Infection Control & Hospital Epidemiology Table 3. Risk of Bias Summary for the Studies Included in the Systematic Review and Meta-analysis
Study First Author, Year
Baldoni, 198917
Chongsomchai, 200236
Cormio, 200320
Grossman, 197921
Hemsell, 198437 Hemsell, 198538 Hemsell, 198739 Hemsell, 199522 Jyothi, 201024 Periti, 198818 Periti, 198819
Phoolcharoen, 201225
Stiver, 199023 aAccording to review author.
Comparison with agents that have broad antianaerobic spectrum. The results of the meta-analysis for the SSI risk ratio of cefazolin versus another cephalosporin agent with broad anti- anaerobic spectrum (cefoxitin or cefotetan) are shown in Figure 3. Among the 513 patients in the cefazolin arm, 41 SSIs (8%) were recorded, and among the 495 patients in the comparator (cefoxitin or cefotetan) arm, 24 SSIs (4.8%) were recorded. Compared with cefoxitin or cefotetan antimicrobial prophylaxis, cefazolin had a significantly higher risk of posthysterectomy SSI (relative risk [RR], 1.7; 95% confidence interval [CI], 1.04–2.77; P=.03). The addition of amoxicillin-clavulanate (a penicillin-based
Fig. 2. Funnel plot to evaluate publication bias for randomized controlled trials of cefazolin as antimicrobial surgical prophylaxis in women undergoing abdominal or vaginal hysterectomies. Publication bias was not detected; the Egger test of the intercept was not statistically significant (2-tailed P value=.11273).
antibiotic with antianaerobic agent) to cefoxitin or cefotetan showed a trend for higher post-hysterectomy SSI with cefazolin (RR, 1.6; 95% CI, 0.98–2.64; P=.06) (Fig. 4).
Meta-analysis of the efficacy of cefazolin compared with other antimicrobials in preventing surgical-site infection among women undergoing hysterectomy
Among the 13 RCTs included in the study, 1,782 patients received cefazolin and 1,746 patients received a comparator antimicrobial for surgical prophylaxis. The SSI incidence and relative risk for cefazolin versus other antimicrobials reported in individual RCT is presented in Table 2. Only 1 study found the comparator antimicrobial (cefotetan) to be associated with sig- nificantly less SSI than cefazolin (P=.03).22 For all other studies, the difference in SSI incidence for patients receiving prophylaxis with cefazolin versus a comparator antimicrobial was not sta- tistically significant.
Comparison with penicillin-based antibiotics. When compared with penicillin G, ampicillin, or amoxicillin-clavulanate, cefazolin showed no statistically significant difference in the relative risk of SSI among women undergoing hysterectomy (RR, 0.96; 95% CI, 0.52–1.76; P=.89) (Supplemental Figure 1).
Comparison with other cephalosporin agents without broad antianaerobic activity. Compared with second- or third- generation cephalosporins that have limited antianaerobic spec- trum, cefazolin’s SSI relative risk was not statistically significant among women undergoing hysterectomy (RR, 0.66; 95% CI, 0.36– 1.22; P=0.18) (Supplemental Fig. 2).
Discussion
In this meta-analysis, the efficacy of cefazolin for SSI prevention in hysterectomy was significantly lower than that of other
Random Allocation Sequence
No Yes
No ?
Yes ?
Yes Yes ? ? ?
Yes ?
Allocation Concealed Blinding
? Yes
No ?
?
Yes Yes ? ?
No ?
Yes ? ? Yes
No Yes
Yes Yes ? ?
No No ?
Yes Yes
Loss to Follow-Up Accounted For
Yes Yes
Yes ?
Yes Yes Yes Yes ?
Yes Yes No
?
Complete Outcome Reporting
Yes Yes
Yes No
Yes Yes Yes Yes No Yes Yes Yes
Yes Early
Termination Other Bias Gradea No No
No No
No No No No No No No No
No
Yes High ?
No Low No Low No Low
Yes Indeterminate Yes High Yes High
Yes Indeterminate No Low
? Indeterminate
No Indeterminate No Low
147
Indeterminate
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