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Preoperative and postoperative antibiotic therapy in surgery of the colon
Preoperative and Postoperative Antibiotic Therapy in Surgery of the Colon RUSSEL BURNETTGRANT, M.D. ANDANTHONYCARL BARBARA,M.D., Hackensack, New Jersey
From tbe Department of Surgery, Hackensack Hackensack, New Jersey.
Hospital,
at home. The infections cuItured were nearIy equaIIy divided between StaphyIococcus aureus and Escherichia coli. Leakage at the suture Iine was diagnosed when postoperative fecal drainage occurred from the site of cIosure or anastomosis.
of medicine is repIete with of drug discoveries foIIowed by enthusiasm, skepticism and finaIIy disiIIusionment. The object of this paper is to evaIuate preoperative and postoperative antibiotic therapy in surgery of the coIon in a 368 bed community hospita1. There has been abundant investigation of their preoperative use [r-20] since suIfaniIamide was first reported in rg3g [21]. So far, a paucity of information concerning their postoperative use exists. HE
HISTORY
T exampIes
STUDY There seems to be uniform agreement that the preoperative mechanica cIeansing has some importance. On reviewing the Iiterature, however, one is impressed with the varying degrees of importance attached to cIeansing. In some instances it is reIegated to a minor roIe compared with the use of preoperative antibiotics. It has Iong been our beIief that rather than try to sterilize the feces, it is better to eliminate them. The 469 cases were divided into two groups. Group I (306 cases) were those in which preoperative antibiotics were used. Mechanica cIeansing was used in both groups, but in group 2 it was stressed and considered to be the most important factor in preoperative preparation of the bowe1. Both groups received postoperative antibiotics. It appears germane in view of the information to foIIow, to mention brieffy the routine pre- and postoperative management of each group. Patients in group I were mechanicaIIy cIeansed in the usua1 fashion. This incIuded various Iow residue or residue free diets in conjunction with cathartics and enemas. The preoperative antibiotics used were suIfonamides, neomycin, tetracycline or a combination, The dosages were the accepted ones commonIy used for antibacteria preparation of the intestine. PostoperativeIy broad spectrum antibiotics were administered parenteraIIy. The antibiotics used, in decreasing order of frequency, were tetracycIine, ChIoro-
SELECTIONOF CASES During a nine year period (rg54-r962) 469 patients requiring coIonic surgery were chosen at random. Since the object was to evaIuate the use of antibiotics, no effort was made to separate the malignant from the benign Iesions. The surgica1 procedures studied were those requiring coIotomy with cIosure, cIosure of colostomy, and coIonic resections in one stage. Many other procedures performed on the coIon were eIiminated as it was beIieved that the preoperative preparation might be too varied to aIIow adequate interpretation. Patients were studied with reference to postoperative morbidity which might be inff uenced by the bowe1 preparation and antibiotic usage. It was presumed that many other factors affecting postoperative complications wouId be essentiaIIy the same in a11cases. The occurrence of postoperative infection alone or in addition to Ieakage at the suture Iine was chosen as a saIient criterion. Postoperative infections were defined as those which resuIted in puruIent exudate in the wound or peritonea1 cavity. It wouId have been of vaIue if a11 of these infections had been cuItured, but some were not. Those that were not occurred mainXy American
Journal
of Surgery,
V&me
107,
June
1964
810
Surgery of Colon
Numhcr of paticsnts \C’ou~ldinfections. Anastomotic leaks. Da,vs of hospitnIiz:~tion. hlortality.
,306 6.9s; 5.2”; I ‘4.3 3.5’;;
Anuria. Ccrebrovascular Acute coronary Pneumonia..
‘163
1 I .8Cb : 2 5 : ;I '
11.8
I 4.9’6
acciclent occIusion.
3
yTotaI. Per cent.
mycctinE Cornbiotic@ or a suIfonamide. Therapy was continued for an average of three days and was usually stopped when oraI feedings were begun. Morbidity seemed IittIe influenced by the drug used. Patients in group 2 were pIaced three days before surgery on a cIear Iiquid diet suppIemcnted with hard candy, jeIIo, skimmed miIk, sherbert, sweetened drinks and the Iike. This diet was decided upon after inspection of severa supposedly residue free diet trays reveaIed nearIy a11 kinds of food with the possibIe exception of corn. At the same time the administration of 8 cc. of Phospho-Soda@ three times a day was started. The dose was increased or decreased to produce two or three loose stooIs daily-. The day before surgery 45 cc. of PhosphoSoda was administered at noon time and the patient was given a cIeansing enema that afternoon to allow a restfu1 night without. bowe1 This program was quite uniformIy urgency. successfuI in obtaining an empty colon at surgery. PostoperativeIy these patients were given an average of 3,000 cc. of intravenous fluid daiIy, spaced at 8 A.M., 2 P.M. and 8 P.M. The,v were ahowed nothing by mouth, and in the aerophagic patients nasogastric suction was employed. Each of the 1,000 cc. units of intravenous tIuid contained 500 mg. of tetracycIine. AIthough this dosage may be judged inadequate for intestina1 preparation, it was beIieved sufficient for the purpose of diminishing postoperative infections if possibIe. The patients were maintained on this regimen unti1 they passed flatus, usuaIIy on the third day. At this time ora feedings were begun and consisted of the same diet as preoperativeIy. If the disease invoIved the Ieft side of the colon, this diet was continued for two to three clays. It was hoped that the period when the suture Iine wouId be most vuInerabIe wouId be passed before any appreciabIe stoo1 couId come
0 1 4 II 3 6
I 2 ‘3
2
8 4.9
in contact with it. This was postuIated on the presumption that the 17 or 18 per cent of norma stoo1 composed of ceIIuIar debris and bacteria wouId not pose a problem, and any stress resuIting thereby wouId be minimal. Gastric suction in aerophagic patients was used to prevent intestina1 distention. “An empty bowe1 wiI1 not Ieak” [22]. RESULTS
There wouId seem to be considerabIe evidence that preoperative antibacteria preparation of the intestine is desirabIe. As one reviews the literature however, it becomes obvious that since the introduction of suIfaniIamide, many antibiotics have appeared onIy to be discarded in favor of the next one to appear. Some evidence exists that preoperative antibacteria preparation of the intestine resuIts in undesirabIe side effects such as Staph. enteritis [7,23-261 and increased presence of maIignant seeding aIong the suture Iine [27]. It is interesting that in the pursuit of an ideal antibiotic for preoperative howe preparation, there have been few reported studies in which no antibiotics were used as a contro1 series. It is aIso diffrcuIt to find any study of sufficient magnitude to be significant. The resuIts of the present study are listed in TabIes I and II. It is recognized that the choice of preoperative antibiotics used in the 306 patients in group I might be different than it was in 1954. It shouId be mentioned however that with the advent of Neomycin aIone or in combination, our postoperative morbidity has changed very sIightIy. It wouId appear that the preoperative antibiotic administration in intestina1 surgery is of doubtfu1 vaIue and may even contribute to increased morbidity
[7,2~-2WW. 811
Grant and Barbara SUMMARY I. Four hundred sixty-nine randomIy chosen cases invoIving colotomy, coIostomy cIosure or coIonic resection in one stage were studied. 2. Patients in group I (306 cases) were mechanicaIIy cIeansed and aIso prepared with preoperative antibiotics. 3. Patients in group 2 (163 cases) were mechanicaIIy cIeansed and treated with postoperative antibiotics onIy. 4. ResuIts in group I were: 6.9 per cent wound infections, 5.6 per cent anastomotic Ieaks, a hospita1 stay of 14.3 days and a mortaIity of 3.6 per cent: 5. ResuIts in group 2 were: 1.8 per cent wound infections, 2.5 per cent anastomotic Ieaks, a hospita1 stay of I 1.8 days and a mortaIity of 4.9 per cent. REFERENCES I. COHN, I. and LONGACRE, A. B. Preoperative sterilization of &on. Comparison of various antibacteria agents. In: Welch, H. and MartiIbanez, F. (ed.) Antibiotics Annual, p. 105. New York. 1056. Medical EncvcIooedia. Inc. 2. DAVIS, ‘J.‘H., KUHN, L. R., SHAFF& J. R. and AMSPACHER, W. H. Preoperative preparation of bowe1 with Neomycin. Surgery, 35: 434, 1954. 3. DEARING, W. H. and HEILMAN, F. R. Effect of anti-bacteria1 agents on intestina1 Aora of patients. Use of Aureomycin, ChIoromycetin, Dihydrostreptomycin, SuIfasuxidine, and SuIfathalidine. Gastroenterology, 16: 12, 1950. 4. DEARING, W. H. and NEEDHAM, G. M. Effect of Terramycin on intestina1 bacteria1 Aora of patients being prepared for intestina1 surgery. Proc. Staff Meet. Mayo Clin., 26: 49. 1951. 5. DEARING, W. H. and NEEDHAM, G. H. Effect of ora administration of Neomycin on intestina1 bacteria1 Rora of man. Proc. Staff Meet. Mavo Clin., 28: 502, 1953. 6. DEARING, W. H. and NEEDHAM, G. H. Effects of oraI use of Neomycin and OxytetracycIine (Terramycin) on intestina1 bacteria1 Aora of man. Proc. Staff Meet. Mayo Clin., 28: 507, 1953. 7. DEARING, W. H. and NEEDHAM, G. M. Effects of ora use of Neomycin pIus Bacitracin on intestinal Aora of man. Proc. Staff Meet. Mayo Clin., 34: 127, 1959. 8. Dr CAPRIO. J. M. and RANTZ, L. A. Effects of Terramycin on the bacteria1 f&a of the bowe1 of man. Arch. Znt. Med., 86: 649, 1950. g. GAYLORD, D. W., CLARKE, J. S., KUDINOFF, Z. and FINEGOLD, S. M. Preoperative bowe1 “steriIization”: a doubIe-bIind studv comoarina Kanamycin, Neomycin, and pIacebo. 1n::AntimicrobiaI Agents AnnuaI, 1960, p. 392. New York, 1961. PIenum Press. IO. LOCKWOOD, J. S. AppraisaI of ora Streptomycin as intestina1 antiseptic, with observations on raoid deveIooment of resistance of E. coIi to Streptomycin. Ann. Surg., 129: 14, 1949.
II.
H. S. and SMITH, D. Preoperative pIace of Streptomycin in operations on bowel. Arch. Surg., 57: 520, 1948. 12. PETTET, R., JR., JUDD, E. S. and DEARING, W. H. A clinica study of patients prepared for intestina1 surgery with Neomycin-OxytetracycIine and with Neomycin. Proc. Staf Meet. Mayo Clin., 30: 371, 1955. 13. PHILLIPS, D. F., DEARING, W. H. and WAUGH, J. H. Comparison of complications folIowing intestinal surgery after oral and parentera preoperative antibiotic preparation. Surg. Gynec. @ Oh., 106: MORTON,
145. 1958. 14. POTH, E. J. The roIe of intestina1 antisepsis in the preoperative preparation of the colon. Surgery, 47: 1018, 1960. 15. POTH, E. J. The practica1 appIication of intestina1 antisepsis to surgery of the coIon and rectum. Dis. Colon @ Rectum., 3: 491. 1960. 16. POTH, E. J. CriticaI analysis of intestina1 antisepsis. J. A. M. A., 163: 1317, 1957. 17. POTH, E. J. Healing of bowe1 as influenced by SuIfasuxidine and Streptomycin. Surg. Gynec. @ Obst., 86: 641, 1948. 18. PULASKI, E. J. Antibiotics in intestina1 antisepsis. In: WeIch, H. and Marti-Ibanez, F. (ed.) Antibiotics Annual. New York, 1956. Medical EncycIopedia, Inc. 19. PULASKI, E. J., CONNELL, J. F. and SEELEY, S. F. Sterilization of intestinal tract by antibiotics and suppIementa1 agents. Ann. Surg., 132: 225, 20.
1950. RIVERA, J. M. and SBOROV, W. M. Effect of Terramycin on intestinal flora. Gastroenterology, 17:
546, 1951. 21. GARLOCK, J. H. and SELEY, G. P. Use of SuIfaniIamide in surgery of coIon and rectum. PreIiminary report. Surgery, 5: 787, rg3g. 22. TYSEN, R. R. and SPAULDING, E. H. ShouId antibiotics be used in Iarge bowe1 preparation? Surg. Gynec. @ Obst., 108: 623, 1959. 23. DEARING. W. H. Micrococcic enteritis and pseudomembranous enterocoIitis as compIications of antibiotic therapy. Ann. New York Acad. SC., 65: 235. 1957. 24. DEARING, W. H. and HEILMAN, F. R. Micrococcic (StaphyIococcic) enteritis as compIication of antibiotic therapy. Its response to Erythromycin. Proc. Staff Meet. Mayo Clin., 28: 121, 1953. 25. DEARING, W. H., HEILMAN, F. R. and SAUER, W. G. Micrococcic (Staphylococcic) enteritis foIIowing the use of Aureomycin or Terramycin. Gastroenterolog.y, 26: 38, 1954. 26. PETTET, R., JL, BA&ENS%S, A. H., DEARING, W. H. and JUDD. E. S. Postoperative pseudomembranous enterocoIitis. Surg. Gynec. & Obst., 98: 546, 1954. 27. POTH, E. J., JACOBSEN, L. W. and DUNLAP, W. ControI of tumor transplantation after primary anastomosis of the coIon. Surgery, 49: 723, 1961. 28. PITTINGER, C. B. and LONG, J. P. NeuromuscuIar bIocking action of Neomycin SuIfate. Antibiotics ti Cbemotber., 8: 198, 1958. 29. PITTINGER, C. B. and LONG, J. P. PotentiaI dangers associated with antibiotic administration during anesthesia and surgery. Arch. Surg., 79: 207, 1959.
From tbe Department of Surgery, Hackensack Hackensack, New Jersey.
Hospital,
at home. The infections cuItured were nearIy equaIIy divided between StaphyIococcus aureus and Escherichia coli. Leakage at the suture Iine was diagnosed when postoperative fecal drainage occurred from the site of cIosure or anastomosis.
of medicine is repIete with of drug discoveries foIIowed by enthusiasm, skepticism and finaIIy disiIIusionment. The object of this paper is to evaIuate preoperative and postoperative antibiotic therapy in surgery of the coIon in a 368 bed community hospita1. There has been abundant investigation of their preoperative use [r-20] since suIfaniIamide was first reported in rg3g [21]. So far, a paucity of information concerning their postoperative use exists. HE
HISTORY
T exampIes
STUDY There seems to be uniform agreement that the preoperative mechanica cIeansing has some importance. On reviewing the Iiterature, however, one is impressed with the varying degrees of importance attached to cIeansing. In some instances it is reIegated to a minor roIe compared with the use of preoperative antibiotics. It has Iong been our beIief that rather than try to sterilize the feces, it is better to eliminate them. The 469 cases were divided into two groups. Group I (306 cases) were those in which preoperative antibiotics were used. Mechanica cIeansing was used in both groups, but in group 2 it was stressed and considered to be the most important factor in preoperative preparation of the bowe1. Both groups received postoperative antibiotics. It appears germane in view of the information to foIIow, to mention brieffy the routine pre- and postoperative management of each group. Patients in group I were mechanicaIIy cIeansed in the usua1 fashion. This incIuded various Iow residue or residue free diets in conjunction with cathartics and enemas. The preoperative antibiotics used were suIfonamides, neomycin, tetracycline or a combination, The dosages were the accepted ones commonIy used for antibacteria preparation of the intestine. PostoperativeIy broad spectrum antibiotics were administered parenteraIIy. The antibiotics used, in decreasing order of frequency, were tetracycIine, ChIoro-
SELECTIONOF CASES During a nine year period (rg54-r962) 469 patients requiring coIonic surgery were chosen at random. Since the object was to evaIuate the use of antibiotics, no effort was made to separate the malignant from the benign Iesions. The surgica1 procedures studied were those requiring coIotomy with cIosure, cIosure of colostomy, and coIonic resections in one stage. Many other procedures performed on the coIon were eIiminated as it was beIieved that the preoperative preparation might be too varied to aIIow adequate interpretation. Patients were studied with reference to postoperative morbidity which might be inff uenced by the bowe1 preparation and antibiotic usage. It was presumed that many other factors affecting postoperative complications wouId be essentiaIIy the same in a11cases. The occurrence of postoperative infection alone or in addition to Ieakage at the suture Iine was chosen as a saIient criterion. Postoperative infections were defined as those which resuIted in puruIent exudate in the wound or peritonea1 cavity. It wouId have been of vaIue if a11 of these infections had been cuItured, but some were not. Those that were not occurred mainXy American
Journal
of Surgery,
V&me
107,
June
1964
810
Surgery of Colon
Numhcr of paticsnts \C’ou~ldinfections. Anastomotic leaks. Da,vs of hospitnIiz:~tion. hlortality.
,306 6.9s; 5.2”; I ‘4.3 3.5’;;
Anuria. Ccrebrovascular Acute coronary Pneumonia..
‘163
1 I .8Cb : 2 5 : ;I '
11.8
I 4.9’6
acciclent occIusion.
3
yTotaI. Per cent.
mycctinE Cornbiotic@ or a suIfonamide. Therapy was continued for an average of three days and was usually stopped when oraI feedings were begun. Morbidity seemed IittIe influenced by the drug used. Patients in group 2 were pIaced three days before surgery on a cIear Iiquid diet suppIemcnted with hard candy, jeIIo, skimmed miIk, sherbert, sweetened drinks and the Iike. This diet was decided upon after inspection of severa supposedly residue free diet trays reveaIed nearIy a11 kinds of food with the possibIe exception of corn. At the same time the administration of 8 cc. of Phospho-Soda@ three times a day was started. The dose was increased or decreased to produce two or three loose stooIs daily-. The day before surgery 45 cc. of PhosphoSoda was administered at noon time and the patient was given a cIeansing enema that afternoon to allow a restfu1 night without. bowe1 This program was quite uniformIy urgency. successfuI in obtaining an empty colon at surgery. PostoperativeIy these patients were given an average of 3,000 cc. of intravenous fluid daiIy, spaced at 8 A.M., 2 P.M. and 8 P.M. The,v were ahowed nothing by mouth, and in the aerophagic patients nasogastric suction was employed. Each of the 1,000 cc. units of intravenous tIuid contained 500 mg. of tetracycIine. AIthough this dosage may be judged inadequate for intestina1 preparation, it was beIieved sufficient for the purpose of diminishing postoperative infections if possibIe. The patients were maintained on this regimen unti1 they passed flatus, usuaIIy on the third day. At this time ora feedings were begun and consisted of the same diet as preoperativeIy. If the disease invoIved the Ieft side of the colon, this diet was continued for two to three clays. It was hoped that the period when the suture Iine wouId be most vuInerabIe wouId be passed before any appreciabIe stoo1 couId come
0 1 4 II 3 6
I 2 ‘3
2
8 4.9
in contact with it. This was postuIated on the presumption that the 17 or 18 per cent of norma stoo1 composed of ceIIuIar debris and bacteria wouId not pose a problem, and any stress resuIting thereby wouId be minimal. Gastric suction in aerophagic patients was used to prevent intestina1 distention. “An empty bowe1 wiI1 not Ieak” [22]. RESULTS
There wouId seem to be considerabIe evidence that preoperative antibacteria preparation of the intestine is desirabIe. As one reviews the literature however, it becomes obvious that since the introduction of suIfaniIamide, many antibiotics have appeared onIy to be discarded in favor of the next one to appear. Some evidence exists that preoperative antibacteria preparation of the intestine resuIts in undesirabIe side effects such as Staph. enteritis [7,23-261 and increased presence of maIignant seeding aIong the suture Iine [27]. It is interesting that in the pursuit of an ideal antibiotic for preoperative howe preparation, there have been few reported studies in which no antibiotics were used as a contro1 series. It is aIso diffrcuIt to find any study of sufficient magnitude to be significant. The resuIts of the present study are listed in TabIes I and II. It is recognized that the choice of preoperative antibiotics used in the 306 patients in group I might be different than it was in 1954. It shouId be mentioned however that with the advent of Neomycin aIone or in combination, our postoperative morbidity has changed very sIightIy. It wouId appear that the preoperative antibiotic administration in intestina1 surgery is of doubtfu1 vaIue and may even contribute to increased morbidity
[7,2~-2WW. 811
Grant and Barbara SUMMARY I. Four hundred sixty-nine randomIy chosen cases invoIving colotomy, coIostomy cIosure or coIonic resection in one stage were studied. 2. Patients in group I (306 cases) were mechanicaIIy cIeansed and aIso prepared with preoperative antibiotics. 3. Patients in group 2 (163 cases) were mechanicaIIy cIeansed and treated with postoperative antibiotics onIy. 4. ResuIts in group I were: 6.9 per cent wound infections, 5.6 per cent anastomotic Ieaks, a hospita1 stay of 14.3 days and a mortaIity of 3.6 per cent: 5. ResuIts in group 2 were: 1.8 per cent wound infections, 2.5 per cent anastomotic Ieaks, a hospita1 stay of I 1.8 days and a mortaIity of 4.9 per cent. REFERENCES I. COHN, I. and LONGACRE, A. B. Preoperative sterilization of &on. Comparison of various antibacteria agents. In: Welch, H. and MartiIbanez, F. (ed.) Antibiotics Annual, p. 105. New York. 1056. Medical EncvcIooedia. Inc. 2. DAVIS, ‘J.‘H., KUHN, L. R., SHAFF& J. R. and AMSPACHER, W. H. Preoperative preparation of bowe1 with Neomycin. Surgery, 35: 434, 1954. 3. DEARING, W. H. and HEILMAN, F. R. Effect of anti-bacteria1 agents on intestina1 Aora of patients. Use of Aureomycin, ChIoromycetin, Dihydrostreptomycin, SuIfasuxidine, and SuIfathalidine. Gastroenterology, 16: 12, 1950. 4. DEARING, W. H. and NEEDHAM, G. M. Effect of Terramycin on intestina1 bacteria1 Aora of patients being prepared for intestina1 surgery. Proc. Staff Meet. Mayo Clin., 26: 49. 1951. 5. DEARING, W. H. and NEEDHAM, G. H. Effect of ora administration of Neomycin on intestina1 bacteria1 Rora of man. Proc. Staff Meet. Mavo Clin., 28: 502, 1953. 6. DEARING, W. H. and NEEDHAM, G. H. Effects of oraI use of Neomycin and OxytetracycIine (Terramycin) on intestina1 bacteria1 Aora of man. Proc. Staff Meet. Mayo Clin., 28: 507, 1953. 7. DEARING, W. H. and NEEDHAM, G. M. Effects of ora use of Neomycin pIus Bacitracin on intestinal Aora of man. Proc. Staff Meet. Mayo Clin., 34: 127, 1959. 8. Dr CAPRIO. J. M. and RANTZ, L. A. Effects of Terramycin on the bacteria1 f&a of the bowe1 of man. Arch. Znt. Med., 86: 649, 1950. g. GAYLORD, D. W., CLARKE, J. S., KUDINOFF, Z. and FINEGOLD, S. M. Preoperative bowe1 “steriIization”: a doubIe-bIind studv comoarina Kanamycin, Neomycin, and pIacebo. 1n::AntimicrobiaI Agents AnnuaI, 1960, p. 392. New York, 1961. PIenum Press. IO. LOCKWOOD, J. S. AppraisaI of ora Streptomycin as intestina1 antiseptic, with observations on raoid deveIooment of resistance of E. coIi to Streptomycin. Ann. Surg., 129: 14, 1949.
II.
H. S. and SMITH, D. Preoperative pIace of Streptomycin in operations on bowel. Arch. Surg., 57: 520, 1948. 12. PETTET, R., JR., JUDD, E. S. and DEARING, W. H. A clinica study of patients prepared for intestina1 surgery with Neomycin-OxytetracycIine and with Neomycin. Proc. Staf Meet. Mayo Clin., 30: 371, 1955. 13. PHILLIPS, D. F., DEARING, W. H. and WAUGH, J. H. Comparison of complications folIowing intestinal surgery after oral and parentera preoperative antibiotic preparation. Surg. Gynec. @ Oh., 106: MORTON,
145. 1958. 14. POTH, E. J. The roIe of intestina1 antisepsis in the preoperative preparation of the colon. Surgery, 47: 1018, 1960. 15. POTH, E. J. The practica1 appIication of intestina1 antisepsis to surgery of the coIon and rectum. Dis. Colon @ Rectum., 3: 491. 1960. 16. POTH, E. J. CriticaI analysis of intestina1 antisepsis. J. A. M. A., 163: 1317, 1957. 17. POTH, E. J. Healing of bowe1 as influenced by SuIfasuxidine and Streptomycin. Surg. Gynec. @ Obst., 86: 641, 1948. 18. PULASKI, E. J. Antibiotics in intestina1 antisepsis. In: WeIch, H. and Marti-Ibanez, F. (ed.) Antibiotics Annual. New York, 1956. Medical EncycIopedia, Inc. 19. PULASKI, E. J., CONNELL, J. F. and SEELEY, S. F. Sterilization of intestinal tract by antibiotics and suppIementa1 agents. Ann. Surg., 132: 225, 20.
1950. RIVERA, J. M. and SBOROV, W. M. Effect of Terramycin on intestinal flora. Gastroenterology, 17:
546, 1951. 21. GARLOCK, J. H. and SELEY, G. P. Use of SuIfaniIamide in surgery of coIon and rectum. PreIiminary report. Surgery, 5: 787, rg3g. 22. TYSEN, R. R. and SPAULDING, E. H. ShouId antibiotics be used in Iarge bowe1 preparation? Surg. Gynec. @ Obst., 108: 623, 1959. 23. DEARING. W. H. Micrococcic enteritis and pseudomembranous enterocoIitis as compIications of antibiotic therapy. Ann. New York Acad. SC., 65: 235. 1957. 24. DEARING, W. H. and HEILMAN, F. R. Micrococcic (StaphyIococcic) enteritis as compIication of antibiotic therapy. Its response to Erythromycin. Proc. Staff Meet. Mayo Clin., 28: 121, 1953. 25. DEARING, W. H., HEILMAN, F. R. and SAUER, W. G. Micrococcic (Staphylococcic) enteritis foIIowing the use of Aureomycin or Terramycin. Gastroenterolog.y, 26: 38, 1954. 26. PETTET, R., JL, BA&ENS%S, A. H., DEARING, W. H. and JUDD. E. S. Postoperative pseudomembranous enterocoIitis. Surg. Gynec. & Obst., 98: 546, 1954. 27. POTH, E. J., JACOBSEN, L. W. and DUNLAP, W. ControI of tumor transplantation after primary anastomosis of the coIon. Surgery, 49: 723, 1961. 28. PITTINGER, C. B. and LONG, J. P. NeuromuscuIar bIocking action of Neomycin SuIfate. Antibiotics ti Cbemotber., 8: 198, 1958. 29. PITTINGER, C. B. and LONG, J. P. PotentiaI dangers associated with antibiotic administration during anesthesia and surgery. Arch. Surg., 79: 207, 1959.