Antifungal prophylaxis for esophageal perforation: what’s the evidence?

Elsayed H, et al. The impact of systemic fungal infection in patients with perforated oesophagus. Ann R Coll Surg Engl. 2012 Nov;94(8):579-84.

“Some authors have concluded that antifungal prophylaxis could reduce mortality by 25% in non-neutropaenic critically ill patients and should be given prophylactically to patients at increased risk of invasive fungal infections.24 Patients with oesophageal perforation, the majority of whom are managed initially on critical care units, have several factors that increase their risk of secondary candidal infection including prolonged antibiotic use, surgery and being on total parental nutrition as well as a possible higher rate of candidal colonisation. As a result, this makes them ideal candidates for empirical antifungal therapy from diagnosis. This is the routine practice in our hospital now.

Until a randomised study comparing administration of antifungal versus no antifungal therapy proves empirically that there is no benefit of adding this medication, antifungal prophylaxis should be standard in patients with a ruptured oesophagus once diagnosed. We appreciate the limitation of this study in terms of the number of patients (27) but as a ruptured oesophagus is a rare presentation, it would be difficult to have a randomised study with a large number of patients.” (p. 583)

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Intra-Cavity Lavage and Wound Irrigation for Prevention of Surgical Site Infection

1: Ambe PC, Rombey T, Rembe JD, Dörner J, Zirngibl H, Pieper D. The role of saline irrigation prior to wound closure in the reduction of surgical site infection: a systematic review and meta-analysis. Patient Saf Surg. 2020 Dec 22;14(1):47. doi: 10.1186/s13037-020-00274-2. PMID: 33353558; PMCID: PMC7756962.

2: Strobel RM, Leonhardt M, Krochmann A, Neumann K, Speichinger F, Hartmann L,
Lee LD, Beyer K, Daum S, Kreis ME, Lauscher JC. Reduction of Postoperative Wound Infections by Antiseptica (RECIPE)?: A Randomized Controlled Trial. Ann Surg.
2020 Jul;272(1):55-64. doi: 10.1097/SLA.0000000000003645. PMID: 31599810.

3: Thom H, Norman G, Welton NJ, Crosbie EJ, Blazeby J, Dumville JC. Intra-Cavity Lavage and Wound Irrigation for Prevention of Surgical Site Infection: Systematic Review and Network Meta-Analysis. Surg Infect (Larchmt). 2021 Mar;22(2):144-167. doi: 10.1089/sur.2019.318. Epub 2020 Apr 29. PMID: 32352895.

4: Maatman TK, Weber DJ, Timsina LR, Qureshi B, Ceppa EP, Nakeeb A, Schmidt CM,
Zyromski NJ, Koniaris LG, House MG. Antibiotic irrigation during pancreatoduodenectomy to prevent infection and pancreatic fistula: A randomized controlled clinical trial. Surgery. 2019 Oct;166(4):469-475. doi: 10.1016/j.surg.2019.05.053. Epub 2019 Aug 2. PMID: 31383465.

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Article of interest: Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016

Rhodes A, Evans LE, Alhazzani W, Levy MM, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Crit Care Med. 2017 Mar;45(3):486-552.

Full-text for Emory users.

Methods: The panel consisted of five sections: hemodynamics, infection, adjunctive therapies, metabolic, and ventilation. Population, intervention, comparison, and outcomes (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. Each subgroup generated a list of questions, searched for best available evidence, and then followed the principles of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system to assess the quality of evidence from high to very low, and to formulate recommendations as strong or weak, or best practice statement when applicable.

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Infection rates of different CVC insertion sites

Arvaniti K, et al. Cumulative Evidence of Randomized Controlled and Observational Studies onCatheter-Related Infection Risk of Central Venous Catheter Insertion Site in ICU Patients: A Pairwise and Network Meta-Analysis. Crit Care Med. 2017 Apr;45(4):e437-e448.

Full-text for Emory users.

Data Synthesis: Twenty studies were included; 11 were observational, seven were randomized controlled trials for other outcomes, and two were randomized controlled trials for sites. We evaluated 18,554 central venous catheters: 9,331 from observational studies, 5,482 from randomized controlled trials for other outcomes, and 3,741 from randomized controlled trials for sites. Colonization risk was higher for internal jugular (relative risk, 2.25 [95% CI, 1.84-2.75]; I2 = 0%) and femoral (relative risk, 2.92 [95% CI, 2.11-4.04]; I2 = 24%), compared with subclavian. Catheter-related bloodstream infection risk was comparable for internal jugular and subclavian, higher for femoral than subclavian (relative risk, 2.44 [95% CI, 1.25-4.75]; I2 = 61%), and lower for internal jugular than femoral (relative risk, 0.55 [95% CI, 0.34-0.89]; I2 = 61%). When observational studies that did not control for baseline characteristics were excluded, catheter-related bloodstream infection risk was comparable between the sites.

Conclusions: In ICU patients, internal jugular and subclavian may, similarly, decrease catheter-related bloodstream infection risk, when compared with femoral. Subclavian could be suggested as the most appropriate site, whenever colonization risk is considered and not, otherwise, contraindicated. Current evidence on catheter-related bloodstream infection femoral risk, compared with the other sites, is inconclusive.

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World Health Organization: In the presence of drains, does prolonged antibiotic prophylaxis prevent SSI?

One discussion this week included surgical drains and antibiotic PPX.

Reference: World Health Organization. Summary of a systematic review on antimicrobial prophylaxis in the presence of a drain and wound drain removal. WHO Surgical Site Infection Prevention Guidelines, Web Appendix 27 (30p.).

Summary: In the WHO SSI prevention guidelines, one of the PICO questions addressed is:

In the presence of drains, does prolonged antibiotic prophylaxis prevent SSI?

  • Population: inpatients and outpatients of any age undergoing a surgical
    operation (any type of procedure) with the presence of postoperative drainage
  • Intervention: prolonged antibiotic prophylaxis postoperatively
  • Comparator: single-dose antibiotic prophylaxis (or repeated intraoperatively
    according to the duration of the operation)
  • Outcomes: SSI, SSI-attributable mortality

Their findings are quoted below:

Seven RCTs were identified with an SSI outcome comparing prolonged antibiotic prophylaxis in the presence of a wound drain vs. single-dose perioperative prophylaxis, possibly repeated intraoperatively according to the duration of the procedure. The number of days for antibiotic prophylaxis prolongation in the postoperative period varied among studies. Three studies prolonged antibiotic administration until the wound drain was removed. In the remaining trials, patients continued intravenous administration for 3 or 5 days. Included patients were adults undergoing several types of surgical procedures (general surgery, kidney transplantation, and pilonidal sinus surgery). One trial evaluated whether prolonged antibiotic prophylaxis reduced the risk of infectious complications for patients undergoing elective thoracic surgery with tube thoracostomy. The antibiotic was continued for 48 hours after the procedure or until all thoracostomy tubes were removed, whichever came first.

Among the 7 RCTs, 6 studies showed no statistically significant difference between prolonged antibiotic prophylaxis in the presence of a wound drain vs. perioperative prophylaxis alone. Only one study reported that prolonged antibiotic prophylaxis reduced the risk of SSI. A meta-analysis of the 7 RCTs showed no statistically significant difference between the effect of prolonged antibiotic prophylaxis in the presence of a wound drain and perioperative prophylaxis alone for the risk of SSI (OR: 0.79; 95% CI: 0.53 –1.20]).

Overall, a low quality of evidence shows that prolonged antibiotic prophylaxis in the presence of a wound drain has neither benefit nor harm in reducing the SSI rate when compared to perioperative prophylaxis alone (single dose before incision and possible intraoperative additional dose/s according to the duration of the operation).

Risk of postoperative wound infections in neck dissections

One discussion this week focused on complications after neck dissections.

Reference: Man LX, Beswick DM, Johnson JT. Antibiotic prophylaxis in uncontaminated neck dissection. Laryngoscope. 2011 Jul;121(7):1473-1477. doi:10.1002/lary.21815.

Summary: Man et al (2011) performed a retrospective chart review of 273 uncontaminated neck dissections in order to identify risk factors for postoperative wound infections and to describe the outcomes of antibiotic prophylaxis use. Only 15%

Wound infection was not associated with age, sex, tobacco and alcohol use, history of head/neck surgery, history of radiation/chemotherapy, or number of drains placed during surgery.

Wound infection was independently associated with longer operative time, local/pedicled flap closure and radical or extended neck dissection (p.1474).

Their results for risk of wound infection by type of dissection are below. All 9 wound infections occurred in those receiving intraoperative antibiotics only (4) or intra- and postoperative antiobiotics (5).

neck dissection type

Additionally, this study found that antibiotics are prescribed more frequently to older patients, possibly because they are perceived as less healthy (p.1475). Patients requiring more extensive operations are at a higher risk of postoperative infection, as are those who undergo an operation involving the re-positioning of the patient’s head thus exposing the surgical field (p.1476). The under-reporting of postoperative complications in outpatient settings may also contribute to an underestimate of wound infection.

This review was not able to confirm or support the use of antibiotic prophylaxis in uncontaminated neck dissection significantly lowers the risk of infection. Still, the authors recommend its use “for more extensive lymphadenectomy procedures including radical neck dissection, extended neck dissection, or those requiring longer operative time” (p.1477).