Systematic review of the cost-effectiveness of preoperative antibiotic prophylaxis in reducing surgical-site infection

Abstract

BackgroundSurgical‐site infections (SSIs) increase the length of hospital admission and costs. SSI prevention guidelines include preoperative antibiotic prophylaxis. This review assessed the reporting quality and cost‐effectiveness of preoperative antibiotics used to prevent SSI.MethodsPubMed, Web of Science, Cumulative Index to Nursing and Allied Health Literature, Index of Economic Articles (EconLit), Database of Abstracts of Reviews of Effect (including the National Health Service Economic Evaluation Database) and Cochrane Central databases were searched systematically from 1970 to 2017 for articles that included costs, preoperative antibiotic prophylaxis and SSI. Included were RCTs and quasi‐experimental studies conducted in Organisation for Economic Co‐operation and Development countries with participants aged at least 18 years and published in English. Two reviewers assessed eligibility, with inter‐rater reliability determined by Cohen's κ statistic. The Consolidated Health Economic Evaluation and Reporting Standards (CHEERS) and modified Drummond checklists were used to assess reporting and economic quality. Study outcomes and characteristics were extracted, and incremental cost‐effectiveness ratios were calculated, with costs adjusted to euros (2016) (€1 = US $1·25; £1 sterling = €1·28).ResultsTwelve studies published between 1988 and 2014 were included from 646 records identified; nine were RCTs, two were nested within RCTs and one was a retrospective chart review. Study quality was highest in the nested studies. Cephalosporins (first, second and third generation) were the most frequent prophylactic interventions. Eleven studies demonstrated clinically effective interventions; ten were cost‐effective (the intervention was dominant); in one the intervention was dominated by the control; and in one the intervention was more effective and more expensive than the control.ConclusionPreoperative antibiotic prophylaxis does reduce SSI, costs to hospitals and health providers, but the reporting of economic methods in RCTs is not standardized. Routinely nesting economic methods in RCTs would improve economic evaluations and ensure appropriate selection of prophylactic antibiotics.

Efficacy of adjunctive azithromycin versus single-dose cephalosporin prophylaxis for caesarean scar defect: study protocol for a randomised controlled trial

“…Our previously published data first revealed a CSD prevalence of 43.4% (95% CI 39.1% to 47.7%, n=514) in Shanghai, which is a cause for concern 17. Our cohort study also showed that infection might be an important risk factor for CSD and that multidose antibiotic administration has a significant protective effect compared with single-dose antibiotic administration (CSD prevalence 31.1%, 95% CI 23.8% to 38.3% vs 49.0%, 95% CI 43.8% to 54.3%; aOR=0.4, 95% CI 0.3 to 0.7) 18–20. Furthermore, the single-dose cefuroxime subgroup (n=190) was found to have a significantly lower CSD prevalence than the single-dose cefradine subgroup (n=162) (38.9%, 95% CI 34.7% to 48.6% vs 56.8%, 95% CI 51.3% to 66.7%; aOR=0.5, 95% CI 0.3 to 0.8, p=0.006).…”

Surgical site infection and costs in low- and middle-income countries: A systematic review of the economic burden

“…Recently completed and ongoing research studies to find the most cost-effective prevention strategies for SSI, are having mixed success [13,14]. The majority of this research is randomised controlled trials (RCTs) with a parallel economic evaluation based in HIC [15,16]. Plans are in place to carry out similar studies exploring cost-effective strategies to combat SSI in the LMIC setting [17].…”

Highlighting the gaps in quantifying the economic burden of surgical site infections associated with antimicrobial-resistant bacteria

“…The global variability of healthcare systems, financial structures, currencies, local epidemiologic data, and resistance patterns have limited the generalizability and the comparability of the economic evidence between countries [13]. This has highlighted the urgent need for high-quality studies using a standardized methodology for the evaluation of the economic burden of SSI [6, 63]. Literature review has shown that the major limitations in these studies are mainly related to (1) the uses of different definitions to classify SSI [7] and to the inability to follow-up with patients long enough post-surgical discharge [64].…”

“…Limitations in the methods of economic evaluation may also be related to (3) the location and settings were the study was conducted (i.e. Studies grouped into the same surgical specialty may not be comparable due to differences in operating theater conditions and surgical procedures [13, 63]). Some studies assigned the development of SSI to multiple or unspecified surgeries which can be a source of bias, limiting the comparability of data.…”