Cephalosporins in surgical prophylaxis

Controlled clinical trials have shown that antimicrobial prophylaxis can lower the incidence of infection after certain operations, thus reducing morbidity, hospital stay, antibiotic usage and mortality due to sepsis. An effective prophylactic regimen should be directed against the most likely infecting organisms, but need not be active against every potential pathogen. Infection can be prevented when effective concentrations are present in the blood and the tissue during and shortly after the procedure. Therefore, antimicrobial prophylaxis should begin just before the operation: beginning earlier is unnecessary and potentially dangerous, beginning later is less effective. A single-dose prophylaxis after the induction of anesthesia is sufficient. If surgery is delayed or prolonged, a second dose is advisable if an antimicrobial drug with a short half-life is used. Postoperative administration is unnecessary and is harmful. Cephalosporins are considered to be the drug of choice, because they offer fewer allergic reactions. From the first generation cephalosporins, cefazolin has been widely recommended with success. From the second generation cephalosporins, cefuroxime, cefamandole and cefoxitin are increasingly recommended. Their antistaphylococcal activity is somewhat less strong but their activity against gram-negative bacteria is stronger. In addition, cefoxitin has good activity against anaerobes. Third generation cephalosporins, such as cefotaxime, cefoperazone, ceftriaxone, ceftazidime or ceftizoxime are generally not recommended for surgical prophylaxis. Despite these recommendations, they have been accepted by the medical community and are today in use in many countries as the most common drugs in surgical prophylaxis. Ceftriaxone in particular, is far exceeding the sales of any other drug for prophylaxis. Contra-indications, limitations, additional or other drugs and practical recommendations for specific procedures are discussed and the results of several prospective randomized studies are presented.