Abstract
Background: Surgical Antimicrobial Prophylaxis (SAP) is effectively employed in peri-operative practice reducing the incidence of Surgical Site Infection (SSI) post-operatively. In colectomy, surgical manipulation and associated intraluminal disturbance of the gut microbiota results in an unacceptably high risk for life-threatening infective complications, primarily SSI. Evidence demonstrates that this risk if significantly reduced by the utilisation of SAP. However, wider concerns regarding inappropriate antimicrobial use has resulted in increased prevalence of antimicrobial resistance organisms a consequence that has devastating consequences for patients and places on healthcare organisations. It is therefore vital to ensure that SAP regimens are rational, appropriate and based on recent research evidence.
Aim: This integrative literature review had two aims. The first aim; to examine the syntheses to examine the published evidence on antimicrobial prophylaxis regimens for patients undergoing colectomy and to evaluate the Canterbury District Health Board (CDHB) The Pink Book guidelines against this research evidence.
Methods and Methodology: Whittemore and Knafl's (2005) six-step process for conducting an integrative review was undertaken to support the collation of heterogenous research and synthesis of findings that would fulfil the aforementioned aim. This was supported by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Joanna Briggs Institute (2011) Quality Appraisal tools. Utilisation of these tools facilitated the identification and inclusion of appropriate literature, namely articles published in English, between 2010-2020 with a focus on SAP regimens in colectomy in adults (>18 years old). Quality appraisal activities were applied and followed by data synthesis and narrative analysis, and guided by Whittemore and Knafl (2005).
Results: The search strategy resulted in twelve articles that met the standards set for appropriateness and quality. The narrative approach to data analysis supported data extraction and organisation that identified categories within the data. Following careful analysis and review of these data, five over-arching syntheses were then developed. These were: (1) antimicrobial agent selection for maximum efficacy and appropriateness, (2) antimicrobial dosing to achieve and exceed MIC, (3) intravenous administration (IV) is the most effective and standard practice, (4) SAP duration need not exceed 24 hours, and (5) timely administration of SAP is essential.
Conclusion: This review highlighted the significance of specific aspects of the SAP regimen, specifically antimicrobial agent, dosage, route of administration, antimicrobial course length and timing of administration to optimise the efficacy of SAP. Specifically, the utilisation of an appropriate SAP regimen correlated with the ability of the antimicrobial to achieve sufficient plasma and tissue concentrations above the Minimum Inhibitory Concentrations (MIC) and reduce SSI occurrence. Furthermore, this review exemplified how evidence-based practice informs local and international guidelines. The Pink Book (2018) guidelines for SAP in colectomy recommend the administration of 2g IV cefazolin + 500mg IV metronidazole within the 60 minutes prior to surgery. These recommendations were found to be in line with published evidence. At a time where antimicrobial resistance organisms continue to threaten the efficacy of existing treatments, it is important to continue to limit the inappropriate use of antimicrobials where possible. Hence, guidelines should be used to support clinical decisions regarding SAP and ensure the appropriateness of practice.