Clavien, Pierre-Alain

Schäfer, Markus

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INVITED COMMENTARYA Meta-Analysis of Randomized Controlled Trials Assessingthe Prophylactic Use of Ceftriaxone. A Study of Wound, Chestand Urinary InfectionsMarkus Scha¨fer • Pierre-Alain ClavienPublished online: 13 October 2009 Socie´te´ Internationale de Chirurgie 2009The use of prophylactic antibiotics has been nowadaysgenerally accepted as an important precaution to preventinfectious complications following surgery. Surgeons maysometimes lack the required infectiological knowledge, andto keep an up-dated overview of the extensive literatureremains difficult, hence we have to rely on meta-analysisand to benefit from collating information from differentmeta-analysis [1]. In this article, Woodfield et al. haveshown with their meticulously performed meta-analysis of90 publications that ceftriaxone is more effective than mostother prophylactic antibiotics to reduce surgical siteinfections, urinary tract infections and postoperativepneumonia in patients at risk [2].Ceftriaxone is a third generation cephalosporin thatcovers a wide range of gram negative and gram positivebacteria. It has bactericidal effects by inhibiting the syn-thesis of the cell wall. Ceftriaxone has a high stabilityagainst the vast majority of beta-lactamases (i.e. penicil-linases and cephalorsporinases), which remained unchan-ged during the last 40 years. Already 30 min afterintravenous injection, serum levels far above the minimalinhibitory concentration (MIC) for most organisms areachieved. Due its excellent penetration into different tis-sues and fluids (e.g. bone, lung, liver, heart, skin, bile,cerebrovascular fluid) as well as the prolonged half-life of8 h, a sustained concentration well above the MIC for mostbacteria has been observed for 24 h after single-shotapplication.The chemical and pharmacokinetical properties of cef-triaxone have contributed to the rather unique clinicalcharacteristics, which almost fulfil every criteria for an‘‘ideal’’ prophylactic antibiotics. First, despite ceftriaxoneis widely used for more than four decades, no relevantresistance formation could have been observed. Second,the capacity to nearly penetrate in every tissue and fluidcompartment, and the long half-life of 8 h provide a highceftriaxone concentration with a long-lasting protectiveeffect. Thus, ceftriaxone successfully prevents both, sur-gical site infections (local action) and remote infections,away from the surgical site (systemic action). Not sur-prisingly, it reveals its best effects for clean-contaminatedand contaminated surgical interventions. Third, since gen-eric products are now available, cost for ceftriaxone hasbeen decreased in many countries.The main goal of prophylactic antibiotics in surgery isstill to prevent infections directly related to the interven-tion, e.g. surgical site infections, but also remote infectiouscomplications, e.g. respiratory tract in case of abdominalsurgery [3]. In order to achieve those goals, a responsibleuse of antibiotics is pivotal to achieve low infection rates,to prevent resistance formation, and to keep a good cost-effectiveness. There is a broad range of antibiotics that areavailable for prophylaxis. Numerous antibiotic regimenshave been proposed for many different indications andsurgical specialities, respectively. Surgeon’s choice for oneparticular antibiotic is influenced by various factors.Among those, institutional traditions, personal experience,and last but not least, strong economical interests of thepharmaceutical industry often play a key role, while evi-dence is often of subordinate importance.We should keep in mind that the number of newly releasedantimicrobial drugs has steadily decreased over the last30 years, while the number of multiresistant organisms hasM. Scha¨fer  P.-A. Clavien (&)Department of Visceral and Transplantation Surgery, UniversityHospital, Ra¨mistrasse 100, 8091, Zu¨rich, Switzerlande-mail: clavien@chir.uzh.ch123World J Surg (2009) 33:2551–2552DOI 10.1007/s00268-009-0232-yrapidly increased (e.g. MRSA, ESBL bacteria). Therefore, acareful selection of the respective antibiotics for prophylaxisis of utmost importance. The pharmaceutical companies maysuggest new antibiotics with ‘‘better’’ mode of actions,although there is no real need to change current antibioticprophylaxis. Epidemiological aspects weigh harder in thissetting than individual considerations. According to thismeta-analysis, ceftriaxone has kept its excellent profile, andits use is still safe and effective.Despite all the beneficial effects, we should not forgetthat prevention of infectious complications related to sur-gery is not solely based on antibiotic prophylaxis. Localbacterial contamination and systemic spillage are alsodependent on the surgical technique. Prevention of inad-vertent opening of the respiratory, gastrointestinal andgenitourinary tract, minimizing blood loss, preoperativecorrection of malnutrition and other co-morbidities remaincrucial.References1. Bowater RJ, Stirling SA, Lilford RJ (2009) Is antibiotic prophy-laxis in surgery a generally effective intervention? Ann Surg249:551–5562. Woodfield JC, Beshay N, van Rij AM (2009) A meta-analysis ofrandomized controlled trials assessing the prophylactic use ofCeftriaxone. A study of wound, chest and urinary infections.World J Surg. doi:10.1007/s00268-009-0158-43. Wadell TK, Rotstein OD (1994) Antimicrobial prophylaxis insurgery. Can Med Assoc J 151:925–9312552 World J Surg (2009) 33:2551–2552123

A Meta-Analysis of Randomized Controlled Trials Assessing the Prophylactic Use of Ceftriaxone. A Study of Wound, Chest and Urinary Infections

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A Meta-Analysis of Randomized Controlled Trials Assessing the Prophylactic Use of Ceftriaxone. A Study of Wound, Chest and Urinary Infections

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