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Table of Contents
ORIGINAL ARTICLE
Year : 2019  |  Volume : 2  |  Issue : 2  |  Page : 50-53

Prophylactic antibiotic for open mesh repair of inguinal hernia; from principe to nécessité


1 Department of General Surgery, Navy General Hospital; Department of Surgery, Faculty of Medicine, General Sir John Kotelawala Defence University, Colombo, Sri Lanka
2 Department of General Surgery, Navy General Hospital, General Sir John Kotelawala Defence University, Colombo, Sri Lanka

Date of Submission03-Jan-2019
Date of Acceptance20-Feb-2019
Date of Web Publication10-May-2019

Correspondence Address:
Dr. Keerthi Rajapaksha
91/B/3, Raddoluwa, Seeduwa
Sri Lanka
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijawhs.ijawhs_2_19

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  Abstract 


PURPOSE: The use of prophylactic antibiotics (PAs) in open mesh repair (MR) of inguinal hernia (IH) is controversial. Clean surgeries do not require PA. However, prosthetic implants may require PA. As a part of quality improvement project, “guideline-based treatment for IH” where the European Hernia Society guidelines were adapted and PA was administered only if necessary, not as a routine for open MR of IH since May 1, 2015. The aim of this study was to assess the practice in the use of PA in open MR of IH and the outcome at a single surgical unit.
METHODS: This is a retrospective analysis of health records of all the male patients who underwent open MR of IH at a single surgical center, during the period from May 1, 2015 to May 1, 2016, where it was considered not to administer PA routinely, but to only when required (de nécessité). Data of patients who underwent open MR of IH during the period May 1, 2014–April 30, 2015, where PA was administered routinely (de principe) for open MR of IH, were collected for comparison. Demographic, immune-compromised status, operation techniques, PA, and surgical site infections data were analyzed.
RESULTS: There were 62 and 78 male patients who underwent open MR of IH during PA de principe and PA de necessite periods, respectively. The mean ages were 38.32 (range 21–74) and 35.51 (range 21–70) years, respectively, during PA de principe and PA de necessite. There were no patients with immunocompromised status. PA usage has reduced from 96.8% (n = 60) during the PA de principe to 11.5% (n = 9) during PA de nécessité period. Surgical site infection rate was 1.6% and 1.3%, respectively, during PA de principe and PA de nécessité periods.
CONCLUSION: In a low-risk environment, open MR of IH can be carried out without PA in a majority of patients.

Keywords: Inguinal hernia, mesh repair, prophylactic antibiotics, prosthetic mesh, surgical site infections


How to cite this article:
Rajapaksha K, Herath A, M. Silva L J, D. Anandappa M J, G. Bandara T M. Prophylactic antibiotic for open mesh repair of inguinal hernia; from principe to nécessité. Int J Abdom Wall Hernia Surg 2019;2:50-3

How to cite this URL:
Rajapaksha K, Herath A, M. Silva L J, D. Anandappa M J, G. Bandara T M. Prophylactic antibiotic for open mesh repair of inguinal hernia; from principe to nécessité. Int J Abdom Wall Hernia Surg [serial online] 2019 [cited 2022 Aug 8];2:50-3. Available from: http://www.herniasurgeryjournal.org/text.asp?2019/2/2/50/257977




  Introduction Top


Open mesh repair (MR) of inguinal hernia (IH) is one of the most commonly performed general surgical procedures.[1] Open MR of IH is considered as a clean surgical procedure and therefore prophylactic antibiotic (PA) is not recommended in guidelines.[2],[3] However, the use of prosthetic implants may call for PA. In this background, there is a marked variation in the use of PA for open MR of IH among the surgeons worldwide.[4],[5],[6],[7],[8] The current study is an audit to evaluate the outcomes in the implementation of “PA de nécessité rather than de principe for open MR of IH”. PA de nécessité rather than de principe for open MR of IH is a part of Institutional Hernia Programme, where this practice commenced based on guidelines for treatment for IH at a single surgical unit.


  Methods Top


This is a retrospective analysis of health records of all the male patients who underwent open MR of IH, during the period of May 1, 2015–May 1, 2016, where we did not administer PA routinely, but administered PA only when required (PA de nécessité) as decided by the surgeon. Data of patients who underwent open MR of IH from May 1, 2014–April 30, 2015, where we administer PA routinely (PA de principe) for open MR of IH, were collected for comparison. Demographic, immunocompromised status, surgical techniques, PA, and surgical site infection data were recorded and analyzed.

Immunocompromised status is defined by corticosteroid use, active malignancy, receipt of chemotherapy or radiotherapy, diagnosis of human immunodeficiency virus or AIDS, receipt of chronic immune suppressive drugs, and diabetes mellitus.

Surgical site infections were diagnosed as per the criteria for surgical site infection classification published by the Center for Disease Control.[9]

This study has been approved by the Ethics Review Committee of General Sir John Kotelawala Defence University, Sri Lanka.


  Results Top


There were 62 and 78 male patients during the PA de principe and PA de nécessité periods, respectively. The mean age was 38.23 (21–74) and 35.51 (21–70) years, respectively in PA de principe and PA de nécessité. A number of patients who were 70 years and above were three (4.8%) and one (1.3%) in PA de principe and PA de nécessité periods, respectively. The age distribution is shown in [Figure 1], together with antibiotic usage. There were no patients with immunocompromised status in both groups.
Figure 1: Prophylactic antibiotic usage according to age groups. (a) During the period of prophylactic antibiotic de principe. (b) During the period of prophylactic antibiotic de nécessité

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The technique of open MR of IH was tension-free Lichtenstein repair with heavy weight mesh in all patients. None of the patients in both the groups required insertion of drain following open MR of IH. All the cases were primary repairs.

PA usage has reduced to 11.9% (n = 9) during the PA de nécessité period and correspondingly to 96.8% (n = 60) during the PA de principe period. Only one patient in the age 70 years and above during the PA de nécessité period was not given PA, whereas all the other patients in this age category were given PA during the PA de principe period. Cefuroxime sodium (n = 55, 91.7%), metronidazole (n = 4, 7.3%), and co-amoxiclav (n = 1, 1.8%) were the antibiotics used during PA de principe period. Cefuroxime sodium (n = 8,10.2%) and metronidazole (n = 1, 1.3%) were used in PA de nécessité period. All the antibiotic preparations were intravenous. None of the patients who received PA during PA de nécessité period were found of having a valid reason in administering the antibiotic. Five of the nine patients who were given PA during de nécessité period were operated during the first 3 months of the initiation of the “PA de nécessité rather than de principe for open MR of IH” program. The other 4 patients who were given PA during the PA de nécessité period were operated between 4th and 7th month of the survey program.

Surgical site infection rate was 1.6% (n = 1) and 1.3% (n = 1) during PA de principe and PA de nécessité periods, respectively. Both the surgical site infections were superficial infections and managed with a 5-day course of oral co-amoxiclav.


  Discussion Top


Routine use of PA for open MR of IH remains controversial.[10],[11],[12] As open MR of IH is a clean operation, the European Hernia Society Guidelines and the International Guidelines for Groin Hernia Management do not recommend routine use of PA.[2],[3] Guidelines recommend to confine the use of PA only for immunocompromised patients, over the age of 70 years, with recurrent hernia repair and insertion of drain in open MR of IH.[2],[3] However, the use of prosthetic implant may justify PA. Individual surgeon preferences, influence of regional guidelines, surgical environment, and the characteristics of the population dealing with may lead to higher use of PA for open MR of IH.[4],[5],[6],[7],[8]

Antibiotics are dangerous weapons. There is an overwhelming increase in the emergence of resistance varieties of bacteria.[12],[13] Unnecessary use of antibiotics incur additional burden to the healthcare budget.[10] It is not uncommon to develop allergies to certain groups of antibiotics. Hence, there is a need to minimize the unnecessary use of antibiotics without compromising patient safety.[14]

The current study shows a marked reduction in use of PA from 96.8% to 11.5% for open MR of IH with the implementation of project “PA de nécessité rather than PA de principe for open MR of IH”. This achievement is partly due to the absence of immunocompromised individuals treated in our institute.

In both the periods, cefuroxime sodium was the most commonly used PA at our institute followed by the co-amoxiclav. As per the literature, cephalosporin or beta-lactamase is the antibiotic of choice for open MR of IH when prophylaxis is required.[18],[19] In addition to first-generation cephalosporin and beta-lactamase, cefuroxime sodium, levofloxacin, and ciprofloxacin are the antibiotics documented in other studies.[7],[8],[15],[16],[17],[18],[19],[20],[21]

Those who have been administered with antibiotics during the period of PA de nécessité do not show valid reasons and may partly be explained by the practice during the transition period. Absence of immunocompromised patients and patients with recurrent IH during the PA de necessite period has contributed to the excellent results in our practice. The only patient in the age group 70 years and above during the PA de necessite was not given PA as decided by the surgeon.

The surgical site infection rates following open MR of IH as shown in the literature range from 0% to 14%.[10],[22] Proponents of PA for open MR of IH claim that major postoperative infection rates can be reduced by half in larger patient collections.[23] The current study shows 1.6% and 1.3% of infection rates before and during the period of PA the nécessité, respectively, and we believe this is an acceptable level of infection rate and difference is negligible. The patient who had surgical site infection during the PA de principe period was given PA, whereas the patient who had infection PA de nécessité was not given PA. Further infections in both patients were superficial surgical site infections and managed with short course of oral co-amoxiclav. None of them required readmission. Documented surgical site infections following IH repair range from common superficial infection to rare fatal necrotizing fasciitis and toxic shock syndrome.[22],[23],[24],[25],[26],[27] However, whether fatal infectious complications are preventable or not with PA remain controversial. The management of superficial infections is conservative. Management of deep infections of the mesh remains controversial.[28] Removal of mesh in mesh infections may not require all the time.[29]


  Conclusion Top


The present study shows that in a low-risk environment, open MR of IH can be carried out without PA in majority of the patients, with acceptable level of surgical site infections, which can manage conservatively with oral antibiotics.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Bowens NM, Morris JB. Inguinal hernia: Open surgical repair using mesh. J Long Term Eff Med Implants 2010;20:89-104.  Back to cited text no. 1
    
2.
Simons MP, Aufenacker T, Bay-Nielsen M, Bouillot JL, Campanelli G, Conze J, et al. European hernia society guidelines on the treatment of inguinal hernia in adult patients. Hernia 2009;13:343-403.  Back to cited text no. 2
    
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HerniaSurge Group. International guidelines for groin hernia management. Hernia 2018;22:1-65.  Back to cited text no. 3
    
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Praveen S, Rohaizak M. Local antibiotics are equivalent to intravenous antibiotics in the prevention of superficial wound infection in inguinal hernioplasty. Asian J Surg 2009;32:59-63.  Back to cited text no. 5
    
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National Healthcare Safety Network, Centers for Disease Control and Prevention, Surgical Site Infections (SSI) Event. National Healthcare Safety Network; Published in January, 2017. Available from: http://www.cdc.gov/nhsn/pdfs/pscmanual/9pscssicurrent.pdf. [Last accessed on 2017 Jan 25].  Back to cited text no. 9
    
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Zamkowski MT, Makarewicz W, Ropel J, Bobowicz M, Kąkol M, Śmietański M, et al. Antibiotic prophylaxis in open inguinal hernia repair: A literature review and summary of current knowledge. Wideochir Inne Tech Maloinwazyjne 2016;11:127-36.  Back to cited text no. 10
    
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Yin Y, Song T, Liao B, Luo Q, Zhou Z. Antibiotic prophylaxis in patients undergoing open mesh repair of inguinal hernia: A meta-analysis. Am Surg 2012;78:359-65.  Back to cited text no. 11
    
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Terzi C. Antimicrobial prophylaxis in clean surgery with special focus on inguinal hernia repair with mesh. J Hosp Infect 2006;62:427-36.  Back to cited text no. 12
    
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Sengupta S, Chattopadhyay MK, Grossart HP. The multifaceted roles of antibiotics and antibiotic resistance in nature. Front Microbiol 2013;4:47.  Back to cited text no. 13
    
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Khan S, Rao P, Rao A, Rodrigues G. Survey and evaluation of antibiotic prophylaxis usage in surgery wards of tertiary level institution before and after the implementation of clinical guidelines. Indian J Surg 2006;68:150-6.  Back to cited text no. 15
    
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Shankar VG, Srinivasan K, Sistla SC, Jagdish S. Prophylactic antibiotics in open mesh repair of inguinal hernia – A randomized controlled trial. Int J Surg 2010;8:444-7.  Back to cited text no. 16
    
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Kulacoglu H. Current options in inguinal hernia repair in adult patients. Hippokratia 2011;15:223-31.  Back to cited text no. 17
    
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Boonchan T, Wilasrusmee C, McEvoy M, Attia J, Thakkinstian A. Network meta-analysis of antibiotic prophylaxis for prevention of surgical-site infection after groin hernia surgery. Br J Surg 2017;104:e106-17.  Back to cited text no. 18
    
19.
Terzi C, Kiliç D, Unek T, Hoşgörler F, Füzün M, Ergör G, et al. Single-dose oral ciprofloxacin compared with single-dose intravenous cefazolin for prophylaxis in inguinal hernia repair: A controlled randomized clinical study. J Hosp Infect 2005;60:340-7.  Back to cited text no. 19
    
20.
Ergul Z, Akinci M, Ugurlu C, Kulacoglu H, Yilmaz KB. Prophylactic antibiotic use in elective inguinal hernioplasty in a trauma center. Hernia 2012;16:145-51.  Back to cited text no. 20
    
21.
Zhuo Y, Zhang Q, Tang D, Cai D. The effectiveness of i.v. Cefuroxime prophylaxis of surgical site infection after elective inguinal hernia repair with mesh: A retrospective observational study. Eur J Clin Pharmacol 2016;72:1033-9.  Back to cited text no. 21
    
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Erdas E, Medas F, Pisano G, Nicolosi A, Calò PG. Antibiotic prophylaxis for open mesh repair of groin hernia: Systematic review and meta-analysis. Hernia 2016;20:765-76.  Back to cited text no. 22
    
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Köckerling F, Bittner R, Jacob D, Schug-Pass C, Laurenz C, Adolf D, et al. Do we need antibiotic prophylaxis in endoscopic inguinal hernia repair? Results of the herniamed registry. Surg Endosc 2015;29:3741-9.  Back to cited text no. 23
    
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Wang J, Ji G, Yang Z, Xi M, Wu Y, Zhao P, et al. Prospective randomized, double-blind, placebo controlled trial to evaluate infection prevention in adult patients after tension-free inguinal hernia repair. Int J Clin Pharmacol Ther 2013;51:924-31.  Back to cited text no. 24
    
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Slingluff CL Jr., Burns WW, Cooperberg C. Toxic shock syndrome after inguinal hernia repair. Report of a case with patient survival. Am Surg 1990;56:610-2.  Back to cited text no. 25
    
26.
Miller AT, Byrn JC, Divino CM, Weber KJ. Eikenella corrodens causing necrotizing fasciitis after an elective inguinal hernia repair in an adult: A case report and literature review. Am Surg 2007;73:876-9.  Back to cited text no. 26
    
27.
Rutishauser J, Funke G, Lütticken R, Ruef C. Streptococcal toxic shock syndrome in two patients infected by a colonized surgeon. Infection 1999;27:259-60.  Back to cited text no. 27
    
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Johanet H, Contival N; Coelio Club. Mesh infection after inguinal hernia mesh repair. J Visc Surg 2011;148:e392-4.  Back to cited text no. 28
    
29.
Thakur L, Upadhyay S, Peters NJ, Saini N, Deodhar M. Prophylactic antibiotic usage in patients undergoing inguinal mesh hernioplasty – A clinical study. Indian J Surg 2010;72:240-2.  Back to cited text no. 29
    


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