The results of this study indicate that the incidence of postoperative fever was significantly higher in patients who used the first-generation prophylactic antibiotic compared to the third-generation (15.0% vs 2.8%). However, there were no differences in the rates of UTI after surgery, pyelonephritis, and sepsis between the third- and first-generation cephalosporins groups. It is worth noting that significantly lower rates of complications were found in the third-generation cephalosporins group. Additionally, the study findings revealed higher rates of other surgical complications, such as transfusion or hemichorea, in patients who used the first-generation prophylactic cephalosporins. The surgical complication rates in patients undergoing PCNL who used the first-generation prophylactic cephalosporins were significantly higher compared to the third-generation group (31.4% vs 13.0%).
In a previous study conducted by Sung-Jin Bae et al., it was found that there were no differences in postoperative surgical complications between the two groups that used prophylactic third-generation and first-generation cephalosporins. However, they did find that the incidence of surgical site infections was significantly lower in the first-generation prophylaxis group (5.7%) compared to the third-generation prophylaxis group (16.5%). Additionally, they observed that the prevalence of infectious gram-positive bacteria was higher than that of gram-negative bacteria (67% vs 23%) (19).
In a study conducted by Beam et al., it was found that there was a significant difference in the dosage and usage of different third-generation and first-generation cephalosporins. They discovered that a single 1-gram dose of the third-generation cephalosporin ceftriaxone was not only effective and safe, but it also showed higher penetration into the tissue compared to multiple doses of the first-generation cephalosporin cefazolin (20).
In a study by Bratzler et al., it was cautioned that the use of prophylactic antibiotics that are not in line with guidelines may be less effective in reducing infection. Furthermore, the use of antibiotics with excessively broad antimicrobial ranges could potentially lead to the emergence of new multidrug-resistant strains of bacteria. However, Bratzler et al. recommended the use of narrow antibiotic ranges and older antibiotics as a selection for prophylactic antibiotics. This recommendation was based on factors such as cost, half-life, safety, and antibiotic resistance. They advised against the use of newer and broader range antibiotics, as they may contribute to increased tolerance (21).
It is indeed evident that PCNL, a surgical intervention for removing large kidney stones, can be aggressive and may introduce infectious germs to the wound site and inside the body. While the role of gram-positive bacteria like Staphylococcus aureus and Staphylococcus epidermitis in infections cannot be ignored, it appears that multidrug-resistant gram-negative bacteria such as Escherichia coli, Pseudomonas aeruginosa, Klebsiella pneumoniae, Proteus mirabilis, Acinetobacter species, Enterobacter species, and Citrobacter species may play a more significant role in the presentation of postoperative infection. These gram-negative bacteria are known for their resistance to multiple antibiotics, which can complicate treatment and increase the risk of complications (22).
In a current study, it has been found that newer and broader range third-generation cephalosporins have advantages in reducing general surgical complications and fever rates in PCNL surgery. Considering the increasing prevalence of resistant gram-negative bacteria and the antimicrobial characteristics of third-generation cephalosporins like ceftriaxone, it is believed that using third-generation antibiotics in combination with aminoglycosides may have excellent antimicrobial activity and a synergistic effect against gram-negative bacteria as a prophylactic antibiotic. However, it is important to note that some bacteria have intrinsic resistance to first-generation cephalosporins, and this should not be ignored when selecting the appropriate antibiotic.
The duration of postoperative hospitalization was found to be significantly shorter in patients who received the third-generation prophylactic antibiotic compared to those who received the first-generation antibiotic. However, the duration of return to normal life was similar between the two groups. Interestingly, patients who consumed the third-generation antibiotic had a lower duration of return to normal life compared to those who consumed the first-generation antibiotic, and this difference was statistically significant. Additionally, in the third-generation group, the consumption of postoperative analgesics was significantly lower than in the first-generation group. These findings suggest that prophylaxis with third-generation cephalosporins along with aminoglycosides in patients undergoing PCNL may have a positive effect, leading to a decrease in the duration of hospitalization, return to normal life, general complications, postoperative fever, and the consumption of postoperative analgesics.
The results of the current study indicate that administering ceftizoxime along with aminoglycosides as a prophylactic antibiotic 30 minutes prior to surgery can effectively reduce the rates of early postoperative fever, shorten hospitalization length, and expedite the return to normal life for patients undergoing PCNL surgery. This finding is important considering the potential risks associated with indiscriminate antibiotic use and the emergence of antibiotic-resistant bacteria, particularly gram-negative strains, in our population. The simultaneous use of third-generation cephalosporins and aminoglycosides appears to have a positive impact in preventing postoperative fever and facilitating a quicker recovery for patients.
Limitations of the study
This study had several limitations. Firstly, there may have been participants who provided unrealistic answers or refused to provide accurate information about the duration of their return to normal life, which could have affected the results. Secondly, the study was conducted cross-sectionally over a period of 10 years, making it difficult to establish a causal relationship between the use of prophylactic antibiotics and the outcomes observed. Thirdly, the research was conducted in three hospitals in Guilan province, specifically in Rasht city, which limits the generalizability of the findings to the entire population. Lastly, it is important to note that most early postoperative fever is caused by tissue damage and inflammation, while infection-related postoperative fever typically occurs after 4 days. This information should be taken into account when interpreting the results of the study.