Does a patient with leukocytosis (white count of 20) and a high-grade bowel obstruction, with a nasogastric (NG) tube in place, require antibiotic administration?

From the Guidelines

Guidelines recommend antibiotic prophylaxis for patients with colorectal carcinoma obstruction, even in the absence of systemic signs of infection, due to the potential for bacterial translocation. The patient's elevated white count of 20 may be a stress response to the obstruction rather than an indication of infection. However, the presence of a high-grade bowel obstruction on CT and the potential for bacterial translocation justify the use of antibiotic prophylaxis, as stated in the 2017 WSES guidelines on colon and rectal cancer emergencies 1. The guidelines suggest targeting Gram-negative bacilli and anaerobic bacteria, which is consistent with the concept of bacterial translocation as a possible event in patients with intestinal obstruction.

The use of antibiotic prophylaxis in this context is supported by high-quality evidence from a Cochrane review published in 2014, which found that prophylaxis with antibiotics covering aerobic and anaerobic bacteria prior to elective colorectal surgery reduces the risk of surgical wound infection 1. Although the patient's condition is not elective surgery, the principle of preventing surgical site infections and reducing the risk of sepsis applies.

Key points to consider in this case include:

• The patient's elevated white count may be a stress response to the obstruction rather than an indication of infection
• The presence of a high-grade bowel obstruction on CT increases the risk of bacterial translocation
• Antibiotic prophylaxis is recommended to target Gram-negative bacilli and anaerobic bacteria
• The primary treatment is bowel decompression via the NG tube, fluid resuscitation, and addressing the underlying cause of obstruction
• Antibiotics would be indicated if the patient develops fever, peritonitis, signs of sepsis, or if imaging shows pneumoperitoneum or bowel ischemia.

From the Research

Administration of Antibiotics in High-Grade Bowel Obstruction

• The patient's condition, with a white count of 20 and a high-grade bowel obstruction on CT, suggests a potential risk for bacterial translocation and subsequent sepsis 2, 3.
• Studies have shown that intestinal obstruction, including high-grade bowel obstruction, can lead to bacterial translocation from the gut lumen to normally sterile tissues and organs 4, 5, 2, 3.
• The presence of bacterial translocation has been associated with an increased risk of postoperative septic complications 2.
• Although the provided studies do not directly address the administration of antibiotics in this specific scenario, the evidence suggests that bacterial translocation is a significant concern in patients with intestinal obstruction.
• The decision to administer antibiotics should be based on the patient's individual risk factors, clinical presentation, and the presence of signs of infection or sepsis 5.
• Guidelines may recommend the administration of antibiotics in certain cases of bowel obstruction, particularly if there is a high risk of bacterial translocation and subsequent sepsis 2, 3.