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Original Article |

Postoperative Antibacterial Prophylaxis for the Prevention of Infectious Complications Associated With Tube Thoracostomy in Patients Undergoing Elective General Thoracic Surgery:  A Double-blind, Placebo-Controlled, Randomized Trial

David A. Oxman, MD; Nicolas C. Issa, MD; Francisco M. Marty, MD; Alka Patel, PharmD; Christia Z. Panizales, BS; Nathaniel N. Johnson, BS; J. Humberto Licona, MD; Shannon S. McKenna, MD; Gyorgy Frendl, MD, PhD; Steven J. Mentzer, MD; Michael T. Jaklitsch, MD; Raphael Bueno, MD; Yolonda Colson, MD, PhD; Scott J. Swanson, MD; David J. Sugarbaker, MD; Lindsey R. Baden, MD
JAMA Surg. 2013;148(5):440-446. doi:10.1001/jamasurg.2013.1372.
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Objective To determine whether extended postoperative antibacterial prophylaxis for patients undergoing elective thoracic surgery with tube thoracostomy reduces the risk of infectious complications compared with preoperative prophylaxis only.

Design Prospective, randomized, double-blind, placebo-controlled trial.

Setting Brigham and Women's Hospital, an 800-bed tertiary care teaching hospital in Boston, Massachusetts.

Participants A total of 251 adult patients undergoing elective thoracic surgery requiring tube thoracostomy between April 2008 and April 2011.

Interventions Patients received preoperative antibacterial prophylaxis with cefazolin sodium (or other drug if the patient was allergic to cefazolin). Postoperatively, patients were randomly assigned (at a 1:1 ratio) using a computer-generated randomization sequence to receive extended antibacterial prophylaxis (n = 125) or placebo (n = 126) for 48 hours or until all thoracostomy tubes were removed, whichever came first.

Main Outcome Measures The combined occurrence of surgical site infection, empyema, pneumonia, and Clostridium difficile colitis by postoperative day 28.

Results A total of 245 patients were included in the modified intention-to-treat analysis (121 in the intervention group and 124 in the placebo group). Thirteen patients (10.7%) in the intervention group and 8 patients (6.5%) in the placebo group had a primary end point (risk difference, −4.3% [95% CI, −11.3% to 2.7%]; P = .26). Six patients (5.0%) in the intervention group and 5 patients (4.0%) in the placebo group developed surgical site infections (risk difference, −0.93% [95% CI, −6.1% to 4.3%]; P = .77). Seven patients (5.8%) in the intervention group and 3 patients (2.4%) in the placebo group developed pneumonia (risk difference, −3.4% [95% CI, −8.3% to 1.6%]; P = .21). One patient in the intervention group developed empyema. No patients experienced C difficile colitis.

Conclusions Extended postoperative antibacterial prophylaxis for patients undergoing elective thoracic surgery requiring tube thoracostomy did not reduce the number of infectious complications compared with preoperative prophylaxis only.

Trial Registration clinicaltrials.gov Identifier: NCT00818766

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Figure. Patient flowchart showing the enrollment and randomization of 292 patients for a prospective, randomized, double-blind, placebo-controlled trial to determine whether extended postoperative antibacterial prophylaxis for patients undergoing elective thoracic surgery with tube thoracostomy reduces the risk of infectious complications compared with preoperative prophylaxis only. GFR indicates glomerular filtration rate.

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