Preventing Surgical Site Infections with Intradermal Antibiotics.

Authors:
Christian Potter, Dow Stough MD, Tom Ashfield

Body of Abstract:
Intra-Incisional Delivery
The delivery of microdoses of incisional antibiotics to reduce the rate of surgical site infections has been documented in the literature for over 40 years.3,4,5 There is now robust evidence and published meta-analysis to change treatment guidelines in this area. A meta-analysis demonstrated significantly less surgical site infections versus placebo in a study by Mourad.1There are multiple antibiotics involving a variety of classes which potentially could be distributed by the intra-incisional route.
The benefits of a direct deposit of antibiotics into the surgical area include the following:
1. The administration of the preoperative antibiotics can be tailored to the onset of the surgical procedure. Specifically, the intra-incisional antibiotic can be given with a lidocaine diluent 10 to 15 minutes prior to the surgical procedure. The uncertainty of the oral and intravenous routes can be eliminated.
2. The nausea associated with oral administration of antibiotics is no longer a concern.
3. The major organ systems of the body, including the CNS, are not exposed to large amounts of unneeded antibiotics along with the associated adverse events.
4. The normal gastrointestinal microbiota is not altered detrimentally. The emergence of colitis due to Clostridium should be minimized by an intra-incisional approach.
5. Higher tissue levels with greater efficacy are possible with intra-incisional delivery compared to other routes.
6. There is less risk to the patient of medical errors and mishaps involving IV access, mixing of antibiotic solutions, and proper calculation of the intravenous rate of delivery.
7. The development of resistant organisms will be minimized with the intra-incisional route.
8. Compliance issues with oral antibiotics will be eliminated.
9. There is a theoretical possibility to decrease systemic drug interactions by the intra-incisional approach.
10. Current antibiotic recommendations are based primarily on efficacy and safety not on cost. Cost savings could be an additional benefit realized through the intra-incisional route of antibiotic delivery.
11. There is an emerging trend reported by the National Nosocomial Infections Surveillance System (NNIS), that demonstrates gram-negative bacilli decreased from 56% to 33% over the last 25 years. Gram-positive bacteria have increased in prevalence. Surgical site infections caused by staph aureus have increased by 30%. The resistant strains of staph and MRSA, compromise almost 50% of this group. The antibiotics needed to treat this MRSA, are often those that cannot be given orally, and therefore intravenous treatment is recommended. The intra-incisional route offers the advantage of soft tissue antibiotic delivery for the treatment or prevention of MRSA without the requirement for IV access.