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Selective decontamination of the colon before elective colorectal surgery

  • Société International de Chirurgie-Manuscripts Presented at the 35th World Congress of the International Society of Surgery, Hong Kong, August 1993
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Abstract

The controversy over the route of administration of antibiotic prophylaxis in patients undergoing elective colorectal operations persists for oral, parenteral, and a combination of the two routes. The oral antibiotics commonly administered for colorectal prophylaxis, neomycin and eythromycin base, are not absorbed in the gastrointestinal tract (GIT). However, the 4-fluoroquinolones are absorbed in the upper GIT and are excreted in part by the colonic mucosa. Their action is then to remove, or severely depress, the gram-negative aerobic bacilli leaving the anaerobic flora unaffected. This action is the principle of selective decontamination. We have assessed the efficacy of oral ciprofloxacin in a prospective randomized clinical trial in which all patients received piperacillin 4 g IV as single-dose parenteral prophylaxis. A group of 327 evaluable patients were randomized to receive ciprofloxacin 500 mg b.i.d. with the preoperative cathartic (group OA, n=159) or no oral antibiotic (11.3%) patients in group OA and 39 (23.2%) patients in group NOA (χ2 = 7.2, p=0.007). Operation-related infection of any type occurred in 23 (14.5%) patients in group OA compared with 55 (32.7%) in group NOA (χ2 = 14.0, p=0.0002). The median postoperative hospital stay was 11 days (interquartile range 4.5 days) for group OA and 12 days (interquartile range 8 days) for group NOA (Mann Whitney U test, p=0.005). Ignoring the treatment group, the median postoperative hospital stay was 17 days (interquartile range 10 days) for infected patients and 11 days (interquartile range 4 days) for those not infected. We conclude that the administration of ciprofloxacin 500 mg b.i.d. with the preoperative cathartic significantly reduces the incidence of infection after elective colorectal operations and should form part of the preoperative preparation for such operations.

Résumé

La controverse concernant la meilleure voie d'administration d'antibiotiques prophylactiques chez le patient opéré du côlon à froid persiste toujours: voie orale, voie parentérale ou les deux combinées. Les antibiotiques du type néomycine et érythromycine ne sont pas absorbés par le tube digestif. Les 4-fluoro-quinolones, cependant, sont absorbés dans le tube digestif supérieur et sont ensuite excrétés en partie par la muqueuse colique. Leur action consiste donc à éliminer ou du moins déprimer fortement les bactéries aérobies Gram négatif sans pour autant affecter les bactéries anaérobies. Ceci est la base de la décontamination dite sélective. Nous avons testé l'efficacité de la ciprofloxacine par voie orale dans un essai prospectif randomisé chez des patients ayant de toutes manières de la piperacilline par voie intraveineuse (4 gr) en dose unique. Trois cent vingt-sept patients ont été randomisés pour recevoir en même temps que leur préparation colique mécanique de la ciprofloxacine (500 mg x 2) (group OA, n=159) ou non (groupe NOA, n=168). On a constaté une infection pariétale chez 18 (11%) des patients du groupe OA et chez 39 (25%) des patients du groupe NOA (Chi2=7.2, p=0.007). Une complication infectieuse a été notée chez 23 (14.5%) des patients du groupe OA et chez 55 (32.7%) des patients du groupe NOA (Chi2=14.0, p=0.0002). La durée médiane du séjour hospitalier a été de 11 jours (valeur interquartile = 4.5 jours) dans le groupe OA et de 12 (valeur interquartile = 8 jours) dans le groupe NOA (p=0.005) par le U-test de Mann-Whitney. Sans tenir compte du groupe de tirage au sort, la durée médiane de séjour hospitalier pour les patients infectés a été de 17 (valeur interquartile = 10 jours) comparés à 11 (valeur interquartile = 44) jours pour les patients non-infectés. Nous concluons que l'administration de ciprofloxacine 500 mg en deux fois en même temps que la préparation mécanique, réduit de façon significative l'incidence d'infection après une intervention colique à froid et devrait être systématique pour ce type de chirurgie.

Resumen

Persiste la controversia sobre la ruta oral, parenteral o su combinación de administración de los antibióticos profilácticos en pacientes que van a ser sometidos a cirugía colorrectal. Los antibióticos orales más comunmente administrados para profilaxis colorrectal, la neomicina y la eritromicina base, no son absorbidos en el tracto gastrointestinal. Sin embargo, las fluroquinolonas si son absorbidas en el tracto GI superior y son excretadas en parte por la mucosa colónica. Su acción es, por tanto, la de eliminar o reducir los bacilos aeróbicos Gram-negativos, sin afectar la flora anaeróbica. Tal es el principio de la descontaminación selectiva. Hemos evaluado la eficacia de la ciprofloxacina oral en un ensayo prospectivo y randomizado, en el cual la totalidad de los pacientes recibió piperacilina 4 g IV en dosis única como forma de profilaxis parenteral. Se escogieron al azar 327 pacientes valorables para recibir ciprofloxacina 500 mg BD con el agente preoperatorio de catarsis (Grupo OA, n=159) o ningún antibiótico oral (Grupo NOA, n=168). Se registró infección de la herida en 18 (11%) de los pacientes en el Grupo OA y en 39 (25%) de los del Grupo NOA (Chi2=7.2, p=0.007). Se presentó infección, de cualquier tipo relacionada con la operación, en 23 (14.5%) de los pacientes en el Grupo OA y en 55 (32.7%) de los del Grupo NOA (Chi2=14.0, p=0.0002). La estancia hospitalaria postoperatoria media fue de 11 días (rango interquartil 4.5 days) en el Grupo OA y de 12 días (rango i. 8 días) en el Grupo NOA (prueba U de Mann Whitney p=0.005). Al no tener en cuenta el Grupo de tratamiento, la estancia postoperatoria media fue de 17 días (rango i. 10 días) para los pacientes infectados, y de 11 días (rango i. 4 días) para los no infectados. Nuestra conclusión es que la administración profiláctica de ciprofloxacina en dosis preoperatoria de 500 mg BD concomitante con el agente catártico reduce en forma significativa la incidencia de infección luego de operaciones colorrectales y que debe ser parte de la preparación preoperatoria para tal tipo de cirugía.

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Authors and Affiliations

  1. Vale of Leven Hospital, G83 0UA, Alexandria, Dunbartonshire, Scotland, U.K.

    T. W. Taylor

  2. Southern General Hospital, Glasgow, Scotland, U.K.

    G. Lindsay

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  1. T. W. Taylor
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  2. G. Lindsay
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West of Scotland Surgical Infection Study Group

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The following surgeons and microbiologists participated in this study: D. Bremner, J. Gollock, and M. Browne at Borders General Hospital, Melrose; C. Morran, B. Sugden, and R. Hardie, at Crosshouse Hospital, Kilmarnock; A. Walls, M. Henderson, J. McCormick, C. Auld, and F. Bone at Dumfries & Galloway Royal Infirmary; J. MacDonald and J. McGavigan at Falkirk District Royal Infirmary; J. Goldring at Hairmyres Hospital, East Kilbride; J.J. Morrice, G. Bell, and V. Biggs at Inverclyde Royal Hospital; M.K. Browne, J. McKenzie, R. Brooks, and J. Thomson at Monklands District General Hospital, Airdrie; K. Mitchell and F. Russell at Royal Alexandra Hospital, Paisley; J. Ferguson, G. McBain, A. Litton, and G. Lindsay at Southern General Hospital, Glasgow; R. Dalling, J. Smith, and A. Girdwood at Stobhill General Hospital; E.W. Taylor, J.R. Maccallum, P.J. Shouler, and A. Eastaway at Vale of Leven District General Hospital; J. Drury, I. Smith, and P. Redding at Victoria Infirmary, Glasgow.

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Taylor, T.W., Lindsay, G. & West of Scotland Surgical Infection Study Group. Selective decontamination of the colon before elective colorectal surgery. World J. Surg. 18, 926–931 (1994). https://doi.org/10.1007/BF00299111

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