Oral Antibiotic Prophylaxis Reduces Surgical Site Infection and Anastomotic Leakage in Patients Undergoing Colorectal Cancer Surgery

Abstract

Background: Surgical-site infection (SSI) and anastomotic leakage (AL) are major complications following surgical resection of colorectal carcinoma (CRC). The beneficial effect of prophylactic oral antibiotics (OABs) on AL in particular is inconsistent. We investigated the impact of OABs on AL rates and on SSI.

Methods: A systematic review and meta-analysis of recent RCTs and cohort studies was performed including patients undergoing elective CRC surgery, receiving OABs with or without mechanical bowel preparation (MBP). Primary outcomes were rates of SSI and AL. Secondarily, rates of SSI and AL were compared in broad-spectrum OABs and selective OABs (selective decontamination of the digestive tract (SDD)) subgroups.

Results: Eight studies (seven RCTs and one cohort study) with a total of 2497 patients were included. Oral antibiotics combined with MBP was associated with a significant reduction in SSI (RR = 0.46, 95% confidence interval (CI) 0.31-0.69), I² = 1.03%) and AL rates (RR = 0.58, 95% CI 0.37-0.91, I² = 0.00%), compared to MBP alone. A subgroup analysis demonstrated that SDD resulted in a significant reduction in AL rates compared to broad-spectrum OABs (RR = 0.52, 95% CI 0.30 to 0.91), I² = 0.00%).

Conclusion: OABs in addition to MBP reduces SSI and AL rates in patients undergoing elective CRC surgery and, more specifically, SDD appears to be more effective compared to broad-spectrum OABs in reducing AL.

Keywords: anastomotic leakage; colorectal carcinoma; oral antibiotics; surgery; surgical site infection.

Figure 1

PRISMA diagram showing identification of studies from the initial literature search.

Figure 2

Forest plot comparing anastomotic leakage rate for patients receiving OABs in addition to MBP and i.v. antibiotic prophylaxis versus MBP alone with i.v. antibiotic prophylaxis. A random effects model was used to perform the meta-analysis and risk ratios are quoted including 95% confidence intervals.

Figure 3

Forest plot comparing SSI rate for patients receiving OABs in addition to MBP and i.v. antibiotic prophylaxis versus MBP with i.v. antibiotic prophylaxis. A random effects model was used to perform the meta-analysis and risk ratios are quoted including 95% confidence intervals.

Figure 4

Forest plot comparing anastomotic leakage rate for patients receiving SDD (selective decontamination of the digestive tract is selective OAB targeting only the specific aerobe, Gram-negative bacteria) in addition to MBP and i.v. antibiotic prophylaxis versus MBP with i.v. antibiotic prophylaxis. A random effects model was used to perform the meta-analysis and risk ratios are quoted including 95% confidence intervals.

Figure 5

Forest plot comparing anastomotic leakage rate for patients receiving broad-spectrum OABs (defined as OABs that are effective against both aerobe and anaerobe bacteria) in addition to MBP and i.v. antibiotic prophylaxis versus MBP alone with i.v. antibiotic prophylaxis. A random effects model was used to perform the meta-analysis and risk ratios are quoted including 95% confidence intervals.

Figure 6

Forest plot comparing SSI rate for patients receiving SDD (selective decontamination of the digestive tract is selective OAB targeting only specific the aerobe, Gram-negative bacteria) in addition to MBP and i.v. antibiotic prophylaxis versus MBP with i.v. antibiotic prophylaxis. A random effects model was used to perform the meta-analysis and risk ratios are quoted including 95% confidence intervals.

Figure 7

Forest plot comparing SSI rate for patients receiving broad-spectrum OABs (defined as OAB that are effective against both aerobe and anaerobe bacteria) in addition to MBP and i.v. antibiotic prophylaxis versus MBP alone with i.v. antibiotic prophylaxis. A random effects model was used to perform the meta-analysis and risk ratios are quoted including 95% confidence intervals.