Infection Control & Hospital Epidemiology (2019), 40, 133–141 doi:10.1017/ice.2018.295
Original Article
Is the efficacy of antibiotic prophylaxis for surgical procedures decreasing? Systematic review and meta-analysis of randomized control trials
Sumanth Gandra MD1,2,a, Anna Trett MSc1,2,a, Gerardo Alvarez-Uria MD3, Joseph S. Solomkin MD4
and Ramanan Laxminarayan PhD1,2,5 1Center for Disease Dynamics, Economics & Policy, Washington, DC, 2University of Strathclyde, Glasgow, Scotland, United Kingdom, 3Department of Infectious Diseases, Rural Development Trust Hospital, Bathalapalli, AP, India, 4Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States and 5Princeton Environmental Institute, Princeton, New Jersey, United States
Abstract
Objective: Rising antibiotic resistance could reduce the effectiveness of antibiotics in preventing postoperative infections. We investigated trends in the efficacy of antibiotic prophylaxis regimens for 3 commonly performed surgical procedures—appendectomy, cesarean section, and colorectal surgery—and 1 invasive diagnostic procedure, transrectal prostate biopsy (TRPB). Design: Systematic review and meta-analysis. Methods: We searched PubMed and Cochrane databases (through October 31, 2017) for randomized control trials (RCTs) that measured the efficacy of antibiotic prophylaxis for 4 index procedures in preventing postoperative infections (surgical site infections [SSIs] following the 3 surgical procedures and a combination of urinary tract infections [UTIs] and sepsis following TRPB). Results: Of 399 RCTs, 74 studies (9 appendectomy, 11 cesarean section, 39 colorectal surgery, and 15 TRPB) were included. Multilevel logistic regression models with random intercepts for each study showed no statistically significant increase in SSIs over time for appendectomy (adjusted odds ratio [aOR] per year, 1.03; 95% confidence interval [CI], 0.92–1.16; P=.57), cesarean section (aOR per year, 1.01; 95% CI, 0.96–1.05; P=.80), and TRPB (aOR per year, 0.95; 95% CI, 0.77–1.18; P=.67). However, there was a significant increase in SSIs proportion following colorectal surgery (aOR per year, 1.049; 95% CI, 1.03–1.07; P<.001). Conclusion: The efficacy of antibiotic prophylaxis agents in preventing SSIs following colorectal surgery has declined. Small number of RCTs and low infections rates limited our ability to assess true effect for simple appendectomy, cesarean section, or TRPB.
(Received 8 July 2018; accepted 20 October 2018; electronically published 12 November 2018)
Antibiotics are used as prophylactic agents for several surgical and invasive diagnostic procedures to prevent infections.1,2 There is growing concern that the rise in antibiotic resistance has diminished the effectiveness of antibiotic prophylaxis in pre- venting postoperative infections.3,4 A previous modeling study showed that a 30% reduction in the efficacy of antibiotic pro- phylaxis for 10 common surgical procedures and cancer che- motherapy in the United States could result in 120,000 additional infections and 6,300 additional infection-related deaths per year.4 As the pathogen source for surgical site infections (SSIs) could arise from the native flora of patient’s skin, mucous membranes, or internal organs,5 increasing colonization of antibiotic-resistant bacteria in healthy individuals could reduce the effectiveness of antibiotic prophylaxis for various procedures.6 Currently,
Author for correspondence: Ramanan Laxminarayan PhD, MPH, 1400 Eye St NW,
Suite 500, Washington, DC 20005. E-mail:
ramanan@cddep.org. aAuthors of equal contribution.
Cite this article: Gandra S, et al. (2019). Is the efficacy of antibiotic prophylaxis for
surgical procedures decreasing? Systematic review and meta-analysis of randomized control trials. Infection Control & Hospital Epidemiology 2019, 40, 133–141. doi: 10.1017/ ice.2018.295
© 2018 by The Society for Healthcare Epidemiology of America. All rights reserved.
however, no systematic data are available on trends in effective- ness of antibiotic prophylaxis for surgical procedures over time.6 We conducted a systematic review of available literature to investigate trends in the efficacy of the established antibiotic prophylaxis regimens for 3 commonly performed surgical pro- cedures—appendectomy, cesarean section, and colorectal surgery —and 1 invasive diagnostic procedure, transrectal prostate biopsy (TRPB). We systematically reviewed all randomized control trials (RCTs) that included the currently recommended prophylactic antibiotics for the above 4 procedures and analyzed the SSI rates following the 3 surgical procedures and infections following TRPB procedures over the last few decades.
Methods
We conducted the systematic review and meta-analysis according to the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) group checklist (Supple- mentary material), to ensure the inclusion of all required infor- mation. A protocol of this review has not been registered previously.
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