Is the elimination of postoperative antimicrobial prophylaxis in thoracic surgery ready for prime time?: Comment on "Postoperative antibacterial prophylaxis for the prevention of infectious complications associated with tube thoracostomy in patients undergoing elective general thoracic surgery".

M any retrospective series conclude with the admonition that the findings should be corroborated by a well-designed, randomized clinical trial. With regard to the use of antibiotics following thoracic surgery, that study is now available. Oxman and colleagues provide us with a well-conducted, randomized study suggesting that routinely extending antimicrobial prophylaxis into the postoperative period is of no value in preventing infectious complications following thoracic surgery involving tube thoracostomy. Contemporary perioperative guidelines reflect the growing awareness that, for many operations, exposure to antibiotics postoperatively may be ineffective and increases the risk of adverse events. Procedures involving drainage of sterile body cavities such as the pleural space, however, appear to be qualitatively different. The idea of allowing foreign materials to communicate with the outside world unprotected by systemic antibiotics, particularly in the early postoperative period, provokes at least some anxiety among surgeons. These findings may reduce this anxiety and arguably expose the false solace of postoperative prophylaxis, at least in routine, elective cases involving chest tubes. Although the results are compelling, it is important to note that their study, conducted at a single institution, may not reflect real-world processes of care where preoperative prophylaxis is not consistently timely and antibiotic choice is not always appropriate, especially in areas of the world not exposed to value-based payment strategies such as the Surgical Care Improvement Project in the United States. In addition, the reader will take note of the short median time to chest tube removal and the short median length of hospital stay in comparison with those in published data from large data sets. Perhaps it is meticulous aerostasis during surgery and prompt chest tube removal that make postoperative antimicrobial prophylaxis irrelevant. If so, the findings in this study by Oxman and colleagues may not be immediately generalizable as long as real-world measures continue to fall short of those best practices exemplified by their study.