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The British Journal of Oral &... Jul 2021Surgical site infections are a complication of oral and maxillofacial procedures, with the potential for significant morbidity and mortality. Use of preoperative,... (Review)
Review
Surgical site infections are a complication of oral and maxillofacial procedures, with the potential for significant morbidity and mortality. Use of preoperative, perioperative, and postoperative antibiotic prophylaxis to reduce the incidence of surgical site infections must be balanced with considerations of a patients' risk of antibiotic-related adverse events. This review aimed to provide evidence-based recommendations for antibiotic prophylaxis. Searches were conducted using MEDLINE, the Cochrane Library, EMBASE, and PUBMED for maxillofacial procedures including: treatment of dental abscesses, extractions, implants, trauma, temporomandibular joints, orthognathics, malignant and benign tumour removal, and bone grafting, limited to articles published since 2000. A total of 98 out of 280 retrieved papers were included in the final analysis. Systematic reviews were assessed using AMSTAR criteria. Randomised controlled trials were assessed for bias using Cochrane Collaborative tools. The overall quality of evidence was assessed using GRADE. Prophylactic antibiotic use is recommended in surgical extractions of third molars, comminuted mandibular fractures, temporomandibular joint replacements, clean-contaminated tumour removal, and complex implants. Prophylactic antibiotic use is not routinely recommended in fractures of the upper or midface facial thirds. Further research is required to provide recommendations in orthognathic, cleft lip, palate, temporomandibular joint surgery, and maxillofacial surgical procedures in medically-compromised patients.
Topics: Anti-Bacterial Agents; Antibiotic Prophylaxis; Humans; Molar, Third; Surgery, Oral; Surgical Wound Infection
PubMed: 34016464
DOI: 10.1016/j.bjoms.2020.09.020 -
International Journal of Nursing Studies Feb 2020The increasing numbers of surgeries involving high risk, multi-morbid patients, coupled with inconsistencies in the practice of perioperative surgical wound care,... (Meta-Analysis)
Meta-Analysis
BACKGROUND
The increasing numbers of surgeries involving high risk, multi-morbid patients, coupled with inconsistencies in the practice of perioperative surgical wound care, increases patients' risk of surgical site infection and other wound complications.
OBJECTIVES
To synthesise and evaluate the recommendations for nursing practice and research from published systematic reviews in the Cochrane Library on nurse-led preoperative prophylaxis and postoperative surgical wound care interventions used or initiated by nurses.
DESIGN
Meta-review, guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.
DATA SOURCES
The Cochrane Library database.
REVIEW METHODS
All Cochrane Systematic Reviews were eligible. Two reviewers independently selected the reviews and extracted data. One reviewer appraised the methodological quality of the included reviews using A MeaSurement Tool to Assess Systematic Reviews 2 checklist. A second reviewer independently verified these appraisals. The review protocol was registered with the Prospective Register of Systematic Reviews.
RESULTS
Twenty-two Cochrane reviews met the inclusion criteria. Of these, 11 reviews focused on preoperative interventions to prevent infection, while 12 focused on postoperative interventions (one review assessed both pre-postoperative interventions). Across all reviews, 14 (63.6%) made at least one recommendation to undertake a specific practice, while two reviews (9.1%) made at least one specific recommendation not to undertake a practice. In relation to recommendations for further research, insufficient sample size was the most predominant methodological issue (12/22) identified across reviews.
CONCLUSIONS
The limited number of recommendations for pre-and-postoperative interventions reflects the paucity of high-quality evidence, suggesting a need for rigorous trials to address these evidence gaps in fundamentals of nursing care.
Topics: Humans; Postoperative Care; Preoperative Care; Surgical Wound; Surgical Wound Infection
PubMed: 31810020
DOI: 10.1016/j.ijnurstu.2019.103486 -
Indian Journal of Medical Microbiology 2021Morganella morganii is a Gram-negative, rod-shaped, facultative anaerobic bacillus divided into two subspecies, morganii and sibonii. Previously classified as Proteus... (Review)
Review
BACKGROUND
Morganella morganii is a Gram-negative, rod-shaped, facultative anaerobic bacillus divided into two subspecies, morganii and sibonii. Previously classified as Proteus morganii, it belongs to human gut commensal microbiota. Nevertheless, on rare occasions, especially in nosocomial and postoperative environment as well as in patients with the impaired immune system and young children, it may cause potentially fatal systemic infection.
OBJECTIVES
The aim of our systematic review was to determine whether and what invasive infections in humans were caused by Morganella morganii and to estimate outcomes of administered antibiotic management.
DATA SOURCES
This systematic review was registered at the PROSPERO database of systematic reviews and meta-analyses before initiation of the research (registration number CRD42020171919). Study eligibility criteria and participants. patients of any age and both sex harbouring Morganella morganii as the only microorganism in bodily fluids or tissues, from where it was isolated and identified by one or more of the following diagnostic methods: conventional techniques including colony morphology, Vitek 2, API or BD Phoenix biochemical systems, as well as more sophisticated methods, such as Matrix-assisted laser desorption ionization-time-of-flight mass spectrometry (MALDI-TOF MS) and species-specific PCR for M. morganii.
METHODS AND INTERVENTIONS
We have systematically searched MEDLINE, EBSCO, SCOPUS, SCINDEX and GOOGLE SCHOLAR for case reports and case series with M. morganii invasive infections.
RESULTS
M. morganii can cause serious infections of different tissue in patients of any age. The most isolates were susceptible to ceftazidime, imipenem and amikacin. Majority of the patients completely recovered after antibiotic treatment. About 15% of the patients died despite of the therapy. Gentamicin was the most frequently used antibiotic in the treatment of infection caused by M. morganii.
CONCLUSION
M. morganii invasive infections should be taken into consideration by the clinicians, especially in hospital conditions, due to its high degree of mortality and high potential of this bacterium to develop multidrug resistance. Treatment of M. morganii infections should include gentamycin in combination with third generation cephalosporin or another antibiotic to which M. morganii is susceptible (after testing isolates for third cephalosporin generation for the production of AmpC β -lactamases).
Topics: Anti-Bacterial Agents; Cephalosporins; Enterobacteriaceae Infections; Humans; Morganella morganii
PubMed: 34193353
DOI: 10.1016/j.ijmmb.2021.06.005 -
The Cochrane Database of Systematic... Feb 2021The most frequent indications for tooth extractions, generally performed by general dental practitioners, are dental caries and periodontal infections. Systemic... (Meta-Analysis)
Meta-Analysis
BACKGROUND
The most frequent indications for tooth extractions, generally performed by general dental practitioners, are dental caries and periodontal infections. Systemic antibiotics may be prescribed to patients undergoing extractions to prevent complications due to infection. This is an update of a review first published in 2012.
OBJECTIVES
To determine the effect of systemic antibiotic prophylaxis on the prevention of infectious complications following tooth extractions.
SEARCH METHODS
Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health Trials Register (to 16 April 2020), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2020, Issue 3), MEDLINE Ovid (1946 to 16 April 2020), Embase Ovid (1980 to 16 April 2020), and LILACS (1982 to 16 April 2020). The US National Institutes of Health Trials Registry (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases.
SELECTION CRITERIA
We included randomised, double-blind, placebo-controlled trials of systemic antibiotic prophylaxis in patients undergoing tooth extraction(s) for any indication.
DATA COLLECTION AND ANALYSIS
At least two review authors independently performed data extraction and 'Risk of bias' assessment for the included studies. We contacted trial authors for further details where these were unclear. For dichotomous outcomes, we calculated risk ratios (RR) and 95% confidence intervals (CI) using random-effects models. For continuous outcomes, we used mean differences (MD) with 95% CI using random-effects models. We examined potential sources of heterogeneity. We assessed the certainty of the body of evidence for key outcomes as high, moderate, low, or very low, using the GRADE approach.
MAIN RESULTS
We included 23 trials that randomised approximately 3206 participants (2583 analysed) to prophylactic antibiotics or placebo. Although general dentists perform dental extractions because of severe dental caries or periodontal infection, only one of the trials evaluated the role of antibiotic prophylaxis in groups of patients affected by those clinical conditions. We assessed 16 trials as being at high risk of bias, three at low risk, and four as unclear. Compared to placebo, antibiotics may reduce the risk of postsurgical infectious complications in patients undergoing third molar extractions by approximately 66% (RR 0.34, 95% CI 0.19 to 0.64; 1728 participants; 12 studies; low-certainty evidence), which means that 19 people (95% CI 15 to 34) need to be treated with antibiotics to prevent one infection following extraction of impacted wisdom teeth. Antibiotics may also reduce the risk of dry socket by 34% (RR 0.66, 95% CI 0.45 to 0.97; 1882 participants; 13 studies; low-certainty evidence), which means that 46 people (95% CI 29 to 62) need to take antibiotics to prevent one case of dry socket following extraction of impacted wisdom teeth. The evidence for our other outcomes is uncertain: pain, whether measured dichotomously as presence or absence (RR 0.59, 95% CI 0.31 to 1.12; 675 participants; 3 studies) or continuously using a visual analogue scale (0-to-10-centimetre scale, where 0 is no pain) (MD -0.26, 95% CI -0.59 to 0.07; 422 participants; 4 studies); fever (RR 0.66, 95% CI 0.24 to 1.79; 475 participants; 4 studies); and adverse effects, which were mild and transient (RR 1.46, 95% CI 0.81 to 2.64; 1277 participants; 8 studies) (very low-certainty evidence). We found no clear evidence that the timing of antibiotic administration (preoperative, postoperative, or both) was important. The included studies enrolled a subset of patients undergoing dental extractions, that is healthy people who had surgical extraction of third molars. Consequently, the results of this review may not be generalisable to all people undergoing tooth extractions.
AUTHORS' CONCLUSIONS
The vast majority (21 out of 23) of the trials included in this review included only healthy patients undergoing extraction of impacted third molars, often performed by oral surgeons. None of the studies evaluated tooth extraction in immunocompromised patients. We found low-certainty evidence that prophylactic antibiotics may reduce the risk of infection and dry socket following third molar extraction when compared to placebo, and very low-certainty evidence of no increase in the risk of adverse effects. On average, treating 19 healthy patients with prophylactic antibiotics may stop one person from getting an infection. It is unclear whether the evidence in this review is generalisable to patients with concomitant illnesses or patients at a higher risk of infection. Due to the increasing prevalence of bacteria that are resistant to antibiotic treatment, clinicians should evaluate if and when to prescribe prophylactic antibiotic therapy before a dental extraction for each patient on the basis of the patient's clinical conditions (healthy or affected by systemic pathology) and level of risk from infective complications. Immunocompromised patients, in particular, need an individualised approach in consultation with their treating medical specialist.
Topics: Anti-Bacterial Agents; Antibiotic Prophylaxis; Bacterial Infections; Bias; Controlled Clinical Trials as Topic; Dry Socket; Humans; Molar, Third; Pain, Postoperative; Postoperative Complications; Tooth Extraction; Tooth, Impacted
PubMed: 33624847
DOI: 10.1002/14651858.CD003811.pub3 -
The Spine Journal : Official Journal of... Mar 2020There are three phases in prophylaxis of surgical site infections (SSI): preoperative, intraoperative and postoperative. There is lack of consensus and paucity of... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND CONTEXT
There are three phases in prophylaxis of surgical site infections (SSI): preoperative, intraoperative and postoperative. There is lack of consensus and paucity of evidence with SSI prophylaxis in the postoperative period.
PURPOSE
To systematically evaluate the literature, and provide evidence-based summaries on postoperative measures for SSI prophylaxis in spine surgery.
STUDY DESIGN
Systematic review, meta-analysis, evidence synthesis.
METHODS
A systematic review conforming to PRIMSA guidelines was performed utilizing PubMed (MEDLINE), EMBASE, and the Cochrane Database from inception to January 2019. The GRADE approach was used for quality appraisal and synthesis of evidence. Six postoperative care domains with associated key questions were identified. Included studies were extracted into evidence tables, data synthesized quantitatively and qualitatively, and evidence appraised per GRADE approach.
RESULTS
Forty-one studies (nine RCT, 32 cohort studies) were included. In the setting of preincisional antimicrobial prophylaxis (AMP) administration, use of postoperative AMP for SSI reduction has not been found to reduce rate of SSI in lumbosacral spine surgery. Prolonged administration of AMP for more than 48 hours postoperatively does not seem to reduce the rate of SSI in decompression-only or lumbar spine fusion surgery. Utilization of wound drainage systems in lumbosacral spine and adolescent idiopathic scoliosis corrective surgery does not seem to alter the overall rate of SSI in spine surgery. Concomitant administration of AMP in the presence of a wound drain does not seem to reduce the overall rate of SSI, deep SSI, or superficial SSI in thoracolumbar fusion performed for degenerative and deformity spine pathologies, and in adolescent idiopathic scoliosis corrective surgery. Enhanced-recovery after surgery clinical pathways and infection-specific protocols do not seem to reduce rate of SSI in spine surgery. Insufficient evidence exists for other types of spine surgery not mentioned above, and also for non-AMP pharmacological measures, dressing type and duration, suture and staple management, and postoperative nutrition for SSI prophylaxis in spine surgery.
CONCLUSIONS
Despite the postoperative period being key in SSI prophylaxis, the literature is sparse and without consensus on optimum postoperative care for SSI prevention in spine surgery. The current best evidence is presented with its limitations. High quality studies addressing high risk cohorts such as the elderly, obese, and diabetic populations, and for traumatic and oncological indications are urgently required.
Topics: Antibiotic Prophylaxis; Humans; Postoperative Period; Scoliosis; Spinal Fusion; Spine; Surgical Wound Infection
PubMed: 31557586
DOI: 10.1016/j.spinee.2019.09.013 -
International Journal of Nursing Studies Mar 2022Chlorhexidine and povidone-iodine are the most common disinfectants used in preoperative skin preparation. However, there is no consistent conclusion regarding the... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Chlorhexidine and povidone-iodine are the most common disinfectants used in preoperative skin preparation. However, there is no consistent conclusion regarding the prevention of surgical site infection (SSI) and bacterial culture data.
OBJECTIVE
To assess the efficacy of chlorhexidine and povidone-iodine in the prevention of postoperative SSI and relevant bacterial data.
DESIGN
Systematic Review and Meta-Analysis SETTINGS: N/A PARTICIPANTS: N/A METHOD: Literature relevant to "skin antisepsis" and "surgical site infections" was retrieved from PUBMED, Web of Science, EMBASE, CINHAL and CNKI. The incidence of SSI was the primary outcome, while the secondary outcome was bacterial data from the infected incision. All data were analyzed with Revman 5.3 and Stata Statistical Software.
RESULTS
A total of 36 studies were identified in this study, which included 16,872 participants. This study revealed that chlorhexidine is superior to povidone-iodine in the prevention of postoperative SSI (risk ratio [RR], 0.73; 95% confidence interval [CI], 0.61-0.87; p = 0.019, I = 39%). Further meta-regression analysis revealed that the effect of chlorhexidine was directly associated with the type of incision, but failed to differentiate between the subgroups divided according to the type of incision. With respect to bacteria colonization, the most common bacteria for chlorhexidine arm were propionibacterium's, while the most common bacteria for the iodine arm were staphylococci species.
CONCLUSION
In comparison to povidone-iodine, chlorhexidine showed better results in preventing postoperative SSI.
Topics: Anti-Infective Agents, Local; Chlorhexidine; Humans; Iodine; Preoperative Care; Surgical Wound Infection
PubMed: 35121520
DOI: 10.1016/j.ijnurstu.2021.104059 -
RMD Open Nov 2022To conduct a systematic literature review (SLR) on the screening and prophylaxis of opportunistic and chronic infections in autoimmune inflammatory rheumatic diseases... (Review)
Review
Systematic literature review informing the 2022 EULAR recommendations for screening and prophylaxis of chronic and opportunistic infections in adults with autoimmune inflammatory rheumatic diseases.
OBJECTIVE
To conduct a systematic literature review (SLR) on the screening and prophylaxis of opportunistic and chronic infections in autoimmune inflammatory rheumatic diseases (AIIRD).
METHODS
SLR (inception-12/2021) based on the following search domains: (1) infectious agents, (2) AIIRD, (3) immunosuppressives/immunomodulators used in rheumatology, (4) screening terms and (5) prophylaxis terms. Articles were retrieved having the terms from (1) AND (2) AND (3) plus terms from (4) OR(5). Databases searched: PubMed, Embase and Cochrane Library.
EXCLUSION CRITERIA
studies on postoperative infections, paediatric AIIRD, COVID-19, vaccinations and non-Εnglish literature. Study quality was assessed with Newcastle-Ottawa scale for non-randomised controlled trials (RCTs), RoB-Cochrane for RCTs, AMSTAR2 for SLRs.
RESULTS
From 5641 studies were retrieved, 568 full-text articles were assessed for eligibility, with 194 articles finally included. For tuberculosis, tuberculin skin test (TST) is affected by treatment with glucocorticoids and conventional synthetic disease modifying anti-rheumatic drugs (DMARDs) and its performance is inferior to interferon gamma release assay (IGRA). Agreement between TST and IGRA is moderate to low. For hepatitis B virus (HBV): risk of reactivation is increased in patients positive for hepatitis B surface antigen. Anti-HBcore positive patients are at low risk for reactivation but should be monitored periodically with liver function tests and/or HBV-viral load. Risk for Hepatitis C reactivation is existing but low in patients treated with biological DMARDs. For , prophylaxis treatment should be considered in patients treated with prednisolone ≥15-30 mg/day for >2-4 weeks.
CONCLUSIONS
Different screening and prophylaxis approaches are described in the literature, partly determined by individual patient and disease characteristics.
Topics: Adult; Child; Humans; Antirheumatic Agents; COVID-19; Hepatitis B virus; Opportunistic Infections; Rheumatic Diseases
PubMed: 36323488
DOI: 10.1136/rmdopen-2022-002726 -
Clinical Microbiology and Infection :... Apr 2023The aim of the guidelines is to provide recommendations on perioperative antibiotic prophylaxis (PAP) in adult inpatients who are carriers of multidrug-resistant...
SCOPE
The aim of the guidelines is to provide recommendations on perioperative antibiotic prophylaxis (PAP) in adult inpatients who are carriers of multidrug-resistant Gram-negative bacteria (MDR-GNB) before surgery.
METHODS
These evidence-based guidelines were developed after a systematic review of published studies on PAP targeting the following MDR-GNB: extended-spectrum cephalosporin-resistant Enterobacterales, carbapenem-resistant Enterobacterales (CRE), aminoglycoside-resistant Enterobacterales, fluoroquinolone-resistant Enterobacterales, cotrimoxazole-resistant Stenotrophomonas maltophilia, carbapenem-resistant Acinetobacter baumannii (CRAB), extremely drug-resistant Pseudomonas aeruginosa, colistin-resistant Gram-negative bacteria, and pan-drug-resistant Gram-negative bacteria. The critical outcomes were the occurrence of surgical site infections (SSIs) caused by any bacteria and/or by the colonizing MDR-GNB, and SSI-attributable mortality. Important outcomes included the occurrence of any type of postsurgical infectious complication, all-cause mortality, and adverse events of PAP, including development of resistance to targeted (culture-based) PAP after surgery and incidence of Clostridioides difficile infections. The last search of all databases was performed until April 30, 2022. The level of evidence and strength of each recommendation were defined according to the Grading of Recommendations Assessment, Development and Evaluation approach. Consensus of a multidisciplinary expert panel was reached for the final list of recommendations. Antimicrobial stewardship considerations were included in the recommendation development.
RECOMMENDATIONS
The guideline panel reviewed the evidence, per bacteria, of the risk of SSIs in patients colonized with MDR-GNB before surgery and critically appraised the existing studies. Significant knowledge gaps were identified, and most questions were addressed by observational studies. Moderate to high risk of bias was identified in the retrieved studies, and the majority of the recommendations were supported by low level of evidence. The panel conditionally recommends rectal screening and targeted PAP for fluoroquinolone-resistant Enterobacterales before transrectal ultrasound-guided prostate biopsy and for extended-spectrum cephalosporin-resistant Enterobacterales in patients undergoing colorectal surgery and solid organ transplantation. Screening for CRE and CRAB is suggested before transplant surgery after assessment of the local epidemiology. Careful consideration of the laboratory workload and involvement of antimicrobial stewardship teams before implementing the screening procedures or performing changes in PAP are warranted. High-quality prospective studies to assess the impact of PAP among CRE and CRAB carriers performing high-risk surgeries are advocated. Future well-designed clinical trials should assess the effectiveness of targeted PAP, including the monitoring of MDR-GNB colonization through postoperative cultures using European Committee on Antimicrobial Susceptibility Testing clinical breakpoints.
Topics: Male; Adult; Humans; Gram-Negative Bacterial Infections; Antibiotic Prophylaxis; Prospective Studies; Gram-Negative Bacteria; Anti-Bacterial Agents; Drug Resistance, Multiple, Bacterial; Carbapenems; Cephalosporins; Monobactams; Fluoroquinolones
PubMed: 36566836
DOI: 10.1016/j.cmi.2022.12.012 -
British Journal of Sports Medicine Jan 2023The primary aim was to evaluate risk factors for surgical site infections after anterior cruciate ligament reconstruction (ACLR). The secondary aim was to investigate... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVES
The primary aim was to evaluate risk factors for surgical site infections after anterior cruciate ligament reconstruction (ACLR). The secondary aim was to investigate the surgical site infection incidence rate and the mean time to postoperative surgical site infection symptoms.
DESIGN
Systematic review and meta-analysis.
DATA SOURCES
PubMed, Embase and Web of Science were searched from database inception to September 2021 and updated in April 2022.
ELIGIBILITY CRITERIA
Quantitative, original studies reporting potential risk factors for surgical site infections after ACLR were included.
RESULTS
Twenty-three studies with 3871 infection events from 469 441 ACLRs met the inclusion criteria. Male sex (OR 1.78, p< 0.00001), obesity (OR 1.82, p=0.0005), tobacco use (OR 1.37, p=0.01), diabetes mellitus (OR 3.40, p=0.002), steroid use history (OR 4.80, p<0.00001), previous knee surgery history (OR 3.63, p=0.02), professional athlete (OR 4.56, p=0.02), revision surgery (OR 2.05, p=0.04), hamstring autografts (OR 2.83, p<0.00001), concomitant lateral extra-articular tenodesis (OR 3.92, p=0.0001) and a long operating time (weighted mean difference 8.12, p=0.005) were identified as factors that increased the risk of surgical site infections (superficial and deep) after ACLR. Age, outpatient or inpatient surgery, bone-patellar tendon-bone autografts or allografts and a concomitant meniscus suture did not increase the risk of surgical site infections. The incidence of surgical site infections after ACLR was approximately 1% (95% CI 0.7% to 1.2%). The mean time from surgery to the onset of surgical site infection symptoms was approximately 17.1 days (95% CI 13.2 to 21.0 days).
CONCLUSION
Male sex, obesity, tobacco use, diabetes mellitus, steroid use history, previous knee surgery history, professional athletes, revision surgery, hamstring autografts, concomitant lateral extra-articular tenodesis and a long operation time may increase the risk of surgical site infections after ACLR. Although the risk of surgical site infections after ACLR is low, raising awareness and implementing effective preventions for risk factors are priorities for clinicians to reduce the incidence of surgical site infections due to its seriousness.
Topics: Humans; Male; Surgical Wound Infection; Bone-Patellar Tendon-Bone Grafting; Anterior Cruciate Ligament Reconstruction; Risk Factors; Obesity; Steroids; Anterior Cruciate Ligament Injuries; Knee Joint
PubMed: 36517215
DOI: 10.1136/bjsports-2022-105448 -
The Lancet. Infectious Diseases Oct 2020Antibiotic prophylaxis is frequently continued for 1 day or more after surgery to prevent surgical site infection. Continuing antibiotic prophylaxis after an operation... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Antibiotic prophylaxis is frequently continued for 1 day or more after surgery to prevent surgical site infection. Continuing antibiotic prophylaxis after an operation might have no advantage compared with its immediate discontinuation, and it unnecessarily exposes patients to risks associated with antibiotic use. In 2016, WHO recommended discontinuation of antibiotic prophylaxis after surgery. We aimed to update the evidence that formed the basis for that recommendation.
METHODS
For this systematic review and meta-analysis, we searched MEDLINE, Embase, CINAHL, CENTRAL, and WHO regional medical databases for randomised controlled trials (RCTs) on postoperative antibiotic prophylaxis that were published from Jan 1, 1990, to July 24, 2018. RCTs comparing the effect of postoperative continuation versus discontinuation of antibiotic prophylaxis on the incidence of surgical site infection in patients undergoing any surgical procedure with an indication for antibiotic prophylaxis were eligible. The primary outcome was the effect of postoperative surgical antibiotic prophylaxis continuation versus its immediate discontinuation on the occurrence of surgical site infection, with a prespecified subgroup analysis for studies that did and did not adhere to current best practice standards for surgical antibiotic prophylaxis. We calculated summary relative risks (RRs) with corresponding 95% CIs using a random effects model (DerSimonian and Laird). We evaluated heterogeneity with the χ test, I, and τ, and visually assesed publication bias with a contour-enhanced funnel plot. This study is registered with PROSPERO, CRD42017060829.
FINDINGS
We identified 83 relevant RCTs, of which 52 RCTs with 19 273 participants were included in the primary meta-analysis. The pooled RR of surgical site infection with postoperative continuation of antibiotic prophylaxis versus its immediate discontinuation was 0·89 (95% CI 0·79-1·00), with low heterogeneity in effect size between studies (τ=0·001, χ p=0·46, I=0·7%). Our prespecified subgroup analysis showed a significant association between the effect estimate and adherence to best practice standards of surgical antibiotic prophylaxis: the RR of surgical site infection was reduced with continued antibiotic prophylaxis after surgery compared with its immediate discontinuation in trials that did not meet best practice standards (0·79 [95% CI 0·67-0·94]) but not in trials that did (1·04 [0·85-1·27]; p=0·048). Whether studies adhered to best practice standards explained all variance in the pooled estimate from the primary meta-analysis.
INTERPRETATION
Overall, we identified no conclusive evidence for a benefit of postoperative continuation of antibiotic prophylaxis over its discontinuation. When best practice standards were followed, postoperative continuation of antibiotic prophylaxis did not yield any additional benefit in reducing the incidence of surgical site infection. These findings support WHO recommendations against this practice.
FUNDING
None.
Topics: Anti-Bacterial Agents; Drug Administration Schedule; Humans; Postoperative Care; Surgical Wound Infection
PubMed: 32470329
DOI: 10.1016/S1473-3099(20)30084-0