Postoperative empirical antibiotic use for uncomplicated perianal abscess and fistula, al kindy c ol

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Postoperative Empirical Antibiotic Use for Uncomplicated Perianal Abscess and Fistula

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Riyadh Mohamad Hasan 1

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De pa rtm e nt of Surge ry, Al-Kindy C olle ge of Me dicine , Unive rsity of Ba ghda d

*C orre sponding a uthor: R iya dh Moha m a d Ha sa n, De pa rtm e nt of Surge ry, Al-Kindy C olle ge of Me dicine , Unive rsity of Ba ghda d, E-m a il: riyadhmoh57@gmail.com.

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Anna ls of C olore cta l R e se a rch. Inpre ss(Inpre ss): e 40795 , DO I: 10.17795/acr-40795 A rticle Type: R e se a rch Article ; Received: Jul 14, 2016; Revised: De c 4, 2016; A ccepted: De c 22, 2016; epub: De c 28, 2016;

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Abstract Background: P e ria na l a bsce sse s re m a in one of the m ost fre que nt surgica l ca se s e ncounte re d by both ge ne ra l a nd colore cta l surge ons. The use of broa d-spe ctrum e m pirica l a ntibiotics for pe ria na l a bsce sse s a fte r dra ina ge a lso re m a ins

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com m on, a lthough with que stiona ble be ne fit.

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Objectives: The a im of the study conducte d wa s to e va lua te the role a nd e ffica cy of intra - a nd post-ope ra tive e m pirica l a ntibiotic com bina tion with a wide a ntiba cte ria l spe ctrum for the tre a tm e nt of pe ria na l a bsce ss a nd fistula -in-a no.

Methods: An obse rva tiona l longitudina l study consiste d of 150 pa tie nts; 50% of the m unde rwe nt incision a nd dra ina ge of the ir pe ria na l a bsce ss. The re st ha d fistula -in-a no a nd we re tre a te d with fistulotom y. P a tie nts we re pre scribe d a course of e m piric a ntibiotics a t the tim e of dia gnosis. The pre scribe d a ntibiotic consiste d of two re gim e s. The m e cha nism of the first re gim e wa s ba se d on inhibiting ba cte ria l ce ll wa ll synthe sis, whe re a s the se cond re gim e include d a ntibiotics inhibiting prote in synthe sis of the ba cte ria . Afte rwa rds, a na lysis of the e ffe ct of postope ra tive use of e m piric a ntibiotics wa s pe rform e d re ga rding sym ptom a sse ssm e nt, re curre nce ra te of a bsce ss, fistula form a tion, ce llulitis, ba cte re m ia a nd se psis.

Results: Am ong 150 pa tie nts include d in the study, 92% we re m a le a nd 8% we re fe m a le . The a ge ra nge wa s 20 to 66 ye a rs (m e a n 39.97 Âą 0.16 ye a rs). Se ve nty-five of the m ha d pe ria na l a bsce ss a nd the re st ha d fistula -in-a no. The y we re pre scribe d a course of e m piric a ntibiotics. P a tie nts who ha d pe ria na l a bsce ss showe d a n a bsce ss re curre nce ra te of 10% a nd 5% a fte r six a nd twe lve m onths re spe ctive ly. P e ria na l fistula form a tion occurre d a t the ra te of 25% a nd 5% a fte r six a nd twe lve m onths re spe ctive ly whe n Lincom ycin tre a tm e nt wa s use d. P a tie nts with pe ria na l fistula tre a te d with both fistulotom y a nd Lincom ycin we re followe d up for six a nd twe lve m onths. Follow-up showe d a n 11.42% ra te of a bsce ss form a tion a fte r six m onths, howe ve r no re curre nce of fistula wa s found.

Conclusions: The re sults of this study conclude d tha t a ntibiotics a dm iniste re d a fte r incision a nd dra ina ge ha d re duce d the ra te of fistula form a tion, a bsce ss re curre nce , ce llulitis a nd se psis. O ur lim ite d pa tie nt sa m pling doe s not provide a de finite conclusion, a lthough it is cle a r tha t fistula form a tion is of clinica l im porta nce in the role of e m piric a ntibiotics in pre ve nting re curre nce a nd m e rits furthe r study.

Keywords: P e ria na l Absce ss; Antibiotic; Em piric; Fistula

1. Background P e ria na l a bsce ss (P A) is the a cute m a nife sta tion of pe ria na l infe ction re quiring im m e dia te surge ry (1, 2). It m a nife sts a s se ve re pa in, te nde rne ss a nd swe lling (3). C ryptogla ndula r infe ctions a re the m a in ca use of pe ria na l a bsce sse s, a s sugge ste d for the first tim e in 1878 by C hia ri (4). This re sults in sta sis, coloniza tion, suppura tion a nd a bsce ss form a tion (5). The principa l m a na ge m e nt is incision a nd a de qua te surgica l dra ina ge (ID) (6). The use of routine intra -ope ra tive swa b for culture s a nd se nsitivity a nd the use of broa d-spe ctrum a ntibiotics for pe ria na l a bsce sse s post-dra ina ge re m a ins com m onpla ce in surgica l pra ctice , a lthough the role of a ntibiotic the ra py a s a n a djuva nt to incision a nd dra ina ge is ye t uncle a r with que stiona ble be ne fit (7). Studie s pe rform e d in 1980 de m onstra te d tha t re sults of pus culture for de te cting the type of ba cte ria wa s e sse ntia l in de te rm ining furthe r a ction (8), in the sa m e wa y tha t the pre se nce of gut orga nism s on a swa b wa s se nsitive in de te cting the pre se nce of a na l fistula (9). In a ddition to tha t, m ost surge ons do not te nd to re vie w swa b culture re sults (10). The routine ly use of a ntibiotics is not sa tisfa ctory a nd doe s not im prove he a ling tim e s in C rohn’s dise a se (11). The ir use should be lim ite d to the tre a tm e nt of pa tie nts with im pa ire d re sista nce to infe ction such a s im m unosuppre ssion, dia be te s a nd e x te nsive ce llulitis (12). R e ga rding a fistula , it is a tiny tra ct with the pre se nce of infla m m a tion a nd infe ction. Its tre a tm e nt is usua lly surgica l. Antibiotics, a ntipyre tics a nd a na lge sics a re provide d (13).

Antibiotics should be re se rve d for pa tie nts pre se nting with syste m ic sym ptom s such a s ce llulitis a nd se psis (14). Anothe r study de m onstra te d tha t ce rta in a ntibiotics (m e tronida zole a nd ciproflox a cin) ha d m e re ly a short-te rm be ne fit in the closure of fistula s (15). Lik e a ny type of tre a tm e nt, tre a tm e nt for a na l fistula s ca rrie s a num be r of risk s such a s infe ction, which re quire s a course of a ntibiotics (16). Brook a nd Ma rtin (1980) (17) ha ve de scribe d the type s of ba cte ria involve d in a bsce ss form a tion a nd found a m ix ture of a e robic a nd a na e robic ba cte ria . Ente ric ba cte ria a re m ore com m on in P As (18).

Lohsiriwa t e t a l., 2010 ( 19) a nd Afsa rla r e t a l., 2011 ( 20) showe d tha t the use of a ntibiotics re duce s the de ve lopm e nt of fistula -in-a no. Anothe r study found tha t 98% of positive swa b culture s ha ve be e n se nsitive to routine e m pirica l a ntibiotics (21).

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This is our k nowle dge a bout the a ntibiotic usa ge so fa r. The a dva nta ge s of broa d-spe ctrum a ntibiotics for tre a ting pe ria na l a bsce sse s a fte r dra ina ge a nd fistula e a fte r fistulotom y a s we ll a s its e ffe ct on m a na ge m e nt a nd outcom e re m a ins unk nown a nd with que stiona ble be ne fit. The re fore , this study wa s pe rform e d to inve stiga te the role a nd e ffica cy of postope ra tive e m pirica l a ntibiotics for the tre a tm e nt of pe ria na l a bsce ss a nd fistula -in-a no a na lyzing outcom e m e a sure s re ga rding re m ission, re curre nce , se psis, ce llulitis a nd ba cte re m ia .

2. Methods An obse rva tiona l longitudina l study consiste d of 150 pa tie nts; 75 of the m unde rwe nt incision a nd dra ina ge of pe ria na l a bsce ss a t Al-Kindy Te a ching hospita l a nd priva te hospita ls in Ba ghda d from Ja nua ry 2012 to De ce m be r 2015. The re st (75 pa tie nts) ha d fistula -in-a no a nd we re tre a te d with fistulotom y. The m a in sym ptom s of the pa tie nts we re pe ria na l pa in e x a ce rba te d by m ove m e nt a nd incre a se d pe ria na l pre ssure from sitting or de fe ca tion, discha rge of pus, fe ve r, m a la ise a nd sle e p pa tte rn disturba nce . The inclusion crite ria we re a dults a ge d e ighte e n ye a rs a nd a bove who pre se nte d with a first a tta ck of pe ria na l a bsce ss (supe rficia l ischiore cta l), a bse nce of ide ntifia ble fistula for a dura tion of 2 to 3 da ys or a na l fistula tha t is a ctive ly dra ining for a t le a st one m onth a nd a ne ga tive pa st history for pre vious he a le d a na l fistula or pe ria na l sk in rupture or infe ction. The e x clusion crite ria include d pa tie nts younge r tha n e ighte e n ye a rs, com ple x fistula , ne crotizing fa sciitis, tube rculosis, C rohn’s dise a se , im m unosuppre ssion, m a ligna ncy a nd pyode rm a l sk in infe ctions.

2.1. Ethics Statement The scie ntific a nd e thica l com m itte e of Al-k indy m e dica l colle ge -Ba ghda d unive rsity, Al- Kindy te a ching hospita l a nd priva te hospita ls ha d a pprove d this study. W ritte n inform e d conse nt wa s obta ine d from a ll pa tie nts.

P a tie nts we re a sse sse d by a se nior surge on who a lso pe rform e d the ope ra tion, e ithe r unde r ge ne ra l or loca l a ne sthe sia .

The pa tie nts unde rwe nt a ge ne ra l clinica l physica l e x a m ina tion in the lithotom y or prone ja ck k nife position in orde r to inspe ct the e x te nt of the a bsce ss, to e va lua te its indura tion a nd the pre se nce of a ny pre vious sca r tissue a nd e x te rna l or inte rna l fistula . The n, the pe ria na l sk in wa s disinfe cte d with a lcohol solution followe d by the a pplica tion of 10% povidone onto the sk in. Afte rwa rds, a crucia te incision ove r the a bsce ss wa s m a de a nd dra ina ge wa s ca rrie d out. All ne crotic tissue s we re de bride d a nd a ll se pta tions we re brok e n down pa ying a tte ntion to not injure the sphincte r of the a nus. A dra in wa s a pplie d for dra ina ge of the pus a nd to pre ve nt pre m a ture closure of the a bsce ss ca vity. La stly, a prote ctive dre ssing wa s a pplie d to a bsorb a ny purule nt discha rge from the a bsce ss ca vity a nd to prote ct the ope n wound. P a tie nts we re pre scribe d a course of e m piric a ntibiotics a t the tim e of dia gnosis. P a tie nts we re discha rge d from hospita l ba se d on the surge on’s de cision, re ce ive d a dvice for da ily dre ssing a nd we re followe d up in the outpa tie nt surgica l clinic e ve ry two we e k s postope ra tive ly. P a tie nts we re a dvise d to continue ? the ir a ctivitie s a fte r the surge ry.

P a tie nts with inte rsphincte ric fistula we re tre a te d with fistulotom y. The pre pa ra tion of the pa tie nts wa s the sa m e a s a bove .

Unde r a ne sthe sia , the e ntire fistula tra ck wa s de fine d from the inte rna l to e x te rna l ope ning with ide ntifica tion a nd oblite ra tion of the tra ck s by probing it. The fistula wa s la id ope n by cutting out the whole tra ct a fte r which a ll infe cte d tissue wa s cure tte d. The fistula tunne l wa s ope ne d a nd conve rte d to a groove , which a llows the fistula to he a l from the inside out.

The re sulting wound is ge ne ra lly not close d a nd is pa ck e d, a fte r which the wound he a ls by itse lf. Sa m e a s a bove , pa tie nts we re discha rge d from hospita l ba se d on the surge on’s de cision, re ce ive d a dvice for da ily dre ssing a nd we re followe d up in the outpa tie nt surgica l clinic e ve ry two we e k s postope ra tive ly.

The pre scribe d a ntibiotics we re se le cte d tha t cove r G+ a nd G-ba cte ria , divide d into two re gim e s a ccording to the ir m e cha nism s of a ction:

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1- Those inhibiting ba cte ria l ce ll wa ll synthe sis: P e nicillin; Am piclox (Am picillin 250 m g a nd C lox a cillin 250 m g) ca psule four tim e s a da y ora lly (Aja nta P ha rm a Lim ite d-India ) a nd Augm e ntin (Am ox icillin 875 m g a nd C la vula na te 125 m g) ta ble t thrice da ily ora lly (Sm ithk line Be e cha m P LC -UK) + Me tronida zole (Fla gyl) (500 m g thrice da ily) ora lly (Sa nofi-Fra nce ). The othe r a ntibiotic use d is a C e pha losporin which wa s of the fourth ge ne ra tion C e pha losporin (C e fe pim e , one gra m twice da ily) by slow intra ve nous infusion (Bristol-Mye rs Squibb- USA) or a third ge ne ra tion C e pha losporin (C e ftria x one , one gra m twice da ily intra ve nously (R oche -Switze rla nd) or C e fix im e 400 m g ca psule once da ily) ora lly (Me dico La bs-Hom s-Syria ) or first ge ne ra tion C e pha losporin (C e pha le x in 500 m g ca psule four tim e s a da y) (Gla x o W e llcom e - UK) ora lly with m e tronida zole (500 m g thrice da ily) (Sa nofi-Fra nce ) ora lly for se ve n da ys.

2- Antibiotics which inhibit prote in synthe sis of the ba cte ria include Lincocin 600 m g twice da ily ora lly (Upjohn- Unite d Sta te s). O the r a ntibiotics use d we re Ge nta m icin 80 m g twice da ily intra m uscula rly (R ousse l- Fra nce ) + m e tronida zole (500 m g thrice da ily) (Sa nofi-Fra nce ) ora lly. C linda m ycin HC L 150 m g (two ca psule s four tim e s da ily) (Ta j pha rm a ce utica ls India ) ora lly for se ve n da ys.

Ana lysis of the e ffe ct of postope ra tive use of e m piric a ntibiotics a fte r 6 a nd 12 m onths wa s pe rform e d by the sa m e se nior surge on a nd consiste d of obse rva tion of the re curre nce ra te of a bsce ss, a sse ssing ra te of fistula form a tion by clinica l e x a m ina tion, MR I a nd ultra sound, ce llulitis, com plica tions from a ntibiotic use , for e x a m ple , dia rrhe a a ssocia te d C. difficile colitis, a lle rgy a nd re sista nce to a ntibiotics, ba cte re m ia a nd se psis a fte r ID of pe ria na l a bsce ss a nd fistulotom y. The se fa ctors we re use d to a sse ss the be ne fits of using e m piric a ntibiotics postope ra tive ly in re ducing the re curre nce ra te of a bsce ss a nd fistula form a tion. The lim ita tions, howe ve r, a re the sm a ll sa m ple size a nd the follow-up of the pa tie nts.

2.2. Statistical Analysis Da ta wa s sta tistica lly a na lyze d using: De scriptive sta tistics: fre que ncie s for ta ble s, pe rce nta ge s, m e a n a nd sta nda rd de via tion. C a lcula tions we re pe rform e d using MiniTa b sta tistica l softwa re progra m 13.20.

3. Results Am ong 150 pa tie nts include d in the study, 92% we re m a le a nd 8% we re fe m a le . The a ge ra nge wa s 20 to 66 ye a rs (m e a n 39.97 ± 0.16). P a tie nts we re e x pe rie ncing a na l pa in, swe lling a nd te nde rne ss since 4 to 10 da ys (6.93 ± 0.23). Ha lf of the m ha d pe ria na l a bsce ss a nd the othe r ha lf ha d fistula -in-a no a s shown in Table 1. The pa tie nts with dia be te s m e llitus, whe the r on die t or ora l hypoglyce m ic drugs, form e d 9.33% of the tota l group (14/150).

Table 1.

P a tie nts’ De m ogra phic Da ta

Six ty-one (81.33%) pa tie nts with pe ria na l a bsce ss we re pre scribe d a course of e m piric a ntibiotics a t tim e of dia gnosis a nd se ve n da ys postope ra tive on discha rge . The pre scribe d a ntibiotic re gim e to pa tie nts with pe ria na l a bsce ss wa s re gim e 2

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consisting of the inhibition of prote in synthe sis of the ba cte ria ; this group re pre se nte d 52% (No. = 39). P a tie nts tre a te d with Lincom ycin 600 m g re pre se nte d 26.66% (No. = 20) followe d by Ga ra m ycin 80 m g + m e tronida zole (500 m g) (13.33%) a nd C linda m ycin 150m g (12.00%). The othe r re gim e of a ntibiotic tre a tm e nt (re gim e 1) pla ye d a role in inhibiting ba cte ria l ce ll wa ll synthe sis a nd include s pe nicillin (24%) a nd ce pha losporins (24%). The type of P e nicillin use d wa s Am piclox (Am picillin 250 m g a nd C lox a cillin 250 m g) + m e tronida zole (500 m g), constituting 12% followe d by Augm e ntin (Am ox icillin 875 m g a nd C la vula na te 125 m g) + m e tronida zole (500 m g) (12%). R e ga rding ce pha losporins, the C e ftria x one , one gra m ) + m e tronida zole (500 m g) is use d (8%) the n C e fe pim e (one gra m )+ m e tronida zole (500 m g), C e fix im e 500 m g ca psule ) + m e tronida zole (500 m g) a nd C e pha le x in 500 m g)+ m e tronida zole (500 m g) tha t re pre se nts (5.33%) a s shown in Table 2.

Table 2.

R e gim e s of Em piric Antibiotic Tre a tm e nt of P a tie nts with P e ria na l Absce ss According to The ir Me cha nism s of Action

Table 3 de m onstra te s the pa tie nts with fistula -in-a no (50%) who we re tre a te d with e m piric a ntibiotics tha t inhibit prote in synthe sis of the ba cte ria (52%). Lincom ycin 600 m g wa s use d in tre a tm e nt constitute s (46.66%) followe d by C linda m ycin 150 m g (5.33%). The othe r re gim e use d wa s a ntibiotics which inhibit the ce ll wa ll synthe sis (24%) a nd include s P e nicillin a nd ce pha losporins.

Table 3.

R e gim e s of Em piric Antibiotic Tre a tm e nt of P a tie nts with Fistula -In-Ano Me cha nism s of Action

According to

The ir

The se pa tie nts we re followe d up for a pe riod of six to twe lve m onths a s shown in Table 1. The outcom e m e a sure s of this e m piric a ntibiotic tre a tm e nt a re shown in Table 4. About 26.66% of the pa tie nts with pe ria na l a bsce ss who we re tre a te d with Lincom ycin ha d a re curre nce of the a bsce ss a t a ra te of 10% a nd 5% a fte r six a nd twe lve m onths re spe ctive ly.

De ve lopm e nt of fistula during the follow-up of pe ria na l a bsce ss postope ra tive ly wa s 25% a nd 5% a fte r six a nd twe lve m onths re spe ctive ly. O the r re gim e s of e m piric a ntibiotics a re shown in Table 4. About 10% of the pa tie nts de ve lope d dia rrhe a following the use of Lincom ycin a nd C linda m ycin, which wa s proba bly due to pse udom e m bra nous colitis a nd it stoppe d shortly a fte r ce ssa tion of a ntibiotic a dm inistra tion a nd wa s furthe r not of clinica l significa nce .

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Table 4.

O utcom e Me a sure s of Diffe re nt P ostope ra tive Em piric Antibiotic R e gim e s Use d in the Tre a tm e nt of P a tie nts with P e ria na l Absce ss

O ut of the pa tie nts with pe ria na l fistula , 46.66% of the m we re a lso tre a te d with the e m piric re gim e of Lincom ycin. Follow-up for six a nd twe lve m onths did not show a ny fistula re curre nce but did show a pe rce nta ge of 11.42% of a bsce ss form a tion occurring a fte r six m onths, a s de m onstra te d in Table 5. The only com plica tion due to a ntibiotic use wa s dia rrhe a . About 5.71% of the pa tie nts de ve lope d dia rrhe a following use of Lincom ycin a nd C linda m ycin, which wa s proba bly ca use d by pse udom e m bra nous colitis due to Clostridium difficile. The dia rrhe a stoppe d shortly a fte r ce ssa tion of the a ntibiotics a nd wa s furthe r not of clinica l significa nce .

Table 5.

O utcom e Me a sure s of Diffe re nt P ostope ra tive Em piric Antibiotic R e gim e s Use d for Tre a ting P a tie nts with Fistula -In-Ano

O the r pa tie nts we re tre a te d with othe r re gim e s of a ntibiotics. None of the pa tie nts, ne ithe r with pe ria na l a bsce ss nor fistula -in-a no, de ve lope d ce llulitis, se psis or ba cte re m ia . Thus, the se re sults de m onstra te tha t e m pirica l a ntibiotic use le a ds to the pre ve ntion a nd de cre a se of re curre nce of pe ria na l a bsce ss a nd fistula form a tion.

4. Discussion Anore cta l a bsce ss is a pote ntia lly de bilita ting a nd de va sta ting condition tha t m a y re sult in conside ra ble discom fort a nd fe ve r. Ex te nsive re se a rch in the fie ld of pe ria na l tre a tm e nt a nd a ntibiotic usa ge ha s be e n inve stiga te d. The re is howe ve r, a controve rsy; one study re porte d tha t routine swa b culture s a re unne ce ssa ry a nd do not a ffe ct tre a tm e nt or outcom e a nd tha t the use of postope ra tive e m piric a ntibiotics m a y re duce the ra te s of re curre nce of a bsce sse s a nd fistula e (21). O the rs ha ve shown tha t a ntibiotics a re not e ffe ctive in the tre a tm e nt a nd pre ve ntion of a bsce sse s or fistula e . W e a gre e tha t a ntibiotics a re not e ffe ctive in the tre a tm e nt a nd pre ve ntion of a bsce sse s, including pe ria na l a bsce sse s, a s a whole , but we a re howe ve r inve stiga ting the role of e m piric a ntibiotics in re curre nce of a bsce ss a fte r incision a nd dra ina ge . Ma na ge m e nt of pe ria na l dise a se s ha s be e n m e ntione d in the guide line s of the Am e rica n socie ty of colon a nd re cta l surge ons (ASC R S) in 2011 (22) which re porte d tha t a pe ria na l a bsce ss should be tre a te d by incision a nd dra ina ge a nd tha t a ntibiotics ha ve a lim ite d role in the tre a tm e nt of uncom plica te d a nore cta l a bsce ss a nd m a y be conside re d in pa tie nts with significa nt ce llulitis, unde rlying im m unosuppre ssion or concom ita nt syste m ic illne ss. In our study, e m piric Lincom ycin use d in pa tie nts with pe ria na l a bsce ss (26.66%), showe d a n a bsce ss re curre nce ra te of 10% a nd 5% a fte r six a nd twe lve m onths re spe ctive ly while fistula form a tion a fte r six a nd twe lve m onths wa s 25% a nd 5% re spe ctive ly. De spite the sm a ll sa m ple

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size , othe r re gim e s of e m piric a ntibiotics showe d a highe r re curre nce ra te a nd fistula form a tion. The othe r group consiste d of pa tie nts with fistula -in-a no a nd a bout 46.66% of the m we re tre a te d with the e m piric re gim e of Lincom ycin. Follow-up for the de te ction of com plica tions during six a nd twe lve m onths showe d no fistula re curre nce but did displa y a bsce ss form a tion in 11.42% of the pa tie nts a fte r six m onths. Thus, we a gre e with the principle s outline d by the ASC R S, sugge sting tha t incision a nd dra ina ge is still the m a insta y of tre a tm e nt. In a ddition, our re sults support the fa ct tha t a dm iniste ring pre ope ra tive e m piric a ntibiotics de cre a se s the re sulting fistula a nd num be r of re curre nce s re sulting from incision a nd dra ina ge of the pe ria na l a bsce ss. He nce is it to sa y tha t e m pirica l a ntibiotic usa ge pre ve nts fistula form a tion a nd the prognosis of a na l fistula (23). Fistula form a tion is worrisom e for both the pa tie nt a nd the surge on a nd the re quire m e nt for re pe a te d surgica l inte rve ntion m a y prolong the pa tie nt’s hospita l sta y a nd incre a se the costs. Va rious studie s ha ve de m onstra te d tha t the re curre nce of a nore cta l a bsce sse s a nd fre que ncy of a na l fistula de ve lopm e nt ra nge be twe e n 25% a nd 50% (24), which is highe r tha n found in our study. This m a y be due to the type of a ntibiotic use d postope ra tive ly, dura tion of tre a tm e nt, sa m ple size , sa m ple pa tie nts’ crite ria a nd se le ction. It ha s be e n found tha t pa tie nts’ crite ria a re im porta nt; pa tie nts with ne utrophil counts le ss tha n 500 - 1000/m m 3 a nd/or la ck of fluctua nce on e x a m ina tion ha ve be e n succe ssfully tre a te d with a ntibiotics a lone in 30% to 88% (25) while this wa s found to be 50% in pa tie nts with pe ria na l a bsce ss a nd 50% in pa tie nts with fistula in our study. The ca use of re curre nce could be e x pla ine d due to te chnica l re a sons such a s ina de qua te dra ina ge a nd a n unnotice d a bsce ss (26). A study by Ak k a pulu e t a l. in 2015 showe d tha t a ge , se x , type s of a bsce ss, pre se nce of fistula or dra in usa ge we re not a ssocia te d with re curre nce (27). The Am e rica n He a rt Associa tion re com m e nds pre ope ra tive usa ge of a ntibiotics be fore a ny ope ra tion in pa tie nts with prosthe tic va lve s, pre vious ba cte ria l e ndoca rditis, conge nita l he a rt dise a se a nd he a rt tra nspla nt re cipie nts (28).

P ostope ra tive a ntibiotic use is im porta nt be ca use of the e m e rge nce of com m unity-a cquire d m e thicillin re sista nt Staphylococcus aureus in a nore cta l a bsce sse s (29). In our study, Lincom ycin use d in the tre a tm e nt for a bsce ss a nd fistula postope ra tive ly a s e m piric a ntibiotic re sulte d in le ss re curre nce of a bsce ss or fistula de ve lopm e nt. This a lso pre ve nts or tre a ts ba cte re m ia , ce llulitis a nd se psis. Anothe r re gim e use d a ntibiotics which inhibit ba cte ria l ce ll wa ll synthe sis lik e C e ftria x one a nd C e fe pim e . C he ng a nd Tsa i, 2010 ( 23) showe d tha t the m ost com m on a e robic ba cte ria we re E.coli a nd a na e robic ba cte ria we re B. fragilis. E.coli we re se nsitive to a m ox icillin-cla vula m ic a cid (84.6%), ce fa zolin (84.6%), ciproflox a cin (69.2%). For a na e robic ba cte ria (Bacteroides spe cie s a nd Clostridium perfringens), the a ntibiotic se nsitivity ra te s we re de te rm ine d to be 100% for m e tronida zole . The y found tha t fistula de ve lopm e nt a t the 12-m onth follow-up we re 11.42% a nd 0% in pa tie nts who ha d m ix e d flora a nd a pure a e robic infe ction. Thus, this study is in a gre e m e nt with our study re ga rding e m pirica l use of a ntibiotics a nd tha t the first choice of ora l a ntibiotics for the tre a tm e nt of pe ria na l a bsce ss should be m e tronida zole com bine d with a ce pha losporin. O m m e r e t a l., 2012 ( 30) showe d tha t a ntibiotics should be use d in the pre se nce of im m unosuppre ssion. A ra ndom ize d, controlle d, m ulti-ce nte r clinica l tria l study showe d tha t the use of a ntibiotics could not pre ve nt the de ve lopm e nt of fistula s a fte r ID of P A (31). The re fore , a ntibiotics should be com bine d with surgica l m e a sure s. Asse ssm e nt of pe ria na l a bsce ss a nd fistula wa s done by dyna m ic-contra st e nha nce d MR I, which is the m ost im porta nt a dva nta ge of this te chnique (32) a nd the DW MR I, which is a use ful te chnique for e va lua ting a ctivity of fistula s with a bsce ss. R e ga rding pe ria na l fistula , visibility is gre a te r with com bine d T2W I a nd DW MR I tha n T2W I a lone (33).

5.1. Conclusions The re sults of this study conclude tha t a ntibiotics a dm iniste re d a fte r incision a nd dra ina ge re duce the ra te of fistula form a tion, a bsce ss re curre nce , ce llulitis, se psis a nd ba cte re m ia without a ny side e ffe cts of the drugs such a s a ntibiotic re sista nce a nd dia rrhe a . In this study, a dm inistra tion of the e m piric a ntibiotics wa s we ll tole ra te d a nd ha s shown a good re sponse . Thus, in the role of e m piric a ntibiotics in pre ve nting re curre nce , fistula form a tion is of clinica l im porta nce .

Footnotes Conflicts of Interest: The re is no conflict of inte re st.

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Funding/Support: The re is no funding for this re se a rch.

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