermeiden. Surgical site infections (SSI) are a severe complication following surgical or orthopaedic procedures and are associated with significant increases in hospital length of stay (LOS), additional costs, morbidity and mortality. Hence, the prevention of SSI is essential and poses a major challenge in the healthcare system. Strategies and key points are presented and discussed. Infection control measures such as active surveillance of SSI, implementation of a checklist, compliance observations and instruction/training of healthcare workers as well as Staphylococcus aureus/MRSA screening, clipping instead of shaving, adherence to perioperative antibiotic prophylaxis, maintaining intraoperative normothermia and blood glucose control are essential for a comprehensive bundle in order to prevent SSI. SchlüsselwörterSurveillance–Präventionsmaßnahmen–Hygiene–Compliance–Screening KeywordsSurveillance–Prevention measures–Infection control–Compliance–Screening
    Full-text · Article · Mar 2011 · Der Unfallchirurg
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