Guideline for Antimicrobial Prophylaxis for Thoracic Surgery

1. Summary table of routine recommendations
2. Background information
3. Special antimicrobial prophylaxis recommendations

1. Summary table of routine recommendations.

MRSA Risk Factors
Patients within these categories are considered at increased risk of MRSA infection:

• Known previous infection or colonisation with MRSA at any site.
• Resident of a long term care facility (nursing home, residential home or any other long term residential facility) without a negative MRSA screening result.
• Any history of inpatient hospital stay within the previous 6 months without a negative MRSA screening result

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2. Background information

A review of antimicrobial prophylaxis recommendations for thoracic surgery procedures in Leeds has been prompted by the publication of the NICE guideline on the prevention of Surgical Site Infection plus the continued presence of methicillin-resistant Staphylococcus aureus (MRSA) in the Trust and the ongoing problem of Clostridium difficile infection. It is appropriate to use a single pre-operative dose of prophylaxis in most situations to reduce the risks related to antimicrobial use while gaining maximum benefit from prophylaxis. ³

These guidelines should be applicable to the majority of patients. Where the recommendations in these guidelines do not seem appropriate for a particular patient, the surgeon or cardiologist is advised to discuss the case with a Microbiologist.

Patients undergoing major pulmonary resections (Thoracotomy / VATS) are at high risk of experiencing pulmonary infections in the postoperative period. Despite a correct use of antibiotic prophylaxis recommended today, the prevalence of these infections has reached more than 20% in recent studies. ⁸

Presently, there are no specific guidelines regarding antibiotic prophylaxis for pulmonary surgery. Current recommendations enclose pulmonary resections in the vast category of “cardiothoracic surgery,” therefore applying the same antibiotic prophylactic regimen as for cardiac surgery. Agents proposed are first-generation and second-generation cephalosporins (e.g. cefazolin, cefuroxime, and cefamandole). In case of beta-lactam allergy, vancomycin or clindamycin are the alternatives. In cardiac surgery these antibiotics are targeted against surgical wound contaminants, mainly skin flora and their contaminants, and their aim is to reduce the rate of surgical wound infections. ⁸

According to these recommendations, today’s usual practice in general thoracic surgery in England for antibiotic prophylaxis is the use of one to three doses of cefuroxime, depending on the duration of the surgical intervention, therefore intended to reduce only the surgical wound infections.

Pulmonary surgery is quite different from cardiac and mediastinal surgery, regarding pathologic diagnosis, organs involved, and contamination class. Cardiac surgery is considered as clean surgery. In contrast, pulmonary surgery is a clean-contaminated surgery as the bronchus or trachea is opened during the procedure. As a result, besides skin flora, microbiologic pathogens responsible for postoperative infections belong also to oropharyngeal flora and contaminants, with subsequent tracheobronchial colonization.

Infectious complications after pulmonary surgery include operative wound infection, empyema, and nosocomial pneumonia. Antibiotic prophylaxis should therefore be guided against these three entities. Although the rate of operative wound infections has declined ever since the use of first-generation and second-generation cephalosporins in prophylaxis, this is not the case for empyema or postoperative pneumonia. ⁸

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3. Special antimicrobial prophylaxis recommendations

Lung resection: The SIGN & NICE surgical site infection guidelines both identified two RCTs of patients undergoing operations in general thoracic surgery units were identified.^{2, 3}

One RCT⁵ (n = 211 participants) randomised patients to receive either cefalotin or placebo at induction of anaesthesia [evidence level (EL) = A].  Patients were undergoing lung, hernia, gastroplasty and oesophageal surgery. Seven wound infections were found in the antibiotic group (n = 118 participants) and 22 in the placebo group (n = 93 participants) (OR 0.20, 95% CI 0.08 to 0.50).

The other RCT⁶ (n = 127 participants) randomised participants to receive either cefazolin or placebo half an hour before surgery [EL = A]. Patients were undergoing pulmonary resection, atypical pulmonary resection, bullectomy, chest wall resection, oesophageal surgery and surgery for mediastinal tumours. There were statistically significantly fewer wound infections in the antibiotic group (2/70) than in the placebo group (8/57) (OR 0.18, 95% CI 0.04 to 0.89).

A meta-analysis (below) of these two studies that included a total of 238 participants also found that there were statistically significantly fewer wound infections with antibiotic prophylaxis compared with placebo (OR 0.20, 95% CI 0.09 to 0.43).

Fig. Meta-analysis of two trials comparing the effect of antibiotic prophylaxis versus placebo on SSI incidence in general thoracic surgery

A more recent trial⁷ questioned whether 2nd generation cephalosporins are still the gold standard for lung resection.  An 18 month prospective trial switching from a 48 hour 2nd generation cephalosporin (cefmandole) to a 24 hour Co-Amoxiclav (Amoxicillin-Clavulanate) regime showed a 45% decrease in post-op pneumonia, and a 30 mortality reduction from 6.5% to 2.9%.

Chest tube insertion: Studies of the use of antibiotic prophylaxis for chest tube insertion have been performed but have failed to reach significance because of small numbers of infectious complications. However, a meta-analysis of these studies has been performed which suggested that, in the presence of chest trauma (penetrating or blunt), the use of prophylactic antibiotics reduces the absolute risk of empyema by 5.5–7.1% and of all infectious complications by 12.1–13.4%.⁹ The use of prophylactic antibiotics (cephalosporins or clindamycin) were recommended in trauma cases until a RCT proved otherwise. A randomised placebo controlled, double-blinded trial in 224 patients of prophylactic antibiotics (cefazolin – 1st generation cephalosporin) in haemopneumothorax for either 24 hours, the entire tube placement period or placebo, showed no significant difference in any arm.  From this, prophylactic antibiotics should not be used routinely for pneumothoraces. ¹⁰

The use of prophylactic antibiotics is less clear in the event of spontaneous pneumothorax or pleural effusion drainage as no studies were found which addressed these circumstances. In one study only one infectious complication (in the chest tube track) occurred in a series of 39 spontaneous pneumothoraces treated with chest tubes. ⁹

Other thoracic surgery procedures.
There is limited evidence available to provide evidence for other thoracic procedures e.g. VATS procedures and lung biopsies in high risk groups, so local consensus has been used.

The evidence for the use of mesh repairs of chest wall defects is controversial in that long courses of antibiotics have been used more out of tradition than good science.¹¹Infection rates have been low, but relied on an early switch for potential infection rather than continue the planned antimicrobial prophylaxis until discharge.  The recommendation would be for a 24 hour regime only.

Specify antimicrobial agent(s), dose, route of administration, duration, antimicrobial allergy advice Evidence level (A, B, C, D)

A. Meta-analyses, randomised controlled trials/systematic reviews of RCTs
B. Robust experimental or observational studies
C. Expert consensus.
D. LTHT Consensus (no national guidelines exist, guidelines from different learned bodies contradict each other, or no evidence exists)

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