Foley or no Foley? Criteria for perioperative Foley placement

One discussion this week included the use of Foley catheters.


Reference: Meddings J, et al. Michigan Appropriate Periopeartive (MAP) criteria for urinary catheter use in common general and orthopaedic surgeries: results obtained using the RAND/UCLA Appropriateness Method. BMJ Quality & Safety. 2019 Jan;28(1):56-66. doi:10.1136/bmjqs-2018-008025

Summary: Indwelling urinary catheters are commonly used for patients undergoing general and orthopaedic surgery. Despite infectious and non-infectious harms of urinary catheters, there is limited guidance available to surgery teams regarding appropriate perioperative catheter use.

Meddings et al (2019) used the RAND Corporation/University of California Los Angeles (RAND/UCLA) Appropriateness Method 21 to formally rate the appropriateness of urinary catheter placement and timing for removal across routine general and
orthopaedic surgical procedures in adults, as rated by clinicians in different clinical settings across the US and informed by the available literature involving perioperative urinary catheter use.

foley

(Meddings et al, 2019, p.61)

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).