|Year : 2008 | Volume
| Issue : 2 | Page : 200-205
|Is Antibiotic Usage Necessary after Donor Nephrectomy? A Single Center Experience
Afshar Zomorrodi, Abulfasel Buhluli
Kidney Transplantation Ward, Emam Hospital, Tabriz Medical University Science, Tabriz, Iran
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| Abstract|| |
Proper management of living kidney donors is a very important aspect of all renal transplants. To date, approximately 60,000 living donor nephrectomies have been performed worldwide and about 20 deaths directly related to the operation have been reported. The most common cause of death has been pulmonary embolism. Wound infection following surgery is the third most common nosocomial infection, and is dependent on the surgeon and his/her team, the operating room, number and virulence of contaminated bacteria, patient characteristics (immunity and defense), as well as time and duration of administration of antibiotics. Approach to the prophylaxis of wound infection in kidney donors varies in different transplant centers.
This study was conducted at the Emam Hospital, Tabriz, Iran in order to delineate the protocol regarding antibiotic usage after donor nephrectomy. One hundred kidney donors were enrolled in the study. They were classified randomly in two groups: Group-1, comprising 50 donors, who received antibiotics immediately following surgery and for at least seven days thereafter. Group-2, comprised of 50 donors, in whom one gram of cephazoline was injected intravenously before anesthesia and continued for 24 hours after surgery. The patients were followed-up for one month with particular emphasis on occurrence of wound infection. One patient in Group-1, and two in Group-2 had wound infection; the difference was not statistically significant (p = > 0.5). Our study suggests that antibiotic prophylaxis started before incision and continued for 24 hours after donor nephrectomy is safe and effective in preventing wound infection.
Keywords: Antibiotic prophylaxis, Wound infection, Kidney donor
|How to cite this article:|
Zomorrodi A, Buhluli A. Is Antibiotic Usage Necessary after Donor Nephrectomy? A Single Center Experience. Saudi J Kidney Dis Transpl 2008;19:200-5
|How to cite this URL:|
Zomorrodi A, Buhluli A. Is Antibiotic Usage Necessary after Donor Nephrectomy? A Single Center Experience. Saudi J Kidney Dis Transpl [serial online] 2008 [cited 2020 Jan 20];19:200-5. Available from: http://www.sjkdt.org/text.asp?2008/19/2/200/39030
| Introduction|| |
Based on the National Nosocomial Infection System (NNIS) reports, surgical site infections (SSIs) are the third most frequently reported nosocomial infection, accounting for 14 to 16% of all nosocomial infections among hospitalized patients.  Also, the distribution of pathogens isolated from SSIs has not changed markedly during the last decade. , Staphylococcus aureus, Enterococcus species, and Escherichia More Details coli remain the most frequently isolated pathogens. An increasing proportion of SSIs are caused by antimicrobial-resistant pathogens, such as methicillin-resistant S. aureus (MRSA) , or by Candida albicans.  From 1991 to 1995, the incidence of fungal SSIs among patients at NNIS hospitals increased from 0.1 to 0.3 per 1,000 discharges.  The increased proportion of SSIs caused by resistant pathogens and candida may reflect increasing numbers of severely ill and immunocompromised surgical patients as well as the impact of widespread use of broad-spectrum antimicrobial agents.
Surgical wound infections include those that are confined to the incisional wound and those that involve structures adjacent to the wound (sometimes called "deep infections"). About 60 - 80% of infections are incisional, while the remaining involve adjacent sites such as intra-abdominal/ retroperitoneal and deep soft tissues. , Pathogens that infect surgical wounds can be acquired from the patient, the hospital environment, or personnel. The patient's own flora appears to be responsible for most infections, especially if clean-wound infections are excluded.  Sources of contamination include the gastrointestinal, respiratory, genital, and urinary tracts as well as the skin and anterior nares. As determined by reports from the NNIS, gram-negative aerobic bacteria constitute approximately 40% of pathogens isolated from surgical wounds. However, S. aureus remains the single most frequently isolated species. 
Since the risk of wound infection increases with the length of the operation, an expeditious operation is important. ,,, However, the surgeon must balance the need to operate quickly with the need to handle tissues gently, reduce bleeding and hematoma formation, and eradicate dead space.
Numerous studies have examined whether surgeons are in compliance with the generally accepted standards of preventive antibiotic usage. ,,,, These studies have shown that in as many as 25% of cases in which antibiotics have documented benefit, patients do not receive the drugs preoperatively and/or the majority continue to receive antibiotics for multiple postoperative days. The probability of infection has numerous complex variables, and the use of preventive antibiotics only affects the viable inoculum of organisms that reside in the wound following operation. Compliance with the principles of preventive antibiotics provides the best opportunity to prevent SSI, while avoiding needless risk and minimizing costs of the antibiotics themselves.
In our kidney transplantation center, the standard protocol is giving full dose antibiotics immediately post surgery, for seven days or more. Since we felt that we should change this protocol according to the prescribed guidelines, this study was undertaken.
| Materials and Methods|| |
One hundred kidney donors aged between 25 and 35 years were randomly divided into two groups: Group-1 had 50 kidney donors (45 males, 5 females) all of whom received antibiotics according to our traditional method. They received cephazoline one gram intravenously (IV) every six hours, which was continued for seven days following surgery.
Group-2 had 50 donors (43 males, 7 females) who received prophylactic antibiotics according the prescribed guidelines. One-gram cephazoline was given before induction of anesthesia (for open nephrectomy via the retroperitoneal flank approach) and the antibiotic was given for only 24 hours after surgery. The surgical wound of both groups was checked regularly for infection during one month post-surgery. The same surgical and anesthesia teams were involved in the surgery of patients of both groups.
| Results|| |
There was one case in Group-1 one and two cases in Group-2 that had evidence of infection. The difference did not reach statistical significance (p = > 0.5).
| Discussion|| |
The efficacy of antibiotic prophylaxis was not proved until the late 1960s.  Studies before then had major design flaws: principally, the administration of the antibiotic was some time after the start of the operation, often in the recovery room. The failure of studies to demonstrate efficacy, and the occasional finding that prophylactic antibiotics worsened rather than improved outcome, led in the late 1950s to profound skepticism about prophylactic antibiotic use in any operation. The principal reason for the apparent inefficacy was inadequate understanding of the biology of SSIs. Fruitful study of antibiotics and how they should be used began after physiologic groundwork established the importance of local blood flow, maintenance of local immune defenses, adjuvants, and local and systemic perfusion.  The key antibiotic study, which was conducted in guinea pigs, unequivocally proved the following about antibiotics:
a). They are most effective when given before inoculation of bacteria.
b). They are ineffective if given three hours after inoculation 
Although efficacy with a complicated regimen was demonstrated in 1964,  the correct approach was not defined until 1969.  Established by these studies are the philosophical and practical bases of the principles of antibiotic prophylaxis of SSI in all surgical arenas. ,, Prophylactic antibiotics must be given preoperatively within two hours of the incision, in full dosage, parenterally, and for a very limited period. These principles remain essentially unchanged despite minor modifications from innumerable subsequent studies. ,,, Data suggest that prophylactic use of antibiotics may contribute to secondary Clostridium difficile disease; caution should be exercised when widening the indications for prophylaxis.  If local results are poor, surgical practice should be reassessed before antibiotics are prescribed. When antibiotics are given more than two hours before operation, the risk of infection is increased. ,
Intravenous administration in the operating room (OR) or the pre-anesthetic room guarantees appropriate levels at the time of incision. The organisms likely to be present dictate the choice of antibiotic for prophylaxis. The cephalosporins are ideally suited for prophylaxis: their features include a broad spectrum of activity, an excellent ratio of therapeutic to toxic dosages, a low rate of allergic responses, ease of administration, and attractive cost advantages. Mild allergic reactions to penicillin are not contraindications for the use of a cephalosporin.  First-generation cephalosporins (e.g. cefazolin) are ideal agents for prophylaxis. Thirdgeneration cephalosporins are not ideal because they cost more, are not more effective, and promote emergence of resistant strains. ,,
The most important first-generation cephalosporin for surgical patients continues to be cefazolin. Administered IV in the OR at the time of skin incision, it provides adequate tissue levels throughout most of the operation. A second dose administered in the OR after three hours will be bene-ficial if the procedure lasts longer than that.  Data on all operative site infections are imprecise, but SSIs can clearly be reduced by this regimen. No data suggest that further doses are required for prophylaxis.
Complications of antibiotic prophylaxis are few. Although data linking prophylaxis to the development of resistant organisms are meager, resistant microbes have developed in every other situation in which antibiotics have been utilized, and it is reasonable to expect that prophylaxis in any ecosystem will have the same result,  particularly if selection of patients is poor, if prophylaxis lasts too long, or if too many late-generation agents are used.
A rare but important complication of antibiotic use is pseudomembranous enterocolitis, which is induced most commonly by clindamycin, the cephalosporins, and ampicillin.  The common denominator among different cases of pseudomembranous enterocolitis is hard to identify. Diarrhea and fever can develop after administration of single doses of prophylactic antibiotics. The condition is rare, but difficulties occur because of failure to make a rapid diagnosis. No change in the criteria for antibiotic prophylaxis is required in laparoscopic procedures; the risk of infection is lower in such cases. ,
One study showed that the most important factor in the development of a wound infection was the number of bacteria present in the wound at the end of an operative procedure.  Thus, both the operating team; surgeon, assistants, nurses, and anesthetists, and the OR air have been reported as significant sources of bacteria. In fact, personnel are the most important source of exogenous bacteria. ,, Very good studies have shown that dramatic reductions in SSI rates can be achieved through careful avoidance of hypothermia. ,
Thus, it is apparent that technique of surgery (expeditious), core body temperature, immunity of patient, oxygen pressure in tissue, duration of operation, surgical team, anesthetists and presence of antibiotic in tissue during surgery are important factors that predict SSI. Possibly, the most important factors in donor nephrectomy are gentle handling of the tissue, achieving good homeostasis without any hematoma and presence of antibiotic in tissue during surgery.
Our study suggests that we can safely discard traditional method in using antibiotic and replace it with antibiotic prophylaxis guidelines. It is not only effective in preventing wound infection but also offers the benefit of fewer side effects apart from the cost benefit.
| Conclusion|| |
We conclude that administration of one gram of cefazolin IV 30-45 minutes before skin incision followed by a second dose if procedure lasts longer than three hours, and continuation of antibiotic for 24 hours after surgery is safe and effective antibiotic prophylaxis against wound infection following donor nephrectomy.
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Associate Professor of Urology, Kidney Transplantation Ward, Emam Hospital, Tabriz Medical University Science, Tabriz
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