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Eur J Cardiothorac Surg 2000;18:375-376
© 2000 Elsevier Science NL

Letter to the Editor

Antibiotic prophylaxis in general thoracic surgery in the UK

^a Department of Cardiothoracic Surgery, Nottingham City Hospital, Hucknall Road, Nottingham NG5 1PB, UK
^b Department of Pharmacy, Nottingham City Hospital, Nottingham, UK

Received 21 February 2000; received in revised form 26 May 2000; accepted 21 June 2000.

Corresponding author. Tel.: +44-115-969-1169; fax: +44-115-840-2605
e-mail: m.rogers{at}diamond.co.uk

1. Introduction

Antimicrobial resistance is a major public threat [1]. Following the House of Lords Science and Technology Select Committee Report ‘Resistance to Antibiotics and Other Antimicrobial Agents’ [2], the NHS Executive issued a directive to all NHS Trust Hospitals [1] to review and optimize antibiotic prescribing by March 2002.

Although antibiotic prophylaxis in general thoracic surgery is recommended the type of antibiotic and duration of administration remains contentious [3–5]. In order to clarify an appropriate antibiotic policy for prophylaxis we asked other thoracic surgery units in the UK for their antibiotic policy.

2. Materials and methods

Questionnaires were sent to 26 units within the UK with a known general thoracic surgery interest in order to establish their policy.

3. Results

Twenty-one replies were received. All had an antibiotic policy (Table 1). A large variation is evident. Cefuroxime alone was the most frequently used antibiotic (38%), with 1.5 g at induction and three post-operative doses the most popular regime (14%).

Patients undergoing thoracic surgery risk developing wound infection, empyaema and pneumonia. Antibiotic prophylaxis prevents wound infection in thoracic surgery [3–5]. However, the antibiotic used and its duration is still debated. Antibiotics administered for prophylaxis in thoracic surgery may need to cover a wide spectrum of Gram-positive and Gram-negative bacteria [3]. They should also take account of the upper alimentary tract flora when oesophageal surgery is undertaken [5]. Cephalosporins reduce infections in pulmonary surgery [4], and some studies have advocated sulbactam plus ampicillin [3]. The addition of metronidazole to cefuroxime for oesophageal surgery has been shown to reduce postoperative infections when compared to cefuroxime alone [5].

Duration of prophylactic antibiotic usage is also contentious. Long-term prophylactic antibiotic use until drain removal or hospital discharge is no longer recommended [3]. In pulmonary surgery, two studies demonstrate that one dose is as effective as multiple doses in reducing all infections [3,4]. Despite this evidence, only one of our 21 responders has adopted a single-shot antibiotic policy.

In oesophageal surgery, however, a 4-day regime of cefuroxime and metronidazole significantly reduces infections when compared to a single dose [5]. Although two units employed a 5-day regime, the majority have antibiotic policies for 2 days or less.

The purpose of this questionnaire was to assist us in developing an effective antibiotic prophylaxis protocol for general thoracic surgery in Nottingham. The large variety amongst the responding institutions and the discrepancy with the published evidence has raised more questions than given answers. Resistance to antibiotics is important, and, in an era that is increasingly evidence based, we believe that only antibiotic regimes which demonstrably reduce infections should be used.

Acknowledgments

The authors gratefully acknowledge the thoracic surgical units which kindly supplied their antibiotic prophylaxis policies.

References

1. NHS Executive. Health service circular 1999/049. Resistance to antibiotics and other antimicrobial agents, 5 March. 1999.
2. House of Lords Select Committee on Science and Technology. Report: Resistance to antibiotics and other antimicrobial agents, April 1998. London: HMSO, 1998.
3. Wertzel H., Swobada L., Joos-Wurtemberger A., Frank U., Hasse J. Perioperative antibiotic prophylaxis in general thoracic surgery. Thorac Cardiovasc Surg 1992;40:326-329.[Medline]
4. Olak J., Jeyasingham K., Forrester-Wood C., Hutter J., Al-Zeerah M., Brown E. Randomised trial of one-dose versus six-dose cefazolin prophylaxis in elective general thoracic surgery. Ann Thorac Surg 1991;51:956-958.[Abstract]
5. Sharpe D.A.C., Renwick P., Mathews K.H.R., Moghissi K. Antibiotic prophylaxis in oesophageal surgery. Eur J Cardio-thorac Surg 1992;6:5561-5564.

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