Effect of postoperative continuation of antibiotic prophylaxis on the incidence of surgical site infection: a systematic review and meta-analysis

Abstract

Background Antibiotic prophylaxis is frequently continued for 1 day or more after surgery to prevent surgical site infection. Continuing antibiotic prophylaxis after an operation might have no advantage compared with its immediate discontinuation, and it unnecessarily exposes patients to risks associated with antibiotic use. In 2016, WHO recommended discontinuation of antibiotic prophylaxis after surgery. We aimed to update the evidence that formed the basis for that recommendation.Methods For this systematic review and meta-analysis, we searched MEDLINE, Embase, CINAHL, CENTRAL, and WHO regional medical databases for randomised controlled trials (RCTs) on postoperative antibiotic prophylaxis that were published from Jan 1, 1990, to July 24, 2018. RCTs comparing the effect of postoperative continuation versus discontinuation of antibiotic prophylaxis on the incidence of surgical site infection in patients undergoing any surgical procedure with an indication for antibiotic prophylaxis were eligible. The primary outcome was the effect of postoperative surgical antibiotic prophylaxis continuation versus its immediate discontinuation on the occurrence of surgical site infection, with a prespecified subgroup analysis for studies that did and did not adhere to current best practice standards for surgical antibiotic prophylaxis. We calculated summary relative risks (RRs) with corresponding 95% CIs using a random effects model (DerSimonian and Laird). We evaluated heterogeneity with the χ² test, I², and τ², and visually assesed publication bias with a contour-enhanced funnel plot. This study is registered with PROSPERO, CRD42017060829.Findings We identified 83 relevant RCTs, of which 52 RCTs with 19 273 participants were included in the primary meta-analysis. The pooled RR of surgical site infection with postoperative continuation of antibiotic prophylaxis versus its immediate discontinuation was 0•89 (95% CI 0•79-1•00), with low heterogeneity in effect size between studies (τ²=0•001, χ² p=0•46, I²=0•7%). Our prespecified subgroup analysis showed a significant association between the effect estimate and adherence to best practice standards of surgical antibiotic prophylaxis: the RR of surgical site infection was reduced with continued antibiotic prophylaxis after surgery compared with its immediate discontinuation in trials that did not meet best practice standards (0•79 [95% CI 0•67-0•94]) but not in trials that did (1•04 [0•85-1•27]; p=0•048). Whether studies adhered to best practice standards explained all variance in the pooled estimate from the primary meta-analysis.Interpretation Overall, we identified no conclusive evidence for a benefit of postoperative continuation of antibiotic prophylaxis over its discontinuation. When best practice standards were followed, postoperative continuation of antibiotic prophylaxis did not yield any additional benefit in reducing the incidence of surgical site infection. These findings support WHO recommendations against this practice.

<p>Evaluation of Surgical Antimicrobial Prophylaxis and Incidence of Surgical Site Infection at Borumeda Hospital, Northeast Ethiopia: Retrospective Cross-Sectional Study</p>

“…13 Since the risk of SSI in most clean operations is low, SAP is not recommended in such procedures. 14,15 However, in clean procedures such as breast cancer operations, SAP is recommended. 36 In the present study, more than half (62.2%) of the patients who had clean wound received prophylaxis, while nearly all (96.3%) of the patients who had clean-contaminated wound and all the patients who had contaminated wound received antimicrobial prophylaxis.…”

“…13 Since the risk of SSI in clean wounds which do not involve insertion of implants is low, the use of SAP is controversial. 14,15 Critical aspects of SAP administration are: giving the appropriate antimicrobial agent in adequate dose, proper preoperative prophylaxis timing, and maintaining drug level throughout the operation. 16 Different guidelines for the prevention of SSI have been developed by the American Society of Health-System Pharmacist (ASHP), World Health Organization, 17 Centers for disease control (CDC) and Healthcare Infection Control Practices Advisory Committee, and the National Institute for Clinical Excellence.…”

Identifying targets for improvement using a nationally standardized survey: Surgical antimicrobial prophylaxis in orthopedic surgery

“…35 Most recently, a systematic review with meta-analysis of 52 RCTs (n = 19,273 participants across multiple surgical procedure types) demonstrated that no significant benefit (SSI reduction) accrued from prolonging SAP (in comparison to no postoperative doses), with a pooled RR of 0.89 (95% CI, 0.79-1.00). 36 Multiple recent studies advocate for a well-powered, randomized, prospective trial comparing infection outcomes using singleand multiple-dose SAP regimens for TKJR. 30,35,37,38 Importantly, Duke University and the AAHKS are conducting a multicenter clinical trial (estimated n = 8,000) comparing single dose and Fig.…”

A cluster randomized stepped-wedge trial to de-implement unnecessary post-operative antibiotics in children: the optimizing perioperative antibiotic in children (OPerAtiC) trial

“…For example, even one additional dose of surgical prophylaxis in a child is associated with a sixfold increased risk for CDI [9]. Further, this overprescribing has not reduced the amount of post-operative complications in clean and clean contaminated surgical cases [11].…”