Combined Mechanical and Oral Antibiotic Bowel Preparation Reduces Incisional Surgical Site Infection and Anastomotic Leak Rates After Elective Colorectal Resection

Scarborough, John; Mantyh, Christopher R.; Sun, Zhifei; Migaly, John

doi:10.1097/sla.0000000000001041

Cited by 289 publications

(193 citation statements)

References 19 publications

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“…Advocates of preoperative antibiotics believe that cleansing of intestinal flora influences rates of subsequent infection. Controversy remains regarding the use of short‐course oral antibiotics in the preoperative setting; although use of oral antibiotics in combination with MBP is a strategy employed widely in North America4, it remains much less common across Europe. The reasons for avoidance of MBP in Europe are multifactorial, but the trend towards enhanced recovery after surgery (ERAS) protocols that exclude routine MBP is probably a significant contributor5.…”

Section: Introductionmentioning

confidence: 99%

Meta‐analysis of oral antibiotics, in combination with preoperative intravenous antibiotics and mechanical bowel preparation the day before surgery, compared with intravenous antibiotics and mechanical bowel preparation alone to reduce surgical‐site infections in elective colorectal surgery

2018

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BackgroundSurgical‐site infection (SSI) is a potentially serious complication following colorectal surgery. The present systematic review and meta‐analysis aimed to investigate the effect of preoperative oral antibiotics and mechanical bowel preparation (MBP) on SSI rates.MethodsA systematic review of PubMed, Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Trials was performed using appropriate keywords. Included were RCTs and observational studies reporting rates of SSI following elective colorectal surgery, in patients given preoperative oral antibiotic prophylaxis, in combination with intravenous (i.v.) antibiotic prophylaxis and MBP, compared with patients given only i.v. antibiotic prophylaxis with MBP. A meta‐analysis was undertaken.ResultsTwenty‐two studies (57 207 patients) were included, of which 14 were RCTs and eight observational studies. Preoperative oral antibiotics, in combination with i.v. antibiotics and MBP, were associated with significantly lower rates of SSI than combined i.v. antibiotics and MBP in RCTs (odds ratio (OR) 0·45, 95 per cent c.i. 0·34 to 0·59; P < 0·001) and cohort studies (OR 0·47, 0·44 to 0·50; P < 0·001). There was a similarly significant effect on SSI with use of a combination of preoperative oral aminoglycoside and erythromycin (OR 0·40, 0·25 to 0·64; P < 0·001), or preoperative oral aminoglycoside and metronidazole (OR 0·51, 0·39 to 0·68; P < 0·001). Preoperative oral antibiotics were significantly associated with reduced postoperative rates of anastomotic leak, ileus, reoperation, readmission and mortality in the cohort studies.ConclusionOral antibiotic prophylaxis, in combination with MBP and i.v. antibiotics, is superior to MBP and i.v. antibiotic prophylaxis alone in reducing SSI in elective colorectal surgery.

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Section: Introductionmentioning

confidence: 99%

Meta‐analysis of oral antibiotics, in combination with preoperative intravenous antibiotics and mechanical bowel preparation the day before surgery, compared with intravenous antibiotics and mechanical bowel preparation alone to reduce surgical‐site infections in elective colorectal surgery

2018

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“…Results from other studies have been discordant. Although one study14 found a lower rate of SSI for MBP plus OABP versus OABP alone (3·2 versus 4·4 per cent respectively), with lower anastomotic leak (2·8 versus 5·5 per cent) and mortality (0·3 versus 1·1 per cent) rates, the differences were not statistically significantly different owing to the low number of patients (91) who received OABP alone. In a matched analysis of NSQIP data15, albeit with much smaller numbers, there was no difference in SSI, anastomotic leak, ileus or mortality when comparing MBP plus OABP with OABP alone.…”

Section: Discussionmentioning

confidence: 91%

“…Unlike earlier analyses with small numbers6 14, 16 20, the present study included 2018 patients who received OABP alone, a number sufficient to observe that addition of MBP to OABP was associated with lower odds of developing SSI, postoperative ileus, sepsis or the need for reoperation, and a reduction in postoperative LOS.…”

Section: Discussionmentioning

confidence: 99%

“…In contrast, recent studies4 11, 12, 13, including RCTs and meta‐analyses, have demonstrated a clear reduction in SSI with MBP plus OABP compared with no bowel preparation. MBP plus OABP has also been independently associated with reduced rates of anastomotic leak and postoperative ileus compared with MBP alone and with no bowel preparation5 14, 15. The reduction in SSI associated with MBP plus OABP was also associated with a reduction in wound dehiscence, pneumonia, prolonged ventilation, sepsis, septic shock, LOS, unplanned reoperations and readmissions6 7, 16.…”

Section: Introductionmentioning

confidence: 96%

“…Existing RCTs have not investigated this question, and observational studies have not answered it adequately owing to small sample sizes13 14, 16. With the 2015 release of the American College of Surgeons' National Surgical Quality Improvement Program (ACS‐NSQIP), there is now a sufficient sample size to measure the effect of MBP plus OABP on postoperative outcomes relative to OABP alone.…”

Section: Introductionmentioning

confidence: 99%

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Clinical outcomes following mechanical plus oral antibiotic bowel preparation versus oral antibiotics alone in patients undergoing colorectal surgery

et al. 2018

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BackgroundDespite growing evidence to support use of preoperative mechanical bowel preparation (MBP) plus oral antibiotic bowel preparation (OABP) compared with MBP alone or no bowel preparation before colorectal surgery, evidence supporting use of MBP plus OABP relative to OABP alone is lacking. This study aimed to investigate whether the addition of MBP to OABP was associated with improved clinical outcomes after colorectal surgery compared with outcomes following OABP alone.MethodsPatients who underwent colorectal surgery and preoperative bowel preparation with either OABP alone or MBP plus OABP were identified using the American College of Surgeons' National Surgical Quality Improvement Program Colectomy Targeted Participant Use Data File for 2012–2015. Thirty‐day postoperative outcomes were compared, estimating the average treatment effect with propensity score matching and inverse probability‐weighted regression adjustment.ResultsIn the final study population of 20 594 patients, 90·2 per cent received MBP plus OABP and 9·8 per cent received OABP alone. Patients who received MBP plus OABP had a lower incidence of superficial surgical‐site infection (SSI), organ space SSI, any SSI, postoperative ileus, sepsis, unplanned reoperation and mortality, and a shorter length of hospital stay (all P < 0·050). After propensity score matching and inverse probability‐weighted regression adjusted analysis, MBP plus OABP was associated with a reduction in superficial SSI, any SSI, postoperative ileus and unplanned reoperation (all P < 0·050).ConclusionsUse of MBP plus OABP before colectomy was associated with reduced SSI, postoperative ileus, sepsis and unplanned reoperations, and shorter length of hospital stay compared with OABP alone.

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Association of Mechanical Bowel Preparation and Oral Antibiotics Before Elective Colorectal Surgery With Surgical Site Infection

et al. 2018

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Key Points Question Which approach is best to reduce surgical site infections and anastomotic leak in colorectal surgery: mechanical bowel preparation with oral antibiotics, oral antibiotics only, mechanical bowel preparation only, or no preparation? Findings Among 38 randomized clinical trials (8458 patients) in this network meta-analysis, mechanical bowel preparation with oral antibiotics was associated with the lowest rate of surgical site infections, reducing both incisional and organ/space infections. There was no significant difference in anastomotic leak rate between the 4 approaches. Meaning Mechanical bowel preparation with oral antibiotics is the best approach to reduce surgical site infections in patients undergoing colorectal surgery.

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Combined Mechanical and Oral Antibiotic Bowel Preparation Reduces Incisional Surgical Site Infection and Anastomotic Leak Rates After Elective Colorectal Resection

Abstract: Combined bowel preparation with mechanical cleansing and oral antibiotics results in a significantly lower incidence of incisional surgical site infection, anastomotic leakage, and hospital readmission when compared to no preoperative bowel preparation.

Cited by 289 publications

References 19 publications

Meta‐analysis of oral antibiotics, in combination with preoperative intravenous antibiotics and mechanical bowel preparation the day before surgery, compared with intravenous antibiotics and mechanical bowel preparation alone to reduce surgical‐site infections in elective colorectal surgery

Meta‐analysis of oral antibiotics, in combination with preoperative intravenous antibiotics and mechanical bowel preparation the day before surgery, compared with intravenous antibiotics and mechanical bowel preparation alone to reduce surgical‐site infections in elective colorectal surgery

Clinical outcomes following mechanical plus oral antibiotic bowel preparation versus oral antibiotics alone in patients undergoing colorectal surgery

Association of Mechanical Bowel Preparation and Oral Antibiotics Before Elective Colorectal Surgery With Surgical Site Infection

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