Prophylaxis Versus Treatment

Properly identifying the state of an infection is important when using antimicrobial prophylaxis in surgery. Antibiotic prophylaxis begins with the premise that no infection exists but that during surgery there can be a low level inoculum of bacteria introduced into the body. However, if sufficient antimicrobial concentrations are present, the situation can be controlled without infection developing. This is the case when surgery is done under controlled conditions, there are no major breaks in sterile technique or spillage of GI contents, and perforation or damage to the surgical site is absent. An example would be an elective hysterectomy done with optimal surgical technique.

If an infection is already present, or presumed to be present, then antimicrobial use is for treatment, not prophylaxis, and the goal is to eliminate the infection. This is the case when there is spillage of GI contents, gross damage or perforation is already present, or the tissue being operated on is actively infected (pus is present and cultures are positive). An example would be a patient undergoing surgery for a ruptured appendix with diffuse peritonitis.

The distinction between prophylaxis and treatment influences the choice of antimicrobial and duration of therapy. Appropriate antimicrobial selection, dosing, and duration of therapy differ significantly between these two situations. A regimen for antimicrobial prophylaxis ideally involves one agent and lasts less than 24 hours. Treatment regimens can involve multiple antimicrobials with durations lasting weeks to months depending on desired antimicrobial coverage and the surgical site.

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