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Published on: September 12, 2020
The Role of Oral Antibiotic Preparation in Elective Colorectal Surgery: A Meta-analysis
Katie E Rollins1, Hannah Javanmard-Emamghissi1, Austin G Acheson1
1Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, UK.
Objectives:
To compare the impact of the use of oral antibiotics (OAB) with or without mechanical bowel preparation (MBP) on outcome in elective colorectal surgery.
Summary Background Data:
Meta-analyses have demonstrated that MBP does not impact upon postoperative morbidity or mortality, and as such it should not be prescribed routinely. However, recent evidence from large retrospective cohort and database studies has suggested that there may be a role for combined OAB and MBP, or OAB alone in the prevention of surgical site infection (SSI).
Methods:
A meta-analysis of randomized controlled trials and cohort studies including adult patients undergoing elective colorectal surgery, receiving OAB with or without MBP was performed. The outcome measures examined were SSI, anastomotic leak, 30-day mortality, overall morbidity, development of ileus, reoperation and Clostridium difficile infection.
Results:
A total of 40 studies with 69,517 patients (28 randomized controlled trials, n = 6437 and 12 cohort studies, n = 63,080) were included. The combination of MBP+OAB versus MBP alone was associated with a significant reduction in SSI [risk ratio (RR) 0.51, 95% confidence interval (CI) 0.46-0.56, P < 0.00001, I = 13%], anastomotic leak (RR 0.62, 95% CI 0.55-0.70, P < 0.00001, I = 0%), 30-day mortality (RR 0.58, 95% CI 0.44-0.76, P < 0.0001, I = 0%), overall morbidity (RR 0.67, 95% CI 0.63-0.71, P < 0.00001, I = 0%), and development of ileus (RR 0.72, 95% CI 0.52-0.98, P = 0.04, I = 36%), with no difference in Clostridium difficile infection rates. When a combination of MBP+OAB was compared with OAB alone, no significant difference was seen in SSI or anastomotic leak rates, but there was a significant reduction in 30-day mortality, and incidence of postoperative ileus with the combination. There is minimal literature available on the comparison between combined MBP+OAB versus no preparation, OAB alone versus no preparation, and OAB versus MBP.
Conclusions:
Current evidence suggests a potentially significant role for OAB preparation, either in combination with MBP or alone, in the prevention of postoperative complications in elective colorectal surgery. Further high-quality evidence is required to differentiate between the benefits of combined MBP+OAB or OAB alone.
Insights
Oral antibiotics (OAB) with mechanical bowel preparation (MBP) significantly reduce complications like surgical site infections and mortality in elective colorectal surgery. OAB alone may also prevent postoperative issues, but more research is needed to compare OAB with MBP versus OAB alone.
Area of Science:
- Colorectal Surgery
- Surgical Site Infections
- Antibiotic Prophylaxis
Background:
- Mechanical bowel preparation (MBP) is not routinely recommended for elective colorectal surgery.
- Recent studies suggest a potential benefit of oral antibiotics (OAB) with or without MBP in preventing surgical site infections (SSI).
Purpose of the Study:
- To compare the impact of oral antibiotics (OAB) with or without mechanical bowel preparation (MBP) on outcomes in elective colorectal surgery.
- To evaluate the effectiveness of OAB and MBP in preventing postoperative complications.
Main Methods:
- A meta-analysis of randomized controlled trials and cohort studies.
- Included adult patients undergoing elective colorectal surgery.
- Examined outcomes such as SSI, anastomotic leak, mortality, morbidity, ileus, reoperation, and Clostridium difficile infection.
Main Results:
- MBP+OAB significantly reduced SSI, anastomotic leak, 30-day mortality, overall morbidity, and ileus compared to MBP alone.
- MBP+OAB also showed reduced 30-day mortality and ileus compared to OAB alone.
- No significant difference in SSI or anastomotic leak between MBP+OAB and OAB alone was observed.
Conclusions:
- Oral antibiotic preparation, with or without MBP, shows potential in preventing postoperative complications in elective colorectal surgery.
- Further high-quality evidence is needed to distinguish the benefits of combined MBP+OAB versus OAB alone.
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