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609

Current Practices of Preoperative Bowel Preparation Among North American


Colorectal Surgeons
Ronald Lee Nichols, Jeffrey W. Smith, Rena Y. Garcia,

Ruth S. Waterman, and James W. C. Holmes

From the Department of Surgery, Tulane University School of Medicine,


New Orleans, Louisiana

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

Received 30 July 1996; revised 1 October 1996.


This work was presented in part at the 9th Annual Meeting of the Surgical
Infection Society-Europe held on 30 May to 1 June 1996 in Paris.
Reprints or correspondence: Dr. Ronald Lee Nichols, Department of Surgery
(SL-22), Tulane University School of Medicine, 1430 Tulane Avenue, New
Orleans, Louisiana 70112-2699.
Clinical Infectious Diseases 1997; 24:609-19
1997 by The University of Chicago. All rights reserved.
1058-4838/97/2404-0011$02.00

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.

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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

In many questions, the responses added up to more than


the number of surgeons responding because the questionnaires
asked open-ended questions rather than limiting or forcing
choices to one answer. A Likert scale (a five value rating scale
ranging from "not important" to "very important" ) was used
to evaluate the factors influencing the overall choice of bowel
preparations. Eight hundred eight questionnaires were sent in
two mailings in March and May 1995. The respondents were
asked to return the anonymous questionnaires by either prepaid
business reply mail or toll-free facsimile. The responses were
analyzed by use of Statview 4.01 (Abacus Concepts, Berkeley,
CA) on a Macintosh PowerBook 5300.

Participating surgeons. Four hundred seventy-one (58%)


of the 808 colon and rectal surgeons who were sent questionnaires returned their surveys within 4 months, and their responses were analyzed for this report. Responses were received
from 45 states, the District of Columbia, Puerto Rico, and three
Canadian provinces. Response rates for the states or provinces
with more than five board-certified surgeons ranged from 44%
to 88%.
Most surgeons (391 [83%]) identified their community size
as large (population, >100,000); 72 (15.3%), as medium (population, 25,000-100,000); and only 8 (1.7%), as small (population, <25,000). The most commonly reported medical affiliations were a community hospital (62.6%), teaching hospital
(44.4%), or a large medical center (33.3%) (table 1). The responding surgeons received their colon and rectal surgery board
certification an average of 11.4 years ago (range, 1-39 years).
Only three surgeons had been recertified in colon and rectal
surgery, all since 1991.
Four hundred forty-seven surgeons indicated the number of
procedures that they perform each month. They reported approximately equal average numbers of colon (6.1) and rectal
(8.3) procedures each month and twice as many anal procedures

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

* Respondents reported all affiliations; the total number of affiliations is


greater than the number (471) of surgeons responding.

(15.4) (table 2). Most of their procedures are elective


(86%-91% depending upon the type of procedure), with most
of the patients being admitted to the hospital on the day of
surgery (65%-81%) following completion of the bowel preparation at home.
Mechanical procedures. All 471 surgeons who reported
their bowel preparative procedures routinely use some form of
mechanical preparation with their patients (figure 1). The most
commonly preferred forms of mechanical bowel preparation
are oral PEG solution (70.9% of respondents), oral sodium
phosphate-buffered solution with or without bisacodyl
(28.4%), or the "traditional" usage of dietary restriction, cathartics (including magnesium citrate or sulfate), and enemas
(28.4%) (table 3). Only a small number of surgeons reported
that they routinely use whole-gut irrigation, mannitol, or other
methods.
The preferred time to start the mechanical preparation is
usually 18-24 hours before the surgical procedure (figure 2).
Although there is some variation in the timing, all respondents
start the preparation r 24 hours before the procedure. Most
patients complete this mechanical preparation on an outpatient
basis at home before hospital admission.
The traditional bowel preparation, when used, is started an
average of 29.8 hours (range, 12-48 hours) before the surgical
procedure. Those surgeons preferring PEG solution employ an
average of 3.7 L (range, 1-8 L) over 3-4 hours (range, 1-24
hours). Although the participants reported their most commonly
used mechanical methods, they would consider other procedures when they thought that it was in the patients' best interests or when it was medically indicated. Factors in the decisionmaking process include noncooperative or noncompliant
patients; those who are very young, old, or frail; or those
with disease states that might be compromised (e.g., severe
diverticulitis; active colitis; inflammatory bowel disease; pulmonary, cardiac, or renal disease; severe nausea, cramping, or
constipation; partial obstruction; or tight strictures).
Antibiotic prophylaxis. Of 468 respondents, almost all (464
[99.1%]) reported that they routinely use preoperative prophylactic antibiotics (table 4). Most (391 [85.4%]) of the 458 surgeons
who listed the rationale for antibiotic choice reported that the
antibiotics should protect against facultative and anaerobic colonic
bacteria. Smaller numbers of surgeons were concerned with either
aerobes alone (42 [9.2%]) or anaerobes alone (25 [5.4%]). Correspondingly, 45.9% (194) of 423 surgeons reported that both facultative and anaerobic bacteria were responsible for infections following colorectal procedures at their hospitals. Problems with
facultative bacteria alone were reported by 43.7% (185) of the
surgeons, while only 8% (34) related concerns solely with anaerobic infections. Ten surgeons (2.4%) were unsure of the bacterial
cause of infections at their institutions.
The choices of oral and parenteral antibiotics are listed in
table 5. The 471 surgeons who responded reported a total of
711 different antibiotic regimens, 625 of which include oral
antibiotics. The many regimens had slight variations in the
antibiotic and dosage choices, and for this report, the parenteral

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Results

CID 1997;24 (April)

Preoperative Preparation of the Colon

CID 1997;24 (April)

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

Influencing factors. Six factors were addressed concerning


the surgeons' choices for bowel preparation. The results showed
that the most important concerns are reduced rates of infections
in their patients that result from both reduction of bacterial burden
and a grossly clean colon at the time of operation (table 6). Patient
acceptability and ease of administration were of lesser importance,
while the least important concern was the cost of the preparation.
Specific questions concerning the use of a home bowel preparation
before surgery were also addressed. Although most surgeons (283
[59.5%] of 476) thought it was as good as inpatient administration,
approximately one-third (146 [30.7%]) did not agree, and 10%
(47) thought it was usually all right but did express concerns for
some patients.
The concerns noted by the surgeons who responded "no"
and "usually OK" included such problems as dehydration,
lack of compliance, the patients' inability to self-administer an
effective enema, and an inadequately prepared colon found
during surgery. They believed that certain patients should not
receive home bowel preparations unless there was adequate
supervision by a family member or visiting nurse. These patients would be elderly individuals, those with disabilities, nonreliant or nonmotivated patients, or those distracted or overly
anxious over the impending surgery. Only a small number

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.

Liquid or low-residue diet I

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%**

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choices were combined into antibiotic families. As can be seen,


the most prevalent oral regimens are neomycin with either
erythromycin or metronidazole. In most cases (77.8% of the
711 regimens), oral neomycin and either erythromycin or metronidazole are combined with the perioperative use of a parenteral antibiotic.
The oral antibiotics are normally started on the day before
surgery (97.2%), with only 11 respondents (2.8%) beginning them
earlier than 1 day before (figure 2). Of all reported regimens, the
parenteral antibiotics most often chosen are second-generation
cephalosporins (figure 1). Some surgeons prefer to use a firstor third-generation cephalosporin, penicillin with a /3-lactamase
inhibitor, or intravenous metronidazole. Most surgeons start the
parenteral antibiotics 1 hour before surgery (figure 2).
Most (93.7%) of the surgeons limit the routine administration
of the parenteral antibiotics to four or less doses stopping within
24 hours after surgery. A few, however, do give the drugs for 2
to 4 days. The surgeons stated that the antibiotic regimens would
be continued if perforation or spillage was noted during surgery.
They also would consider alternate regimens, presumably increased duration or different drugs, for immunocompromised patients or those with Crohn's disease, prosthetic devices, antibiotic
allergies, or cardiac valve replacements.

Nichols et al.

612

Table 3. Mechanical preparations used by respondents to a survey


on North American bowel preparation practices before elective colorect4l procedures.
Mechanical preparation used

No.* of
preparations

Percent of
respondents

Polyethylene glycol solution


Sodium phosphate solutions
"Traditional" 1.
Whole-gut irrigation
Mannitol
Other

334
134
134
11
9
4

70.9
28.4
28.4
2.3
1.9
0.9

CID 1997; 24 (April)

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].

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* Respondents reported their normally used preparation(s); the total number


(626) of preparations is more than the number (471) of surgeons responding.
All surgeons used some form of mechanical preparation.
t With or without bisacodyl.
I Combination of dietary restriction, enemas, and cathartics.

of surgeons thought that a home preparation should only be


performed for colonoscopy and that an inpatient preparation
should be used for all other procedures.
Discussion

During colon and rectal surgical procedures, it is important


to avoid bacterial contamination of the peritoneal cavity or
adjacent tissues by colonic microflora to prevent serious postoperative intraabdominal or surgical site infections. For most
of this century, surgeons have tried to sterilize the lumen of
the colon to reduce the rates of surgical morbidity and mortality
following colon or rectal surgery [2]. As early as 1951, Finegold [8] reported on the effects of various antimicrobials on
the colonic microflora. Although coliform bacteria were suppressed, the anaerobes were not significantly affected.
Before the 1970s, the primary method of reducing the bacterial burden was through effective mechanical cleansing [2].
In 1971, studies of traditional mechanical cleansing (dietary
restrictions, cathartics, and enemas) showed that although gross
lumps of stool were removed, bacterial counts in the remaining
liquid colonic contents were still significant [9]. Oral antibiotics
used at that time (e.g., sulfonamides, streptomycin, kanamycin,
and neomycin) had activities effective in suppressing facultative bacteria alone but often failed to prevent postoperative
infection [2, 3, 10]. In addition, the oral antibiotics were given
for up to 5 days, resulting in intracolonic overgrowth of staphybelieved that
lococci or yeast. Consequently, many
antibiotic prophylaxis was of little use and did not routinely
employ it [2].
In the early 1970s, it was found that the intraluminal anaerobic microflora of the colon and rectum greatly outnumbered
the facultative organisms ( 1,000 to 1) [10, 11] . In
1972-1973, it was shown that the addition of an antibiotic
effective against the predominant anaerobic bacteria (oral
erythromycin base) to an antibiotic previously shown to be
effective against facultative organisms (oral neomycin) was
'

Figure 2. Timing of the mechanical and antibiotic components of


the preoperative bowel preparation in North America. Most surgeons
start the mechanical procedures within 18-24 hours before the operative procedure. The oral antibiotics are administered 12-18 hours
before, with parenteral antibiotics being added to the regimen within
1 hour of the procedure.

Preoperative Preparation of the Colon

CID 1997; 24 (April)

Table 4. Use of oral and parenteral antibiotic bowel preparative


techniques by respondents to a survey on North American bowel
preparation practices before elective colorectal procedures.
No. (%) using parenteral antibiotics
Use of oral antibiotics

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.

Previous surveys have shown that the percentage of North


American colon and rectal surgeons using effective antibiotic
prophylaxis has increased from 85% in 1979 to 100% in 1988
[6, 18, 19]. In 1976, one survey indicated that 6% of surgeons
did not use antibiotic prophylaxis but relied upon mechanical
techniques to reduce the rate of postoperative infections [20]. It
was also seen that systemic antibiotics alone were used by 8%
of the respondents, oral antibiotics alone were used by 37%, and
a combination of both were used by 49%. A sizable percentage
(18%) of the surgeons began to administer the systemic antibiotics
postoperatively, a practice now known to be suboptimal. Although
a small percentage (0.9%) of surgeons still fail to use effective
antibiotic prophylaxis, our survey indicates that it remains the
standard of care in North America.
In 1990, a comparison with British surgeons indicated that
92% used antibiotic prophylaxis routinely [21]. However, only
17% used topical (oral) antibiotic prophylaxis. Seventy-eight
percent of the British surgeons favored a regimen of parenteral
cephalosporin plus metronidazole. A three-dose regimen (one
during surgery and two postoperatively) was reported by 43%
of the surgeons, while an additional 48% continued to administer the antibiotics beyond the three doses.
Although the antibiotic combination should be effective as
preoperative prophylaxis, both the duration of administration
and the use of mechanical preparations with enemas (3 8%),
purgatives (37%), mannitol (19%), or whole-gut irrigation (6%)
are in sharp contrast to North American practices and might
help explain the traditionally higher rates of wound infection
in the United Kingdom [5]. In the United States, rates of postoperative infection following administration of appropriate oral
agents, with or without the addition of a parenteral agent, have
been constantly reported to be < 10% among patients without
additional risk factors for infection [22].

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.

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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

* Higher scores indicate greater importance. Choices varied from 1 (not


important) to 5 (very important).

ities against both aerobes and anaerobes. Certain other lesser


used regimens exhibit variable activities against these organisms, and thus their use should be reconsidered. Those regimens
with oral metronidazole or metronidazole plus erythromycin
alone do not cover the facultative gram-negative bacteria. However, the addition of an effective parenteral antibiotic or antibiotics tends to cover these organisms and will help protect
against postoperative infection.
Despite the numerous studies showing the benefit of oral
prophylaxis, 54 (11.5%) of our respondents administer only
parenteral prophylaxis with drugs that fail to protect against
all intestinal microflora. Some of the antibiotic regimens reported in our survey are redundant, using multiple antibiotics
with like spectra (table 5). While the length of administration
is limited, there remains some concern that this practice may
result in the evolution of resistant organisms. It was noteworthy
that none of the responding surgeons reported prophylaxis with
imipenem/cilistatin. This combination was used in one British
trial without oral prophylaxis and was associated with an infection rate of 26.4%, a rate much higher than seen in North
American trials [25]. We believe that the use of this combination should remain limited to a therapeutic setting.
All surgeons responding to our survey use mechanical bowel
cleansing; the most popular preparation is PEG solution
(-4 L administered over 3-4 hours the morning of the day
before surgery). This regimen has steadily increased in popularity since 1987-1988, while the use of "traditional" procedures
has decreased [6, 19]. Although mannitol bowel preparation
remains common outside the United States, the rate of its use
here has now decreased to <2%.
While not previously reported, a large number (28.4%) of
our surgeons now routinely use oral sodium phosphate solution
with or without bisacodyl in a one- to two-dose regimen before
administration of the oral antibiotics. This solution cleanses
the bowel by acting as an osmotic purgative and has been
shown to be effective for colorectal cleansing without causing
any significant clinical problems [26]. It is currently used at
our hospital, and its efficacy has been shown to be superior
to that of PEG solution in promoting colonic cleansing with
relatively small volumes.
Although PEG solution has been approved for bowel cleansing
before colonoscopy and roentgenographic examinations with barium enemas, oral sodium phosphate solution is also approved for
bowel cleansing before surgery [27]. Its use, however, should
be limited to those patients without evidence- of kidney disease,
congestive heart failure, or other contraindications.
The routine use of mechanical cleansing has recently been
challenged in several reports from the United Kingdom and
Ireland [21, 28-30]. On the basis of observations following
emergent and elective colorectal surgery, the researchers concluded that mechanical preparation is not needed to further
reduce infection rates provided that effective antibiotics are
administered.
Irving and Scrimgeour [28] reported an infection rate of
8.3% among 72 patients undergoing elective and emergent

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Our survey of clinically active colorectal surgeons found


that oral antibiotics remain well accepted and that the rate of
use (91.8%) is similar to that reported in 1990 (87.6%) [6]. A
more limited survey from the same period showed that 87%
of 206 surgeons used oral prophylaxis [19], while one conducted in 1976 indicated its use by 86% of 582 surgeons [20].
From 1988 to the present, the rate of the use of parenteral
antibiotics, with or without oral agents, has slightly increased
from 96.6% to 98.1% [6], which is in contrast to the rates
reported for 1988 and 1976 (90% and 57%, respectively) [19,
20]. Parenteral antibiotics are usually administered within 1
hour of surgery, a time frame that will provide adequate serum
and tissue levels at the time of the procedure. The practice of
having "on call" parenteral agents in the operating room
should be discouraged, as it often results in inadequate tissue
levels during the procedure.
In 1988, 63% of surgeons continued to administer parenteral
antibiotics 1 day postoperatively, and 25% continued their use
for 2-3 days postoperatively [19] . Currently, almost 94% of
surgeons limit administration to a single day (one to four
doses). This practice is in accordance with the current thought
that longer administration does not decrease the incidence of
infection but may actually contribute toward an increase in the
number of resistant organisms. However, certain conditions
require extended antibiotic administration: delayed operations,
oral antibiotics not administered properly, fecal spillage during
the procedure, prolonged operations (i.e., >3.5-4 hours), and
performance of a rectal resection (e.g., abdominal-perineal operations) [14, 23, 24].
The "ideal" antibiotic prophylaxis would result in few infections and would be inexpensive, easy to administer, and
well tolerated by patients. The most popular regimens emulate
this ideal by utilizing oral neomycin plus either erythromycin
or metronidazole combined with a perioperative parenteral antibiotic (table 5). Although the additional benefit of perioperative
antibiotics has not been verified, all recent surveys have shown
their popularity. The agents most often added are second-generation cephalosporins (67.7% of cases), drugs that possess activ-

CID 1997;24 (April)

CID 1997;24 (April)

Preoperative Preparation of the Colon

Approximately 60% of our survey respondents believe that


the home preparation can be as good as the one in the hospital.
They indicated, however, that not all patients are candidates for
this procedure. Elderly patients or those with contraindicating
conditions should not have a home preparation unless they are
sufficiently supervised and adequate written and oral instructions are provided. At our institution, home bowel preparation
is routinely used and is generally believed to be beneficial
provided that the patients are screened and educated about the
procedures.
The present survey of board-certified colon and rectal surgeons indicates that antibiotic prophylaxis efficacious against
both facultative and anaerobic colonic microflora is routinely
used and that effective mechanical preparations are used. Although the cost of the complete preparation was of less concern,
the surgeons prefer one that is acceptable to the patient, is easy
to administer, and results in a low incidence of postoperative
infection. These conditions are accomplished by removing
gross feces from the intestines by mechanical cleansing, reducing the burden of intraluminal bacteria with administration of
oral antibiotics, and providing adequate serum and tissue levels
of antibiotics (oral agents with or without parenteral agents) at
the time of the operation.
No significant changes in antibiotic choices were found from
previous surveys. Although the most common mechanical
preparation remains oral PEG solution, the use of oral sodium
phosphate solution with or without bisacodyl is rapidly increasing. It appears that a combination of a home bowel preparation
and both preoperative oral antibiotics (neomycin plus erythromycin or metronidazole) and perioperative parenteral antibiotics (second-generation cephalosporin) is currently the preferred method of prophylaxis for elective colon and rectal
surgery.
The use of outpatient mechanical preparation is increasing,
apparently without an increase in the rate of complications. It
is imperative that adequate precautions be taken to maintain
the current low level of complications now observed.

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colorectal procedures without bowel cleansing. They believe


that oral antibiotics are unnecessary and that bowel cleansing
is exhausting to the patient and simply turns solid feces into an
uncontrollable liquid. Brownson et al. [29] reported equivalent
wound infection rates but higher intraabdominal infection rates
among patients mechanically cleansed with PEG solution than
among those not mechanically cleansed. Burke and colleagues
[30] found that the presence of solid stool in the colon did not
appear to increase infection rates. Despite these reports, we
believe that further controlled studies are needed before the
discontinuance of mechanical preparation can be recommended.
Most surgeons responding to the present survey indicated
that a grossly clean colon during surgery is an important factor
in their choice of bowel preparation. The most commonly used
methods of bowel cleansing can be performed on an outpatient
basis and can be completed the day before surgery. The increasing use of the sodium phosphate solution shows that an effective mechanical preparation can be obtained relatively quickly
without undue stress in the nonobstructed patient. We believe
that a clean colon is technically easier to work with; if the
colon is clean, the chance of solid fecal spillage decreases, and
normal colonic motility returns more quickly in the postoperative course.
In 1988, a survey showed that most patients (61%) were
admitted to the hospital the day before surgery, and 33% were
admitted 2 days before [19]. Very few (3%) received the
bowel preparation as outpatients and were admitted on the
day of the surgical procedure. The use of outpatient bowel
preparation is now increasing, with one report showing the rate
of its use increasing from zero to 88% in a 4-year period ending
in 1992 [7]. The widespread use of this technique has not
resulted in increased rates of infections or other complications
[7, 31-33]. Moreover, yearly savings in hospitalization costs
of more than $150 million were estimated for the United States
alone [7].

615

616

Nichols et al.

CID 1997;24 (April)

Appendix

Bowel Preparation Survey 1995


DEMOGRAPHICS
1) In what year did you become board certified in colon and rectal surgery?
2)

19

In which state do you practice?

3) In which size community do you practice?



Small
(<25,000)
Medium (25-100,000)

Large
(>100,000)
In which type of institution do you practice? Check ALL that apply.

Community hospital
Veterans Administration hospital

Large medical center
Military hospital

Teaching hospital
Medical school

5)

Approximately how many procedures do you perform each month?


Colon

Rectum

Anus

6) What percentage of your cases are elective or emergent?


Elective:

% Colon

% Rectum
Emergent:

% Colon
% Rectum

% Anus
% Anus

7) What percentage of your cases are admitted to the hospital the day of surgery?
% Colon

% Rectum
% Anus

BOWEL PREPARATION PROCEDURES


Please answer the following questions regarding preoperative bowel preparation for elective colon
and rectal surgical procedures.
,

1) Which form of mechanical, preparation do you normally use?


None
"Traditional" using cathartics and enemas over
hours / days
PEG (polyethylene glycol solution)
liters over
hours
Mannitol
grams
Whole-gut lavage
liters over
hours
Other
2) The mechanical preparation is usually started
scheduled.

hours before the operative procedure is

3) Are there instances where you feel an alternate mechanical preparative method (not your
normal method as checked above) should be used? Please list:

Completed questionnaire can be sent by FAX to 1-800-813-6157 4[Page 1 of 3]

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4)

617

Preoperative Preparation of the Colon

CID 1997;24 (April)

Bowel Preparation Survey 1995


4) Which form ofslat antibiotic prophylaxis do you normally use? Check ALL that apply.
None
Aminoglycoside
doses
hrs X

mg q
Neomycin
doses
hrs X
mg q

Kanamycin
doses
hrs X
mg q

Clindamycin
doses
hrs X

mg q
Erythromycin base
doses
hrs X

mg q
Metronidazole
doses
hrs X

mg q
Tetracycline
doses
hrs X

mg q
Other
,

hours before the operative procedure is scheduled.

6) Which form of parenteral antibiotic prophylaxis do you normally use?


None
hrs X
gram(s) q

First generation cephalosporin
Cefazolin
Other
hrs X
gram(s) q

Second generation cephalosporin
Cefotetan
Cefoxitin
Other
hrs X

gram(s) q
Third generation cephalosporin
,

doses

doses

doses

Ceftizoxime
Ceftriaxone
Other
Other
7) The =Mad antibiotics are started

gram(s) q

hrs X

doses

hours before the operative procedure is scheduled.

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

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5) The ad antibiotics are started

Nichols et al.

618

CID 1997;24 (April)

Bowel Preparation Survey 1995


9)

At xox institution, which microorganisms are most implicated in surgical infections following
colon and rectal procedures?
Aerobic bacteria:
Anaerobes:

Both aerobes and anaerobes are equally implicated.


Neither are recovered.
10) In patients which you consider "high risk", are special antibiotic precautions (e.g., longer
prophylaxis, additional antibiotics, larger doses) utilized?
No

Cleanliness of operative site


Cost
Ease of administration
Patient acceptance
Reduction of bacteria at operative site
Reduction of post-surgical infections

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?

ADDITIONAL COMMENTS if desired:

Thankyou for your valua6k time.


We appreciate your input for this important survey!
4 Completed questionnaire can be sent by FAX to 1-800-813-6157 4[Page 3 of 31

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Yes:
11) Rate the following factors in influencing your choice of bowel preparation (mechanical &
antibiotic):
Not
Very
Neutral
important
important

CID 1997; 24 (April)

Preoperative Preparation of the Colon

Acknowledgments

The authors thank the American Society of Colon and Rectal


Surgeons and the Fellows of the American Society of Colon and
Rectal Surgeons. This report would not have been possible without
their diligence in filling out the questionnaires. We also thank
Whitney T. Michaels, B.S., M.P.H., for her help in reviewing the
survey data and analyses.

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.

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