The Role of Oral Antibiotic Preparation in Elective Colorectal Surgery: A Meta-analysis

Abstract

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.

Figure 1

Forest plot comparing surgical site infection rate for patients receiving MBP+OAB versus MBP alone, divided by evidence from RCTs and cohort studies. A Mantel–Haenszel random effects model was used to perform the meta-analysis and risk ratios are quoted including 95% confidence intervals.

Figure 2

Forest plot comparing surgical site infection rate for patients receiving MBP+OAB versus OAB alone, divided by evidence from RCTs and cohort studies. A Mantel–Haenszel random effects model was used to perform the meta-analysis and risk ratios are quoted including 95% confidence intervals.

Figure 3

Forest plot comparing anastomotic leak rate for patients receiving MBP+OAB versus MBP alone, divided by evidence from RCTs and cohort studies. A Mantel–Haenszel random effects model was used to perform the meta-analysis and risk ratios are quoted including 95% confidence intervals.

Figure 4

Forest plot comparing 30-day mortality rates for patients receiving MBP+OAB versus MBP alone, divided by evidence from RCTs and cohort studies. A Mantel–Haenszel random effects model was used to perform the meta-analysis and risk ratios are quoted including 95% confidence intervals.