Antibiotic Prophylaxis for Surgical Procedures

SBU’s Conclusions

The medical/clinical advantages of antibiotic prophylaxis must be weighed against the risk of increasing numbers of antibiotic resistant strains of bacteria. Development of resistance is more gradual in Sweden than in other countries, but resistant bacteria spread beyond national boundaries.

SBU’s scientific scrutiny of antibiotic prophylaxis for surgical intervention, a survey of established practice in this field and a consequence analysis, have led to the following conclusions with respect to areas with potential for improvement:

Correctly used, antibiotic prophylaxis can reduce the total use of antibiotics.
There is strong scientific support that antibiotic prophylaxis reduces the development of infection after:

• Operations and endoscopic procedures in the large intestine, the rectum, and the stomach (including appendectomies and penetrating abdominal trauma), and after percutaneous endoscopic gastrostomy (PEG)
• Cardiovascular surgery, and insertion of pacemakers
• Breast cancer surgery
• Hysterectomy
• Reduction of simple fractures and prosthetic limb surgery
• Complicated surgery for cancer in the ear, nose, and throat regions
• Transrectal biopsy and resection of the prostate (febrile urinary tract infection and blood poisoning).

In most cases the scientific evidence is inadequate to determine which type of antibiotic is most effective for antibiotic prophylaxis.

A transition to single-dose prophylaxis would probably reduce the risk of development of resistant strains of bacteria without increasing the risk of infection.
Antibiotic resistance is determined by the total use of the antibiotic. When the purpose of antibiotic treatment is to prevent infection, a single dose is in most cases as effective as multi doses (this does not apply to resection of the prostate).

There is inadequate scientific evidence to support the administration of antibiotics to prevent post-operative infection following hernia and gallbladder surgery, arthroscopy, and tonsillectomy in patients that not at special risk.

If all surgical units introduced procedures for registration of post-operative infection, the effectiveness of antibiotic prophylaxis could be documented and applied as a baseline value for improving quality.
To be effective, such a register would need to be based on simple administrative routines, a clear definition of the term post-operative infection, and adequate long-term follow-up of patients.

Infection of the heart valves, bacterial endocarditis, is a potentially life-threatening condition that can arise after oral surgery. The collective scientific evidence is inadequate for any evidence-graded conclusions. Patients with artificial heart valves and complicated congenital heart defects, in whom the development of endocarditis could have more serious consequences, may be considered for prophylaxis.

There is inadequate scientific evidence to determine the effect of antibiotic prophylaxis with respect to many of the surgical interventions for which it is applied today.

Because of the lack of empirical studies, there is inadequate evidence to determine the cost-effectiveness of antibiotic prophylaxis. A few empirical studies and model studies, comparing outcomes with and without antibiotic prophylaxis, support its cost-effectiveness.