Routine Postoperative Antibiotic Prophylaxis Offers No Benefit after Hepatectomy—A Systematic Review and Meta-Analysis

Abstract

Background: Prophylactic antibiotics are frequently administered after major abdominal surgery including hepatectomies aiming to prevent infective complications. Yet, excessive use of antibiotics increases resistance in bacteria. The aim of this systematic review and meta-analysis is to assess the efficacy of prophylactic antibiotics after hepatectomy (postoperative antibiotic prophylaxis, POA). Method: This systematic review and meta-analysis were completed according to the current PRISMA guidelines. The protocol has been registered prior to data extraction (PROSPERO registration Nr: CRD42021288510). MEDLINE, Web of Science and CENTRAL were searched for clinical reports on POA in hepatectomy restrictions. A random-effects model was used for synthesis. Methodological quality was assessed with RoB2 and ROBINS-I. GRADE was used for the quality of evidence assessment. Results: Nine comparative studies comprising 2987 patients were identified: six randomized controlled trials (RCTs) and three retrospectives. POA did not lead to a reduction in postoperative infective complications or have an effect on liver-specific complications—post-hepatectomy liver failure and biliary leaks. POA over four or more days was associated with increased rates of deep surgical site infections compared to short-term administration for up to two days (OR 1.54; 95% CI [1.17;2.03]; p = 0.03). Routine POA led to significantly higher MRSA incidence as a pathogen (p = 0.0073). Overall, the risk of bias in the studies was low and the quality of evidence moderate. Conclusion: Routine POA cannot be recommended after hepatectomy since it does not reduce postoperative infection or liver-specific complications but contributes to resistance in bacteria. Studies into individualized risk-adapted antibiotic prophylaxis strategies are needed to further optimize perioperative treatment in liver surgery.

Current evidence on posthepatectomy liver failure: comprehensive review

“…Early recognition of sources of sepsis with appropriate radiological imaging, drainage of infected collections, and appropriate antibiotics are all important in controlling the infection that could induce or aggravate PHLF 191 . A recent meta-analysis found no benefit in postoperative prophylactic administration of antibiotics in patients following hepatectomy in terms of rate and fatalities 192 ; however when PHLF is diagnosed, aggressive antimicrobial treatment is advised as infectious complications and sepsis are both common in PHLF, increasing the risk for adverse patient outcomes 193 .…”

Surgical Site Infections After Pediatric Liver Transplantation—Impact of a Change in Perioperative Prophylactic Antibiotic Protocol

“…Results from adult trials cannot be extrapolated directly due to differing risk factors and physiological characteristics [30]. Furthermore, studies from nonimmunocompromised children that failed to identify benefit from PAP [31,32] cannot be directly transferred to children in the postoperative phase after LTx, which is characterized by high levels of immunosuppressants, often prolonged ventilation, use of vasopressors and sometimes associated wound healing disorders in the early postoperative phase. Prospective randomized controlled trials are warranted to identify optimal prevention bundles against SSIs at all stages and reduce antimicrobial exposure as well as reoperations.…”

“A breach in the protocol for no good reason”: a surgical antimicrobial prophylaxis experience in an Ethiopian academic medical center

“…Historically, patients undergoing abdominal surgeries were subjected to an “extended” antibiotics course after surgery before the introduction of the guidelines. This patient population included hepatectomy surgeries, colectomy, gastrectomy, small bowel surgery, and biliary interventions (Kappstein and Daschner 1991 ; Murtha-Lemekhova et al 2022 ). Similar group of patients in our series also were subjected to more days on antibiotics beyond the recommended time for SAP.…”