HEALTH-SYSTEM EDITION
CLINICAL TWISTERS

Reducing risk of infection

A 46-year-old male who has had ulcerative colitis for the past 20 years was admitted to your hospital for treatment of adenocarcinoma. Four years ago, when the patient developed a malignant polypoid lesion at the transverse colon, subtotal colectomy with ileorectal anastomosis was performed. The current lesion is at the level of the anastomosis. A proctectomy with construction of ileal J-pouch and ileoanal anastomosis is planned. On admission, the patient is taking sulfasalazine. What recommendations (drug choice, timing, duration of treatment) do you make for prevention of postoperative infection?

Several factors play important roles in the selection of perioperative antimicrobial therapy and prevention of postoperative infections. Close attention should be paid to the patient's drug allergies, social history (alcohol use), medical history, pre-op labs, and type of surgery planned. A proctectomy with construction of ileal J-pouch and creation of an ileoanal anastomosis is considered a clean-contaminated case, and the patient has no allergies or significant medical history.

My recommendations include:

• Standard mechanical bowel preparation containing sodium phosphate solutions on the day prior to surgery, a clear liquid diet, and IV fluid to keep the patient hydrated. Use of these preparations in patients without an ileocecal valve requires close observation.

• Cefoxitin 2 gm should be given with the induction of anesthesia and continued every six hours for 24 hours.

The use of the Nichols-Condon oral neomycin-erythromycin base antibiotic combination with the mechanical bowel preparation would be of questionable additional benefit as this patient has little to no large intestine and the literature for its use is not as strong.

Anne M. Tucker, Pharm.D.
Clinical Pharmacy Specialist
University of Texas M. D. Anderson Cancer Center
Houston

Surgical wound infections account for nearly 16% of hospital-acquired infection sites. Numerous risk factors contribute to surgical infections, but inappropriate antimicrobial prophylaxis is a major cause. Thus, antibiotic choice, timing of administration, and duration of treatment are important. A prophylactic regimen for colorectal surgery should consider that B. fragilis and E. coli are common pathogens that can cause infection. Following completion of mechanical bowel preparation, oral neomycin sulfate 1 gm plus oral erythromycin 1 gm at 19, 18, and nine hours before surgery are recommended.

If the oral route is contraindicat-ed, administer IV cefoxitin 2 gm or cefotetan 2 gm at induction of anesthesia. For high-risk surgeries (this patient) use a combination regimen, including oral neomycin and erythromycin plus either IV metronidazole or second-generation IV cephalosporin. If surgery extends beyond three hours, cephalosporin should be readministered (except for cefotetan). If the patient is allergic to ß-lactam antibiotics, a fluoroquinolone plus clindamycin can be substituted. Multiple antibiotic doses are not required.

Patrick D. Fuller, Pharm.D.
Clinical Pharmacist, Critical Care
Nebraska Health System
Keith M. Olsen, Pharm.D., FCCP
Associate Professor of Pharmacy
University of Nebraska Medical Center
ASHP representative
Surgical Infection Prevention Project

Are you puzzled by a clinical situation that would make a good topic for this column? Or do you relish an opportunity to test your skill in resolving a clinical challenge? Please send us a clinical scenario or indicate your interest in providing us with a patient assessment by e-mailing us at drug.topics@medec.com or fax us at (201) 722-2490.

 

Kathy Hitchens. Reducing risk of infection. Drug Topics 2002;16:HSE16.