An emergency medicine physician asked me to comment on
the use of antibiotics in patients having surgery for acute appendicitis and
acute cholecystitis. He said in hospitals where he has worked in three
different areas—New York, Miami and San Francisco—surgeons are using Imipenem
for cholecystitis and Zoysn for appendicitis.
He wondered why those drugs were chosen and offered a
few theories. They are as follows:
1)
Surgeons are trying to avoid resistant bugs, so they’re using bigger guns
2)
There is more pressure to reduce post-op complication numbers, so they’re using
bigger guns
3)
It’s easier to give one antibiotic to cover multiple bacterial types, instead
of, say, cipro/flagyl or cefoxitin/flagyl
4)
Patients do better with these big gun antibiotics
5) Residents are being taught incorrectly, and are
just developing bad habits
Yes, it is mandated that everyone needs a dose of
prophylactic antibiotics within an hour of surgery for appendicitis and
cholecystitis. Of course, there are nuances.
Appendicitis is a disease involving an inflamed, eventually infected appendix
so the use of antibiotics is possibly therapeutic and not simply prophylactic.
For acute cholecystitis, a similar argument can be made. The problem here is
that it is often difficult to tell acute cholecystitis (with possibly infected
bile) from biliary colic (pain caused by a gallstone impacted in the neck of
the GB) without infection. Sometimes the GB ultrasound says acute
cholecystitis, the surgeon says acute cholecystitis and the path report says
chronic cholecystitis. There are many other permutations of those three
observations. (e.g., US-biliary colic, surgeon-biliary colic, path-acute
cholecystitis, etc.)
Note: I do not routinely culture peritoneal fluid in appendicitis or bile in
cholecystitis because by the time the culture report comes back, most patients
have been home for two or three days. There is evidence to support not
culturing either fluid.
Honestly, I’m not so sure that people with early acute appendicitis really need
antibiotics. Unless the appendix is perforated, I use only one preop dose.
There are also similar differences in the imaging reports, surgeon description
and path reports for this disease too.
I doubt that patients with biliary colic benefit from
antibiotics either. The problem is that one may not discover that acute cholecystitis
is present until one is in the abdomen. The same issue occurs with appendicitis
where an unsuspected perforation may be found at surgery.
At least for now, at least one pre-op dose of an
appropriate antibiotic seems reasonable.
Where I practiced for the last few years, we did not use Imipenem for GBs and
only occasionally is Zosyn used for appys. Most of us used Unasyn for both
except in the penicillin-allergic patient. For that patient, we used Levaquin
and Flagyl. The problem with the latter two drugs is that they each are
supposed to be infused over an hour. This is not always possible because the
surgery may be started within an hour in certain circumstances, such as when an
operating room happens to be vacant and the patient is ready to go. It’s a rare
event, but it does happen.
There is no evidence that patients with either disease, who usually present
from home, have resistant bacteria, and postoperative complications, especially
infections, are not common with either disease. There is no evidence that
patients do better with “big gun” antibiotics. In fact, most of the evidence
that prophylactic antibiotics are even needed in these two operations comes
from the pre-laparoscopic era. Wound infections are extremely uncommon with laparoscopic
appendectomies and cholecystectomies. This is probably due to the fact that the
wounds are small and in most cases, the specimen is removed in a plastic bag so
the infected organ does not touch the subcutaneous tissue.
If residents are being taught to use “big gun” antibiotics for these two
diseases, I agree it’s incorrect. There is little hope of changing this.
It is similar to the unfounded practice of giving
everyone who is NPO a proton pump inhibitor, which I wrote about here. There is no scientific rationale
for it. Yet everyone does it, and no amount of discussion will convince people
to stop.
[Note: A version of this post appeared on General Surgery News a few weeks ago. The version above is better because I thought about it more.]
