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. 2018 Oct 5;1(6):e183226.
doi: 10.1001/jamanetworkopen.2018.3226.

Association of Mechanical Bowel Preparation and Oral Antibiotics Before Elective Colorectal Surgery With Surgical Site Infection: A Network Meta-analysis

James W T Toh  1   2   3 , Kevin Phan  1 , Kerry Hitos  1   2   3 , Nimalan Pathma-Nathan  1   3 , Toufic El-Khoury  1   3   4 , Arthur J Richardson  1   3 , Gary Morgan  1   3 , Alexander Engel  1   5 , Grahame Ctercteko  1   3
Affiliations

Association of Mechanical Bowel Preparation and Oral Antibiotics Before Elective Colorectal Surgery With Surgical Site Infection: A Network Meta-analysis

James W T Toh et al. JAMA Netw Open. .

Abstract

Importance: There has been a resurgence of interest in the use of mechanical bowel preparation (MBP) and oral antibiotics (OAB) before elective colorectal surgery. Until now, clinical trials and meta-analyses have not compared all 4 approaches (MBP with OAB, OAB only, MBP only, or no preparation) simultaneously.

Objective: To perform a network meta-analysis to clarify which approach in colorectal surgery is associated with the lowest rate of surgical site infection (SSI).

Data sources: Five electronic databases were searched, including PubMed, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, ACP Journal Club. and Database of Abstracts of Review of Effectiveness from database inception to November 27, 2017.

Study selection: Only data from randomized clinical trials were included. Inclusion criteria were RCTs that reported on SSI rates or other complications based on MBP or OAB status. Quality of studies was appraised by the Cochrane Collaboration risk of bias tool.

Data extraction and synthesis: The study was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

Main outcomes and measures: Total, incisional, and organ/space SSI rates. Secondary outcomes included rates of anastomotic leak, mortality, readmissions/reoperations, urinary tract infection, and pulmonary complications.

Results: Thirty-eight randomized clinical trials among 8458 patients (52.1% male) were included, providing 4 direct comparisons and 2 indirect comparisons for 8 outcome measures. On Bayesian analysis, MBP with OAB vs MBP only was associated with reduced SSI (odds ratio [OR], 0.71; 95% equal-tail credible interval [CrI], 0.57-0.88). There was no significant difference between MBP with OAB vs OAB only (OR, 0.95; 95% CrI, 0.56-1.62). Oral antibiotics without MBP was not associated with a statistically significant reduction in SSI compared with any other group (except for a risk reduction in organ/space SSI when indirectly compared with no preparation) (OR, 0.13; 95% CrI, 0.02-0.55). There was no difference in SSI between MBP only vs no preparation (OR, 0.84; 95% CrI, 0.69-1.02).

Conclusions and relevance: In this network meta-analysis of randomized clinical trials, MBP with OAB was associated with the lowest risk of SSI. Oral antibiotics only was ranked as second best, but the data available on this approach were limited. There was no difference between MBP only vs no preparation. In addition, there was no difference in rates of anastomotic leak, readmissions, or reoperations between any groups.

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Conflict of interest statement

Conflict of Interest Disclosures: None reported.

Figures

Figure 1.
Figure 1.. Network Plots of the 8 Outcomes Showing Direct Comparisons and Indirect Comparisons Between Treatment Groups Based on Mechanical Bowel Preparation (MBP) and Oral Antibiotic (OAB) Status
Comparison networks were explored by representing each of the 4 bowel preparation approaches as a node, with lines between nodes representing a comparison between 2 linked treatments. Size of the node is proportional to the number of patients randomized to that bowel preparation approach, and the thickness of the lines is proportional to the number of studies comparing the 2 approaches.
Figure 2.
Figure 2.. League Tables of the 8 Outcomes Showing Direct Comparisons and Indirect Comparisons Between Treatment Groups Based on Mechanical Bowel Preparation (MBP) and Oral Antibiotic (OAB) Status
Outcomes are shown as odds ratios (95% equal-tail credible intervals); direct comparisons are represented in bold, and indirect comparisons are represented in italics.
Figure 3.
Figure 3.. Rankograms of the 8 Outcomes Showing the Probability of Being Ranked the Best vs the Worst Based on Mechanical Bowel Preparation (MBP) and Oral Antibiotic (OAB) Status
Outcomes on the far left of the x-axis are ranked best; far right, worst.
Figure 4.
Figure 4.. Forest Plots of the 8 Outcomes Showing Direct Comparisons and Indirect Comparisons Based on Mechanical Bowel Preparation (MBP) and Oral Antibiotic (OAB) Status
Outcomes are shown as odds ratios (ORs) (95% equal-tail credible intervals [CrIs]).
See this image and copyright information in PMC

Comment in

References

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