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Sat Apr 15 16:23:46 BST 2006

Well stated, Claudia.

Please feel free to call me Ben, I am not a physician.

Ben Reynolds, PA-C
Pittsburgh, PA

--- claudia <glamourcv at gmail.com> wrote:

> Dear all,
> 
> I agree on everything that Dr Reynolds pointed out.
> However we must cristalize some concepts here.
> 
> First concept:
> Prophylactic antibiotics - they are given with the
> aim to avoid post
> surgical infectious complications - from wound
> superficial infections
> to overwhelming sepsis.
> They are not able to prevent colonization of
> devitalized tissue,
> however, and if given for more than 5 days, good
> chances are they can
> cause more harm (bacterial resistance ) than good in
> any setting.
> 
> Second concept: There is nothing in EBM to support
> their use in CLEAN
> surgeries. This concept of CLEAN surgery many times 
> is a blurred one.
> Most trauma surgeries are not clean, however, there
> are significant
> outcome differences between a simple pelvic fracture
> with vascular
> bleeding and severe open pelvic trauma with organ
> damage and lesions
> to the sigmoid, genitals, or rectum, or even with
> extensive bone and
> muscle lesions. If the gut is intact, outcomes
> usually are better.
> 
> Third concept: There are conflictant data in the
> literature regarding
> whether prophylactic antibiotics in the contaminated
> pelvic trauma
> surgeries will prevent deep tissue infection and
> sepsis, or even if it
> can save people from a septic death... there is no
> controlled study
> done comparing outcomes in patients who received
> prophylatic ATBs and
> those who didn´t. Bacterial resistance does not
> appear to be a major
> problem with prophylactic antibiotics in this
> particular setting of
> pelvic trauma (it is not proven yet...however it is
> recognized for
> other types of trauma...).It will become a problem,
> indeed, if  the
> patient develops recurrent sepsis and is submitted
> to several courses
> of therapeutic antibiotics or if you prolong too
> much your
> "prophylactic" therapy.Current trends point to
> abandoning the
> prophylactic ATBs, in face of the advances in
> surgical technicques and
> necrectomy as the mainstem for wound management, as
> well as
> improvement of blood cultures positivity and early
> access to the
> adequate drug according with the isolated bug.
> 
> So, In the end, there is nothing to prove that some
> cefoxitin or
> anything like that, before debridement will do any
> harm, but don´t
> expect it to prevent your patient to die from severe
> sepsis, and if
> you decide to administer it to your patient, please,
> do not turn it
> into a therapeutic ATB regimen by extending the
> therapy for more than
> 24 -48 h.
> 
> After reading a bit this issue in the past years, I
> strongly believe
> that most prophylactic ATB schemes are created to
> treat the doctors´
> anxieties ;-) Exceptions are made to those patients
> who are recognized
> as immunosupressed or with some sort of immune
> depression.
> 
> Unfortunately, this paper is in german, it´s very
> clear and treats
> this issue with a lot of common sense.
> 
> Cheers,
> 
> claudia
> 
> Unfallchirurg. 1996 May;99(5):316-22.	Related
> Articles, Links 	
> 
> Comment in:
> Unfallchirurg. 1996 May;99(5):315.
> 
> [Prophylactic and therapeutic use of antibiotics in
> trauma surgery]
> 
> [Article in German]
> 
> Hansis M, Arens S.
> 
> Klinik und Poliklinik fur Unfallchirurgie, Bonn.
> 
> Antibiotic treatment in traumatology (either for
> prophylactic or
> therapeutic purposes) can reduce the local bacterial
> contamination and
> can therefore improve the balance in favor of the
> host defence
> capacity. Above all, its value has to be measured
> depending on the
> local bacterial colonization in the individual case
> and to what extent
> this is the essential pathogenetic factor for
> development of the
> infection or for resistance to infection. In
> situations where local
> host damage (either traumatic or
> iatrogenically/surgically induced) is
> the predominant cofactor for the development or
> persistence of
> infection, the antibiotic or other pharmacological
> reduction of the
> bacterial colonization is of secondary or no
> importance at all. In
> view of this, the indications for routine antibiotic
> prophylaxis or
> therapy, which so far have been accepted as valid,
> should be
> reconsidered. On the one hand, excellent hygienic
> conditions have
> increasingly reduced the relative importance of
> bacterial
> contamination in aseptic procedures. On the other
> hand, the
> surgical-technical evolution in the last 5 years
> (such as biological
> osteosynthesis, unreamed intramedullary nailing,
> stepwise definite
> stabilization in complex fractures, initial open
> wound treatment and
> very early plastic reconstruction in open fractures,
> as well as
> radical necrectomy in chronic infection of bones and
> soft tissues)
> could create a significant improvement in the
> conditions concerning
> prevention and treatment of infection. Therefore,
> the relative
> importance of adjuvant antibiotic treatment is
> considerably less.
> Based on previous studies, the publications of the
> past 3 years
> focusing on this aspect are examined critically.
> Finally, detailed
> recommendations are defined and advice given for
> well-aimed,
> controlled continuation studies.
> 
> Publication Types:
> 
> On 4/14/06, Ben Reynolds <aneurysm_42 at yahoo.com>
> wrote:
> > Having read everyone's posts, I just want to
> clarify a
> > few issues for the readers in such a way which
> doesn't
> > drag me into this discussion.  It seems that the
> > debating parties aren't speaking the same
> language:
> >
> > 1.  Surgery within the pelvis as performed by an
> > OB/GYN and surgery on a fracture of the pelvis as
> > performed an orthopedic surgeon are not the same
> > thing.
> >
> > 2.   Perioperative antibiotic prophylaxis for
> pelvic
> > surgery as performed by an OB/GYN and for
> fractures of
> > the pelvis as performed by an orthopedic surgeon
> > aren't the same.  The organisms you are trying to
> > cover for in those two situations aren't the same,
> > ergo they mandate different coverage.
> >
> > 3.  Pelvic fractures are sterile unless they are
> open
> > or penetrate a hollow viscus (not including the
> > bladder which is sterile) an event which occurs at
> a
> > rate not exceeding 1%; this is why we do rectal
> and
> > vaginal exams to ensure that a suspicious fracture
> > hasn't violated those areas.  When open pelvic
> > fractures do occur it is rare that they aren't
> 
=== message truncated ===

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