INFECTION IN SURGERY

Rational use of antibiotics in

surgery
R Townsend
E J Ridgway

Appropriate antimicrobial use in the clinical environment is vitally

important because resistant organisms are being encountered with
increasing frequency in the UK. A logical approach to caring for
the infected patient (i.e. choosing appropriate antimicrobial agents,
giving them by the optimal route and for the correct duration) is
essential.
This contribution discusses the rationale behind antimicrobial
prescribing in the surgical patient, and should be read with ‘Pro-
phylactic antibiotics in surgery’, page 290.

Antibiotic use and the emergence of resistance

Widespread antibiotic use has contributed to increasing antibiotic
resistance among common bacterial species (e.g. methicillin-
resistant Staphylococcus aureus (MRSA), metronidazole-resistant
anaerobes, multiply-resistant Gram-negative species) and to the
promotion of inherently resistant organisms (e.g. vancomycin-
resistant enterococci).1, 2 Clinicians are treating an increasing
number of patients who are more susceptible to infections (e.g.
elderly, immunosuppressed) and there is often a desire for early
treatment using broad-spectrum antibiotics. An increasing need
for hospital beds results in a tendency to treat empirically rather
than wait for a firm diagnosis. Also, patients (and their carers)
have ever-higher expectations of prescribed therapy. Antibiotics in
widespread use in surgical practice (e.g. cephalosporins, quinolo-
nes) have little activity against common resistant organisms (e.g.
Clostridium difficile, MRSA, vancomycin-resistant enterococci)
and are remarkably effective at selecting out and promoting their
growth.2
Limiting the generation of further resistance and preserving
the efficacy of antimicrobial agents entails adopting strategies that
will treat patients optimally and avoid overuse. There is plenty of
scope for this because antimicrobials account for up to 30% of US
hospital drug budgets, and up to 50% of their use in US hospitals
is inappropriate.3

Antibiotic choice
Does choosing the correct antibiotic make a difference?
Patients who receive inappropriate antibiotic therapy are more
likely to experience complications or stay longer in hospital. Among

R Townsend is a Specialist Registrar in Medical Microbiology at Sheffield

Teaching Hospitals Trust, Sheffield, UK.

E J Ridgway is a Consultant Microbiologist at Sheffield Teaching Hospitals

Trust, Sheffield, UK.

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 INFECTION IN SURGERY
surgical patients with peritonitis, reoperation, abscess formation
and further infection were two to three times more likely in those
who received inappropriate therapy if one or more of the patho-
gens was resistant, compared to those who received appropriate
therapy which was active against the infecting species.4 Inappro-
priate initial antibiotic therapy is also independently associated
with increased mortality.2 Postoperative surgical-site infections are
a common reason for antibiotic therapy. Surveillance figures for
participating English hospitals reported that, between 1997 and
2001, 38% of surgical-site infections were caused by Staphylococcus
aureus, and that 61% of the Staphylococcus aureus strains were
resistant to methicillin.5 Selection of antibiotics to which these
strains are sensitive is important because patients with MRSA-
associated surgical-site infections have a greater 90-day mortality,
longer hospital stay and incur greater costs than those infected
with methicillin-sensitive Staphylococcus aureus.6
How do I choose the correct antibiotic?
The correct antibiotic, given by the correct route to treat the cor-
rect infection for the correct length of time must be chosen; this
ensures that antibiotic concentrations at the site of infection are
optimal and that the pathogen is eradicated. In addition, side-
effects are avoided and costs are minimized. However, it can be
difficult to diagnose infection properly, even before choosing the
correct agent. Progress can be unpredictable and some infections
resolve without treatment, while others progress unchecked
despite appropriate therapy. Specialist advice should be sought if
therapeutic difficulties arise.
Before starting: one must distinguish between antibiotic use for
prophylaxis and for therapeutic indications because allocation to
the wrong category is a major cause of irrational antibiotic use.
The need for therapy should be firmly established, based on
the clinical picture, imaging and inflammatory markers (e.g.
leukocyte count, C-reactive protein, procalcitonin). Targeted
therapy is possible if the causative organism and its sensitivities
have been identified (e.g. an isolate from urine or sputum). How-
ever, empirical therapy (started before definitive identification of
a causative organism) aimed at a suspected focus of infection is
more common. In either case, appropriate specimens must be taken
(e.g. blood culture, sputum, urine, wound swabs, stool) before
antibiotics are started because these cultures may be negative if
taken afterwards.
Empirical regimens: having identified a likely focus (e.g. postop-
erative pneumonia, surgical-site infection), an appropriate empiri-
cal regimen relies on knowledge of the range of organisms likely
to be implicated and on local susceptibility patterns. The latter
will also be required if an organism has been cultured, but sensi-
tivity results are pending. This may be built into local antibiotic
policies or prescribing guidelines (alternatively the Microbiology
Department can offer advice). Usually, empirical regimens give
broad-spectrum Gram-positive, Gram-negative and anaerobic
cover, although a combination of narrow-spectrum antibiotics may
offer benefits over a single ‘easy-to-use’ agent.2
Other factors must be considered when choosing a regimen
(and answers must be available before telephoning the micro-
biologist).
• Are recent or relevant microbiology results already available?
SURGERY 23:8
• Does the patient have a history of antibiotic-resistant organisms?
(e.g. has he previously been colonized with MRSA?)
• What other antibiotics has the patient had recently? A major
risk factor for harbouring resistant bacteria is prior antibiotic
therapy.7
• Where has the patient been admitted from, for how long has
he been an inpatient and what kind of ward is he on? Patients
admitted from home are less likely to be infected with resistant
pathogens than those from a nursing home or those transferred
from another hospital. Acquisition of resistant organisms is more
likely with increasing inpatient stay in ICUs and Burns Units, and
on wards where outbreaks are in progress or background rates of
resistant organisms (e.g. MRSA) are high.2, 3
• Are there abnormalities of renal or liver function and is the
patient allergic to any classes of antibiotic?
Strategies to reduce broad empirical therapy must be in place,
while maintaining effective cover.8 A common practice in the UK is
to discontinue an agent or ‘de-escalate’ to a narrow-spectrum agent
when culture results are available. (e.g. switching a cephalosporin,
such as cefuroxime, to flucloxacillin when a flucloxacillin-sensitive
Staphylococcus aureus is grown from a wound swab). Specialist
advice from pharmacists, microbiologists (as well as computer-
assisted prescribing algorithms) are available to assist the clinician
in this rationalization process.2, 3, 8 Examples of empirical antibiotic
regimens are shown in Figure 1.
Targeted therapy is possible if the choice of antibiotic is guided
by microbiology data. This may also influence the duration of
treatment. An agent with as narrow a spectrum as possible (to
which the patient is not allergic) should be chosen.
Route of administration: it is common practice in the UK to treat
life-threatening infections with parenteral antimicrobials because
delivery to tissues is guaranteed. However, oral treatment is usually
adequate for less serious infections if absorption is unimpaired.
Quinolones, fusidic acid, linezolid, clindamycin and metronidazole
have good oral bioavailability.
What are the next steps?
Having decided on the antibiotic and the route of administration,
the clinical response and inflammatory markers should be closely
monitored.
Duration of treatment
Establishing the duration of treatment is important in order to gain
maximum treatment benefit while minimizing the development
of resistance and other adverse effects (e.g. diarrhoea associated
with Clostridium difficile).9 Antibiotics should be given for the
shortest duration possible and, for many infections, studies show
that short-duration therapy (one week or less) is as effective as
longer durations, and helps to minimize undesirable events. For
example, limiting the duration to three days was effective and safe
in the postoperative treatment of appendicitis in children and, in
some instances, only five days was adequate for postoperative or
hospital-acquired pneumonia.10, 11 A review or stop date should be
clearly stated on the prescription chart, preferably with the need
for continued antimicrobial therapy being reviewed daily. Negative
microbiology results of specimens taken before starting antibiotics
may be reassuring when making a decision to stop treatment.
294 © 2005 The Medicine Publishing Company Ltd
 INFECTION IN SURGERY

This contribution discusses the theory of antibiotic prophylaxis

(specific antibiotic
Empirical prophylaxis
antibiotic regimens regimens in surgery are available
in REFERENCES)1–4 and should be read with ‘Rational use of
antibiotics
Infection in surgery’, page 293.
Initial empirical choice Route Duration Cautions
(approximate)
Background
Peritonitis Cefuroxime + metronidazole i.v. 7 days Recent cefuroxime
Prophylactic antibiotics were introduced in the 1960s and have
become an established part of surgical care. In the UK, it is esti-
Biliary infections Cefuroxime (or a third-generation i.v. 7–10 days Recent cefuroxime
mated that 1 in 10 patients admitted to hospital develops a health
cephalosporin) + metronidazole

Osteomyelitis Flucloxacillin + fusidic acid or rifampicin Initially i.v. 6 weeks in total Previous MRSA-positive
or ciprofloxacin Never use rifampicin or
Clindamycin + ciprofloxacin if fusidic acid monotherapy
allergic to penicillin

Necrotizing infections Amoxicillin + metronidazole + i.v. Depends upon clinical An adjunct to surgery
of soft tissue aminoglycoside (e.g. gentamicin) response/severity
or clindamycin + ciprofloxacin

Surgical-site infection
Acute pyelonephritis
Clean surgery: flucloxacillin or Initially i.v. Depends upon clinical Likely MRSA; using a
clindamycin; contaminated/dirty: response/severity prophylactic antibiotic
cefuroxime + metronidazole may have altered flora
Gentamicin or quinolone (e.g. Initially i.v. 10–14 days
ciprofloxacin) or cefuroxime

Epiglottitis Cefuroxime or quinolone (e.g. i.v. 7–10 days

ciprofloxacin)

Source: British Society of Antimicrobial Chemotherapy (www.bsac.org.uk). Doses are not given; refer to the British National Formulary or the Renal Drug
Handbook (in cases of renal dysfunction). Contact the microbiologist if there is no response, physical condition deteriorates or if there is a possibility of allergies
to empirical agents.

Switching from the intravenous to oral route
Many UK hospitals have a policy on when to switch from intra-
venous to oral antibiotics. This allows parenteral antibiotics to be
limited to the early phase of treatment, with therapy completed via
the oral route. This has a number of advantages, such as earlier
discharge from hospital, reduced risk of hospital-acquired infec-
tions at cannula-site and reduced cost. 3 A switch to oral treatment
is often appropriate after 48 hours of intravenous therapy, but
depends on the individual and upon local policy. The criteria for
switching to oral therapy usually includes:
• clinical response
• defervescence
• improvement in inflammatory markers
• absence of comorbidity or immunosuppression that would
necessitate intravenous treatment
• absence of gastrointestinal problems causing reduced
absorption.3
Other measures
Antibiotics form only one part of the treatment of surgical infection;
collections must be drained and free drainage restored because the
penetration of antibiotics into enclosed spaces is poor and pus may
render the agent inactive. Foreign bodies reduce the effectiveness of
antibiotics and should be removed wherever possible, particularly
if the clinical response is poor. This also applies to intravascular
devices and blood cultures from the individual lumina of a long
catheter (as well as peripheral blood) should be taken as part of
the investigation of fever in a surgical patient. Whilst some line
infections can be managed with the catheter in situ, others, such
as Staphylococcus aureus and Candida spp., nearly always mandate
catheter removal.
Local flora and local guidelines
Many UK hospitals have local policies and guidelines to direct
antimicrobial use in order to:
• provide advice on appropriate choices for a range of
infections
• controlling costs2
• control pressures on the local bacterial ecology8
• consider local epidemiology and resistance patterns.
However, guidelines never cover all eventualities and, in difficult
cases (e.g. those with complex histories, previous exposure to
multiple antibiotics, multiple allergies or unusual or complicated
infections), clinical microbiology advice should always be sought.
Advice on appropriate specimens and investigations may also be
vital in these patients.

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 INFECTION IN SURGERY
Antibiotic therapy
Is the antibiotic for prophylaxis or treatment?
Follow prophylaxis guidelines
appropriate for the procedure
Antibiotics are not indicated
Ensure regular review of patient and laboratory results
Targeted therapy is possible;
base antibiotic choice on sensitivity data
Set a stop or review date
Review need for antibiotics daily
Switch to oral therapy as soon as appropriate
Keep courses of antibiotic short
Are adjunctive measures required?
Yes
• drainage of abscess or collection
• relief of obstruction
• removal of foreign body
• removal of catheter
Complicated patient or infection?
Contact microbiologist
Specialist areas
ICUs and HDUs often appear to have their own unique bacterial
flora and the prevalence of antibiotic-resistant pathogens may be
significantly higher than in other hospital wards. This is largely
because these units are often heavy users of antibiotics and empiri-
cal broad-spectrum agents. Resistance and unusual bacterial spe-
cies may necessitate the use of agents that are infrequently used
in other ward areas, and this may make antibiotic choice difficult
for the inexperienced clinician. Advice from a microbiologist who
is familiar with the ecology of the unit is indispensable.
Summary
The rational use of antimicrobial agents is vital if the future use-
fulness of antibiotics is to be preserved and bacterial resistance
limited. Figure 2 illustrates an example of an algorithm that could
be used to aid antimicrobial therapy and highlights many of the
key decision areas discussed.  Dis 2003; 36: 1006–12.
REFERENCES
1 Goossens H, Ferech M, Vander Stichele R, Elseviers M. Outpatient
antibiotic use in Europe and association with resistance: a cross-
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2 Dancer S J. How antibiotics can make us sick: the less obvious
adverse effects of antimicrobial chemotherapy. Lancet Infect Dis
2004; 4: 611–19.
SURGERY 23:8
WBC: White blood cell
CRP: C-reactive protein
MRSA: Methicillin-resistant Staphylococcus aureus
Is there good clinical evidence of infection?
Send data (cultures, WBC, CRP, imaging) to assist diagnosis
No Yes
Do previous microbiology data exist
Yes to guide therapy?
No
Yes Can you wait for
microbiology data?
No
Empirical regimen
Use local guidelines (if available), but consider:
• likely focus of infection
• carriage of resistant organisms (e.g. MRSA)
• type of ward/outbreaks
• previous use of antibiotics
• allergies; liver/renal function
Set a stop or review date
Review need for antibiotics daily
Narrow the spectrum when data is available,
then move to targeted therapy
Switch to oral therapy as soon as appropriate
Keep courses of antibiotic short
3 Guven G S, Uzun O. Principles of good use of antibiotics in hospitals.
J Hosp Infect 2003; 53: 91–6.
4 Mosdell D M, Morris D M, Voltura A et al. Antibiotic treatment for
surgical peritonitis. Ann Surg 1991; 214: 543–9.
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infections in English hospitals. J Hosp Infect 2005; 60: 93–103.
6 Engemann J J, Carmeli Y, Cosgrove S E et al. Adverse clinical and
economic outcomes attributable to methicillin resistance among
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ill patient: are minimization of selection of resistant organisms and
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296 © 2005 The Medicine Publishing Company Ltd