Infection Control & Hospital Epidemiology
between-study variance of the random effects models.13 To investigate trends in the proportion of infections over time, we performed multilevel logistic regression models with random intercepts for each study, including year and study country as covariates for all 4 procedures.15 Additionally, for colorectal surgery, we performed a sensitivity
analysis including type of surgery (elective versus emergency) and antibiotics in the multivariable model and subanalysis of RCTs that had (1) prophylactic antibiotic administration within 60 minutes or at the time of anesthesia induction, (2) had patient follow-up of at least 4 weeks, and (3) had SSIs that included surgical incision, organ-space infections, or sepsis related to surgery. To facilitate the interpretation of the model results, the probability of infection was plotted against the year of study publication.
Results
Our literature search of the PubMed and Cochrane databases using the search terms in Supplementary Table 1 yielded 399
135
studies. After removing duplicate studies and those not meeting the inclusion criteria, we included a total of 74 RCTs in the final analysis (Fig. 1). Of these 74 RCTs, 9 were for appendectomy, 11 were for cesarean section, 39 were related to colorectal surgery, and 15 were related to TRPB. Of the 74 RCTs, 20 were conducted in the United States. All included studies, individual character- istics, and quality assessments are presented in the supplementary material (appendectomy16–24, cesarean section25–35, colorectal surgery36–74, and TRPB75–89). For appendectomy, there were 1,332 participants in 9 RCTs.
Cefoxitin was the prophylactic antibiotic in 5 RCTs, cefotetan in 1 RCT, and cefazolin plus metronidazole in 1 RCT. Only 1 of the RCTs compared efficacy of cefoxitin versus cefotetan. The pooled proportion of wound infection following appendectomy using the recommended prophylactic antibiotics (cefoxitin, cefotetan, or cefazolin plus metronizadole) was 3% (95% CI, 1.4–5.1; τ2=0.011) (Fig. 2). For cesarean section, there were 1,981 participants in 11 RCTs.
Cefazolin was the prophylactic antibiotic for all included RCTs. The surgery was elective in 4 RCTs, both elective and nonelective (in active labor) in 4 RCTs, and nonelective in 3 RCTs. The
Fig. 1. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow chart for study selection process.
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