TY - JOUR
AU - Mekako, A I
AB - Sir We thank Mr Hopper and Mr Lane for reading and responding to our paper; however, they seem to have completely missed the point. Our study provides level 1 evidence that use of prophylactic antibiotics in patients undergoing groin surgery for varicose veins significantly reduces patient-reported wound complications, postoperative visits to primary care for wound complications and resulting antibiotic prescriptions, all important outcome measures following varicose vein surgery. Many of Hopper and Lane's points are negated by the fact that this was a double-blind randomized controlled trial (RCT). Concerns about bilateral and redo procedures, patient self-assessment, oversensitivity of the ASEPSIS scoring system and accuracy of primary care assessment are essentially irrelevant, as they are equivalent for both arms of the study. Little high-quality evidence exists showing that wound complications are more common following bilateral or redo varicose vein surgery. Defty and colleagues1 found, when analysed according to the number of limbs treated, that there was no difference in wound infections (determined by patient-reported purulent discharge) between unilateral and bilateral surgery. Our trial found no association between wound complications and bilateral or redo surgery. Patient self-assessment for surgical-site infections (SSIs) is not new, and has been shown to be valid, reliable and acceptable with many potential benefits2. Surely, the patient's opinion of what is acceptable is important? Even if we accept that wound parameters were over-reported, it would make no difference in a RCT. Mr Hopper and Mr Lane have listed potential drawbacks of the widespread use of antibiotics. These, however, do not apply to administering appropriately timed, single-dose targeted prophylactic antibiotics, known to prevent 40–60 per cent of SSIs3. Our protocol allowed swabs to be taken at the discretion of the carer, in keeping with usual clinical practice. Where swabs were taken, the randomization was unknown at the time of swabbing. Although we should not deduce much from the swabs, it is an interesting observation that comparatively more swabs were taken from the control group. Commenting on the microbiological flora would be speculative. In the manuscript we alluded to the possibility of inappropriate antibiotic prescription by general practitioners (GPs); we did not claim that this was a method for estimating wound infection. ASEPSIS may be too sensitive4, but remains one of the most robust and widely used wound scoring systems5. It would appear that our wound complication rate was high, but it is in keeping with surveillance data, which encompass complications manifesting in the community. An ASEPSIS score of 21 defines infection. We used a score of 10 for our logistic regression analyses, because we focused on good wound outcome/satisfactory healing. We thank Hopper and Lane for noting with certainty that antibiotic prophylaxis reduces ASEPSIS scores. ASEPSIS scores are evidenced in literature to indicate varying degrees of wound morbidity; therefore, by inference, Hopper and Lane accept with certainty that antibiotic prophylaxis reduces wound morbidity in the early postoperative days. We leave the issue of clinical impact to the judgement of the surgeon. In these days of increasing patient knowledge and choice, if Hopper and Lane's patients and referring GPs were given the evidence from our trial, what would their choice be? References 1 Defty C , Eardley N, Taylor M, Jones DR, Mason PF. A comparison of the complication rates following unilateral and bilateral varicose vein surgery . Eur J Vasc Endovasc Surg 2008 ; 35 : 745 – 749 . Google Scholar Crossref Search ADS PubMed WorldCat 2 Mitchell DH , Swift G, Gilbert GL. Surgical wound infection surveillance: the importance of infections that develop after hospital discharge . Aust N Z J Surg 1999 ; 69 : 117 – 120 . Google Scholar Crossref Search ADS PubMed WorldCat 3 Mangram AJ , Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for Prevention of Surgical Site Infection, 1999. Centers for Disease Control and Prevention (CDC) Hospital Infection Control Practices Advisory Committee . Am J Infect Control 1999 ; 27 : 97 – 132 . Google Scholar Crossref Search ADS PubMed WorldCat 4 Wilson AP , Helder N, Theminimulle SK, Scott GM. Comparison of wound scoring methods for use in audit . J Hosp Infect 1998 ; 39 : 119 – 126 . Google Scholar Crossref Search ADS PubMed WorldCat 5 Bruce J , Russell EM, Mollison J, Krukowski ZH. The quality of measurement of surgical wound infection as the basis for monitoring: a systematic review . J Hosp Infect 2001 ; 49 : 99 – 108 . Google Scholar Crossref Search ADS PubMed WorldCat Copyright © 2010 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) Copyright © 2010 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.
TI - Author's reply: Randomized clinical trial of co-amoxiclav versus no antibiotic prophylaxis in varicose vein surgery (Br J Surg 2010; 97: 29–36)
JF - British Journal of Surgery
DO - 10.1002/bjs.7168
DA - 2010-06-02
UR - https://www.deepdyve.com/lp/oxford-university-press/author-s-reply-randomized-clinical-trial-of-co-amoxiclav-versus-no-G4FZD3O4UQ
SP - 1148
EP - 1149
VL - 97
IS - 7
DP - DeepDyve
ER -