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The true role of colonic intraluminal bacteria, both facultative and anaerobic, in the etiology of infectious complications
following colorectal surgery was clarified 25 years ago
[1-4]. Both the colonic bacterial burden and the rate of subsequent infections were significantly decreased when the preoperative bowel preparation included orally administered antibiotics
effective against both bacterial types [3, 4]. Specifically, it
was shown that mechanical preparation and a three-dose oral
antibiotic regimen consisting of 1 g each of erythromycin base
and neomycin resulted in suppression of the facultative and
anaerobic constituents of the colonic and fecal microflora.
Currently, it is generally accepted that effective bowel preparation includes various oral or parenteral antibiotics, alone or
in combination, that have aerobic and anaerobic activities combined with an effective mechanical preparation [5]. Many different antibiotic regimens have been proposed and tested clinically, with some yielding better results than others. Although
originally only oral antibiotics were used effectively, in current
practice, they are now most often combined with perioperative
parenteral antibiotics. Various mechanical preparations have
also been used to reduce the gross intraluminal contents during
the surgical procedures.
A previous survey done in 1988, and reported in 1990 [6],
showed that the most preferred bowel preparation at that time
was oral polyethylene glycol (PEG) solution for mechanical
cleansing combined with preoperative oral neomycin/erythromycin base and a perioperative parenteral second-generation cephalosporin antibiotic. Since the time frame of the
previous survey, several new antibiotics have become available for use, older agents have become generic and their
prices have been reduced, and additional clinical studies of
various bowel preparations have been conducted [5]. There
has also been an increased influence of managed care approaches to treatment in the interests of cost containment.
An impetus toward preoperative bowel preparation to be conducted on an outpatient basis, commonly at the patient's
home, has likewise gained support [7].
There remains some controversy over which antibiotics provide the optimal prophylaxis; the duration of preparation;
whether oral, parenteral, or a combination is preferred; and
which mechanical method should be used. In an attempt to
gather current knowledge of North American bowel preparation
practices before elective colorectal procedures, we sent a survey to all currently active board-certified colorectal surgeons
in the United States (including Puerto Rico) and Canada (see
appendix at the end of the text).
Methods
The names and addresses of all currently active board-certified colon and rectal surgeons in the United States and Canada
were obtained from the American Society of Colon and Rectal
Surgeons (Arlington Heights, IL). These physicians were sent
a questionnaire inquiring about their preoperative bowel preparations before elective surgical procedures. The 20 questions
covered demographics, patient numbers and types, and both
mechanical and antibiotic preparative techniques. Specific
questions concerned the use of oral vs. parenteral antibiotics,
preferred mechanical cleansing procedures, and the total duration of the preparation.
In North America, the rate of infections following colorectal surgery decreased after the introduction of oral antibiotic bowel preparation against colonic microflora. Eight hundred eight boardcertified colorectal surgeons were surveyed for their current bowel preparation practices before
elective procedures. The 471 responders (58%) all use mechanical preparation: oral polyethylene
glycol solution (70.9% of the respondents), oral sodium phosphate solution with or without bisacodyl
(28.4%), and "traditional" methods of dietary restriction, cathartics, and enemas (28.4%). Most
surgeons (86.5%) add oral and parenteral antibiotics to the regimen; 11.5% add only parenteral
antibiotics, 1.1% add only oral antibiotics, and 0.9% add no antibiotics. Generally (77.8% of cases),
oral neomycin and erythromycin or metronidazole are combined with a perioperative parenteral
antibiotic. Most individuals start the preparation as outpatients the day before surgery, and the
parenteral drugs are added to the regimen 1 2 hours before the procedure. The use of outpatient
bowel preparation is increasing; however, patient selection is critical, and education is needed to
reduce the rate of complications.
Nichols et al.
610
Table 1. Location of professional practices of respondents to a survey on North American bowel preparation practices before elective
colorectal procedures.
Practice type
Community hospital
Teaching hospital
Large medical center
Medical school
Veterans hospital
Military hospital
Health maintenance organization
No. of
affiliations*
Percent of
respondents
295
209
157
48
14
11
1
62.63
44.37
33.33
10.19
2.97
2.34
0.21
Results
611
Table 2. Operative procedures performed per month by 447 respondents to a survey on North American
bowel preparation practices before elective colorectal procedures.
Type of
procedure
Colon
Rectal
Anal
Average no.
of procedures
per month (range)
Percent of
emergent procedures
Percent of
elective procedures
Percent of patients
admitted on the
day of surgery
8.3 (1-60)
6.1 (0-60)
15.4 (1-200)
10.0
8.0
14.5
89.7
91.1
85.5
65.4
72.5
80.9
I
Figure 1. Preoperative bowel
preparation regimens currently
prescribed in North America. All
471 surgeons answering the survey
reported the use of mechanical
preparation. Most (70.9%) of the
surgeons use oral polyethylene
glycol solution, but equal use of
oral sodium phosphate solution
(28.4%) or "traditional" preparative techniques (cathartics and enemas; 28.4%) was also reported.
Antibiotics are added to the regimen by 99.1% of the surgeons,
with most employing both oral and
parenteral types. * = percent of
survey respondents; ** = percent
of 711 antibiotic regimens reported.
Mechanical preparation
28.4% *
70.9% *
Polyethylene glycol
solution (po)
28.4% *
Sodium phosphate
solution (po)
"Traditional"
cathartics and enemas
Antibiotic preparation
0.9% *
None
11.5% *
86.5%*
Parenteral
only
Oral plus
parenteral
Oral
only
Oral components
Neomycin
plus erythromycin
plus metronidazole
53.4%**
35.0%*"
Parenteral components
Second-generation
cephalosporin
Other cephalosporin
Penicillin/inhibitor
combination
Metronidazole
65.4%**
6.8%**
8.3%**
7.5%**
Nichols et al.
612
No.* of
preparations
Percent of
respondents
334
134
134
11
9
4
70.9
28.4
28.4
2.3
1.9
0.9
successful in suppressing intraluminal bacteria when administered in 1-g doses at 1 P.M., 2 P.M., and 11 P.M. on the day
before the surgical procedure [3, 4]. Pharmacokinetic studies
showed that neomycin is not absorbed and remains bacteriologically active within the lumen of the colon, while high intraluminal and serum levels of erythromycin are found at the time
of surgery (8 A.M.) [ 12, 13]. Both intraluminal (local) and
serum (systemic) antibiotics are thought to contribute toward
reducing the occurrence of postoperative infections [5].
Yes
No
Yes
No
405 (86.5)
54 (11.5)
5 (1.1)
4 (0.9)
NOTE. Four hundred sixty-eight of 471 surgeons responded to this question; all reported the use of mechanical bowel preparation in their preoperative
regimen.
Table 5. Most commonly used oral and parenteral antibiotics for preoperative bowel preparation before elective colon or rectal surgery in a
North American survey.
No. using parenteral antibiotic(s)
Cephalosporin
Oral antibiotic(s)
Neomycin
Plus clindamycin
Plus erythromycin
Plus metronidazole
Plus erythromycin and
metronidazole
Metronidazole
Plus erythromycin
Total with oral
antibiotics
Total without oral
antibiotics
Total
0-Lactamase inhibitor
combinations
Metronidazole
Other
Total
1
0
20
16
0
0
14
3
6
2
334
219
0
0
0
0
0
1
32
13
19
41
55
37
18
625
48
4
59
16
53
6
24
86
711
First-generation
Second-generation
Third-generation
1
0
22
18
3
2
222
153
0
0
26
8
30
21
6
4
4
21
7
11
5
2
0
55
419
7
62
46
465
NOTE. Four hundred seventy-one respondents listed all regimens commonly prescribed by them.
Although the early reports showed the efficacy of oral prophylaxis in suppressing the colonic microflora, later studies
tested the idea that parenteral antibiotics added to or substituted
for the oral agents could also be effective [5]. Many different
regimens comparing a multitude of antibiotics were studied
with varying and conflicting results [5]. On the basis of these
reports, some surgeons, predominantly those in Europe, prefer
systemic parenteral agents alone, whereas North American surgeons favor a combination of oral and parenteral agents [14].
It is important that one be cautious when evaluating the
results of prophylactic studies. For example, results of a twocenter trial that were published independently showed striking
differences in the rates of infections between the two arms:
oral neomycin/erythromycin and parenteral metronidazole/ceftriaxone (site 1, 41% and 10%, respectively; site 2, 4% and
7%, respectively) [15, 16]. A questionable study design was
later noted, since mechanical cleansing was used only at the
second hospital [17]. Therefore, it is imperative that multicenter
trials be published together to enable readers to make informed
judgments based upon all available data.
613
614
Nichols et al.
Table 6. Factors influencing choices of bowel preparation in a survey on North American bowel preparation practices before elective
colorectal procedures.
Factor
Reduced rate of infections
Reduction of bacteria at
operative site
Cleanliness of operative
site
Patient acceptability
Ease of administration
Cost
No. of
respondents
Mean score*
Mode
Median
464
4.80
454
4.53
457
459
461
460
4.43
4.07
3.98
3.26
4
4
4
3
5
4
4
3
615
616
Nichols et al.
Appendix
19
5)
Colon
Rectum
Anus
% Anus
% Anus
7) What percentage of your cases are admitted to the hospital the day of surgery?
% Colon
% Rectum
% Anus
3) Are there instances where you feel an alternate mechanical preparative method (not your
normal method as checked above) should be used? Please list:
4)
617
doses
doses
doses
Ceftizoxime
Ceftriaxone
Other
Other
7) The =Mad antibiotics are started
gram(s) q
hrs X
doses
8) Which microorganisms do you feel are most important to protect against in surgical infections
following colorectal surgical procedures?
Aerobic bacteria (E. coli, Kiebsiella, Enterococcus, etc.)
Anaerobes (B. fragilis, Clostridia, etc.)
Both are equally important
Neither are important
Nichols et al.
618
At xox institution, which microorganisms are most implicated in surgical infections following
colon and rectal procedures?
Aerobic bacteria:
Anaerobes:
1
1
1
1
1
1
2
2
2
2
2
2
4
4
4
4
4
4
3
3
3
3
3
3
5
5
5
5
5
5
12) Do you feel that home bowel preparation with the patient admitted to the hospital on the day of
surgery is as good as a full hospital based preparation?
YES
NO (why not)
13) What is the average daily cost per patient day at your institution?
Yes:
11) Rate the following factors in influencing your choice of bowel preparation (mechanical &
antibiotic):
Not
Very
Neutral
important
important
Acknowledgments
619
15. Weaver M, Burdon DW, Youngs DJ, Keighley MRB. Oral neomycin and
erythromycin compared with single-dose systemic metronidazole and
ceftriaxone prophylaxis in elective colorectal surgery. Am J Surg 1986;
151:437-42.
16. Kling P-A, Dahlgren S. Oral prophylaxis with neomycin and erythromycin
in colorectal surgery: more proof for efficacy than failure. Arch Surg
1989;124:705-7.
References
17. Condon RE, Nichols RL, Bartlett JG. Letter to the editor. Am J Surg 1986;
152:564.
18. Baum ML, Anish DS, Chalmers TC, Sacks HS, Smith H Jr, Fagerstrom
RM. A survey of clinical trials of antibiotic prophylaxis in colon surgery:
evidence against further use of no-treatment controls. N Engl J Med
1. Finegold SM. Intestinal bacteria. The role they play in normal physiology, pathologic physiology, and infection. Calif Med 1969;110:
455-59.
2. Nichols RL, Condon RE. Preoperative preparation of the colon. Surg
Gynecol Obstet 1971;132:323-37.
3. Nichols RL, Condon RE, Gorbach SL, Nyhus LM. Efficacy of preoperative antimicrobial preparation of the bowel. Ann Surg 1972; 176:
227-32.
4. Nichols RL, Broido P, Condon RE, Gorbach SL, Nyhus LM. Effect of
preoperative neomycin-erythromycin intestinal preparation on the incidence of infectious complications following colon surgery. Ann Surg
1973;178:453-62.
5. Nichols RL. Bowel preparation. In: Wilmore DW, Cheung LY, Harken
AH, Holcroft JW, Meakins JL, eds. Scientific American: Surgery. Vol.
1. New York: Scientific American, 1995:1-11.
6. Solla JA, Rothenberger DA. Preoperative bowel preparation: a survey of
colon and rectal surgeons. Dis Colon Rectum 1990; 33:154-9.
7. Philip RS. Efficacy of preoperative bowel preparation at home. Am Surg
1995;61:368-70.
8. Finegold SM. Studies on antibiotics and the normal intestinal flora. Tex
Rep Biol Med 1951;9:432-44.
9. Nichols RL, Gorbach SL, Condon RE. Alteration of intestinal microflora
following preoperative mechanical preparation of the colon. Dis Colon
Rectum 1971;14:123-7.
10. Nichols RL, Condon RE. Antibiotic preparation of the colon: failure
of commonly used regimens. Surg Clin North Am 1971; 51:
223--31.
11. Bentley DW, Nichols RL, Condon RE, Gorbach SL. The microflora of
the human ileum and intra-abdominal colon: results of direct needle
aspiration at surgery and evaluation of the technique. J Lab Clin Med
1972; 79:421-9.
12. Nichols RL, Condon RE, DiSanto AR. Preoperative bowel preparation:
erythromycin base serum and fecal levels following oral administration.
Arch Surg 1977;112:1493-6.
13. DiPiro JT, Patrias JM, Townsend RJ, et al. Oral neomycin sulfate and
erythromycin base before colon surgery: a comparison of serum and
tissue concentrations. Pharmacotherapy 1985; 5:91-4.
14. American Medical Association Division of Drugs and Toxicology.
Antimicrobial chemoprophylaxis for surgical patients. In: Drug
evaluations annual 1995. Chicago: American Medical Association,
1995:1369-76.
19. Beck DE, Fazio VW. Current preoperative bowel cleansing methods: results of a survey. Dis Colon Rectum 1990; 33:12-5.
20. Condon RE, Bartlett JG, Nichols RL, Schulte WJ, Gorbach SL, Ochi S.
Preoperative prophylactic cephalothin fails to control septic complications of colorectal operations: results of controlled clinical trial. A Veterans Administration cooperative study. Am J Surg 1979;137:68-74.
21. Duthie GS, Foster ME, Price-Thomas JM, Leaper DJ. Bowel preparation or
not for elective colorectal surgery. J R Coll Surg Edinb 1990;35:169-71.
22. Culver DH, Horan TC, Gaynes RP, et al. Surgical wound infection rates
by wound class, operative procedure, and patient risk index. Am J Med
1991; 91(suppl 3B):152S-7S.
23. Gorbach SL. Antimicrobial prophylaxis for appendectomy and colorectal
surgery. Rev Infect Dis 1991; 13(suppl 10):5815-20.
24. Kaiser AB, Herrington JL Jr, Jacobs JK, Mulherin JL Jr, Roach AC,
Sawyers JL. Cefoxitin versus erythromycin, neomycin, and cefazolin
in colorectal operations: importance of the duration of the surgical
procedure. Ann Surg 1983;198:525-30.
25. Karran SJ, Sutton G, Gartell P, Karran SE, Finnis D, Blenkinsop J. Imipenem
prophylaxis in elective colorectal surgery. Br J Surg 1993;80:1196-8.
26. Cohen SM, Wexner SD, Binderow SR, et al. Prospective, randomized,
endoscopic-blinded trial comparing precolonscopy bowel cleansing
methods. Dis Colon Rectum 1994; 37:689-96.
27. Physicians' desk reference. 50th ed. Montvale, New Jersey: Medical Economics, 1996.
28. Irving AD, Scrimgeour D. Mechanical bowel preparation for colonic resection and anastomosis. Br J Surg 1987; 74:580-1.
29. Brownson P, Jenkins SA, Nott D, Ellenbogen S. Mechanical bowel preparation before colorectal surgery: results of a prospective randomized
trial [abstract]. Br J Surg 1992;79:461-2.
30. Burke P, Mealy K, Gillen P, Joyce W, Traynor 0, Hyland J. Requirement
for bowel preparation in colorectal surgery. Br J Surg 1994;81:907-10.
31. Frazee RC, Roberts J, Symmonds R, Snyder S, Hendricks J, Smith R. Prospective, randomized trial of inpatient vs. outpatient bowel preparation for
elective colorectal surgery. Dis Colon Rectum 1992; 35:223-6.
32. Handelsman JC, Zeiler S, Coleman J, Dooley W, Walrath JM. Experience
with ambulatory preoperative bowel preparation at the Johns Hopkins
Hospital. Arch Surg 1993;128:441-4.
33. Lee EC, Roberts PL, Taranto R, Schoetz DJ Jr, Murray JJ, Coller JA.
Inpatient vs. outpatient bowel preparation for elective colorectal surgery.
Dis Colon Rectum 1996; 39:369-73.
1981; 305:795-9.