Prevention of infection in peripheral arterial reconstruction of the lower limb

Peripheral arterial disease (PAD) results from the narrowing of arteries. Arterial reconstruction surgery is the treatment of choice for severe cases. Graft infections and surgical site infections (SSIs) are a feared and common complication of vascular surgery. These infections have a significant global healthcare impact. Evaluating the effectiveness of preventive measures is essential.

To assess the effects of pharmacological and non-pharmacological interventions, including antimicrobial therapy, antisepsis, and wound management, to prevent infection in patients undergoing any open or hybrid lower limb peripheral arterial reconstruction.

The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, LILACS, and CINAHL databases, as well as the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov up to 26 August 2024.

We included all randomised controlled trials (RCTs) with a parallel (e.g. cluster or individual) design and quasi-RCTs that assessed any intervention to reduce or prevent infection following peripheral arterial reconstruction of the lower limb. There were no limitations on age and gender.

We used standard Cochrane methodological procedures. Two review authors independently extracted the data and assessed the risk of bias in the included studies. We assessed the certainty of evidence using the GRADE approach.

We included 35 RCTs and five quasi-RCTs with a total of 7970 participants. We analysed 16 comparisons for nine outcomes. The four main comparisons were prophylactic antibiotics versus placebo or no treatment; short- (≤ 24 hours) versus long-duration prophylactic antibiotics (> 24 hours); different types of systemic antibiotic prophylaxis (one versus another); and closed incision negative pressure therapy versus standard wound closure. The primary outcomes were graft infection rate and SSI rate. The secondary outcomes were all-cause mortality, arterial reconstruction failure rate, re-intervention rate, amputation rate, pain resulting from the interventions to prevent infection, health-related quality of life, and adverse events resulting from the interventions to prevent infection. Not all outcomes were assessed across the different comparisons. Prophylactic antibiotics versus placebo (eight studies) Low-certainty evidence from eight included studies suggests that antibiotic prophylaxis may reduce the graft infection rate (risk ratio (RR) 0.19, 95% confidence interval (CI) 0.06 to 0.63; 6 studies, 979 participants; low-certainty evidence; number needed to treat (NNT) 5) and SSI rate (RR 0.20, 95% CI 0.11 to 0.34; 8 studies, 1188 participants; low-certainty evidence, NNT 9). There was no difference between the groups in the other outcomes that we could assess. Short-duration (≤ 24 hours) versus long-duration prophylactic antibiotics (> 24 hours) (three studies) Very low-certainty evidence from three included studies suggests that there is little or no significant difference in the graft infection rate (RR 1.40, 95% CI 0.09 to 20.65; 2 studies, 139 participants; very low-certainty evidence) or the SSI rate (RR 0.75, 95% CI 0.40 to 1.40; 3 studies, 247 participants; very low-certainty evidence) between short- and long-duration antibiotic prophylaxis. Different types of systemic antibiotic prophylaxis (one versus another) (seven studies) We divided seven studies comparing one antibiotic to another into four subgroups that compared different classes of antibiotics amongst themselves for short and long-term time points. We found little or no difference between the groups analysed. For graft infection rate, only the second- or third-generation cephalosporins versus first-generation cephalosporins comparison had quantitative data (RR 1.71, 95% CI 0.35 to 8.45; 4 studies, 1512 participants; very low-certainty evidence). For SSI rate, we could assess the following comparisons: second- or third-generation cephalosporins versus first-generation cephalosporins (RR 0.71, 95% CI 0.26 to 1.97; 4 studies, 956 participants; very low-certainty evidence); ciprofloxacin versus cefuroxime (RR 1.02, 95% CI 0.61 to 1.70; 1 study, 580 participants; very low-certainty evidence); cefazolin plus daptomycin versus cefazolin plus vancomycin (RR 1.44, 95% CI 0.58 to 3.54; 1 study, 178 participants; low-certainty evidence); teicoplanin versus cephradine (RR 0.68, 95% CI 0.17 to 2.72; 1 study, 134 participants; very low-certainty evidence); cloxacillin plus gentamicin versus cefotaxime (only in the long term) (RR 1.19, 95% CI 0.33 to 4.23; 1 study, 36 participants; very low-certainty evidence). For amputation rate, there was little or no difference between the second- or third-generation cephalosporin versus first-generation cephalosporin antibiotic classes (RR 3.14, 95% CI 0.33 to 30.13; 2 studies, 1269 participants; very low-certainty evidence). Closed incision negative pressure therapy versus standard wound drainage (nine studies) For graft infection rate, data from five studies showed little or no difference between the groups (RR 0.55, 95% CI 0.19 to 1.59; 5 studies, 802 participants; very low-certainty evidence). Data from nine studies may show a reduction in SSI rate (RR 0.49, 95% CI 0.27 to 0.86; 5 studies, 772 groin access; very low-certainty evidence) in the short and long term. For all-cause mortality (RR 1.78, 95% CI 0.22 to 14.32; 2 studies, 363 participants; very low-certainty evidence), re-intervention rate (RR 0.46, 95% CI 0.20 to 1.04; 3 studies, 436 participants; very low-certainty evidence), amputation (RR 0.34, 95% CI 0.01 to 8.38; 1 study, 234 participants; low-certainty evidence), and pain outcome (MD -0.10, 95% CI -0.25 to 0.05; 1 study, 242 participants; low-certainty evidence) there was little or no difference between the groups.

Prophylactic antibiotics may reduce SSIs in peripheral arterial reconstruction of the lower limb with low-certainty evidence. We found no superiority among specific antibiotics or differences in extended use (over 24 hours) compared with shorter use (up to 24 hours), with low-certainty evidence. Closed incision negative pressure therapy may lower the SSI risk, but this is based on very low-certainty evidence. For other interventions, very low- to moderate-certainty evidence showed little or no significant differences across various outcomes. We advise caution when interpreting these conclusions due to the limited number of events in all groups and comparisons.