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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).
Systematic review and meta-analysis.
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).
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).
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.
The prevention of surgical site infection (SSI) remains a focus of attention because such infections continue to be a major source of expense, morbidity, and even mortality. SSIs are the third most frequently reported nosocomial infection, accounting for 14% to 16% of nosocomial infections in hospitalized patients. Approximately 40% of healthcare-associated infections occurring among surgical patients are SSIs. A patient who develops a surgical site infection while still hospitalized has an approximately 60% greater risk of being admitted to the intensive care unit, and an attributable extra hospital stay of 6.5 days, at an additional direct cost of $3000. Risk of readmission within 30 days is five times more likely for infected patients, at a cost of more than $5000.
Depending on the procedure, between one-half and two-thirds of SSIs affect the incision and the remainder involve deep tissue or organ/space infection. Nearly all deep and organ/space SSIs require hospitalization, operative or radiologic intervention, and intravenous antibiotic therapy. These are the most expensive healthcare-associated infections. Three-quarters of deaths of surgical patients with SSI are attributed to that infection, nearly all of which are organ/space infections. Conversely, superficial incisional infections commonly are noted after discharge, rarely require rehospitalization or intervention, and have little if any documented social or financial cost. The National Healthcare Safety Network no longer publicly reports superficial incisional infection rates.
The prevention of surgical site infection (SSI) remains a focus of attention because wound infections continue to be a major source of expense, morbidity, and even mortality. A patient who develops a wound infection while still hospitalized has an approximately 60% greater risk of being admitted to the intensive care unit, and an attributable extra hospital stay of 6.5 days, at an additional direct cost of $3000. Risk of readmission within 30 days is 5 times more likely for infected patients, at a cost of more than $5000.
The epidemiologic data testifying to the significance of SSI are overwhelming. SSIs are the third most frequently reported nosocomial infection, accounting for 14% to 16% of nosocomial infections in hospitalized patients. Approximately 40% of nosocomial infections occurring among surgical patients are SSIs, two thirds of which affect the incision and one third involve organ/space infection. Three quarters of deaths of surgical patients with SSI are attributed to that infection, nearly all of which are organ/space infections. Because of the importance of these infections following operation, considerable effort has been expended to identify other potentially controllable variables that influence infection rates. A major review of this subject and an extensive list of recommendations for preoperative patient preparation and operating room environment have recently been published by the Hospital Infection Control Practices Advisory Committee (HICPAC) of the Centers for Disease Control and Prevention (CDC).
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