Table 1.
Characteristics of included studies
| Preoperative prophylaxis | Preoperative prophylaxis outcome measures | ||||||
|---|---|---|---|---|---|---|---|
| Reference | Population | Follow‐up | Control | Intervention | Primary (efficacy) | Secondary (cost analysis) | Conclusion |
| Blair et al.35 (1995) | ‘Clean’ neck dissection: 192 | n.s. | No prophylaxis | Cefazolin 600 mg* | First‐generation cephalosporin; clindamycin and penicillin versus no antibiotic to prevent postoperative wound infection | Cost‐benefit analysis (hospital stay and cost) | No significant difference in infections. Preoperative antibiotic prophylaxis advocated. Cost‐effective |
| No prophylaxis | Clindamycin 2 g* | ||||||
| No prophylaxis | Penicillin* | ||||||
| No prophylaxis | Drug name n.s.*, † | ||||||
| Bold et al.36 (1998) | Axillary lymph node dissection: 178 | 4 weeks after surgery | Placebo (normal saline) | Cefonicid 1 g (single dose) | Second‐generation cephalosporin versus placebo to decrease postoperative wound complications | Cost‐benefit analysis | No significant difference in infections. Preoperative antibiotic prophylaxis advocated |
| Davey et al.37 (1988) | Abdominal or vaginal hysterectomy: 400 | Every 3 days, then after discharge (visit week 2, phone call week 6) | Placebo (normal saline) | Cephradine 2 g (single dose) | First‐generation cephalosporin versus broad‐spectrum penicillin to prevent wound infection | Cost‐benefit analysis (patient, hospital and community services) | Cephradine antibiotic prophylaxis advocated in abdominal hysterectomy. Antibiotic prophylaxis questionable in vaginal hysterectomy |
| Mezlocillin 5 g (single dose) | |||||||
| Dhadwal et al.38 (2007) | Median sternotomy for primary CABG of at least 1 thoracic artery and at least 1 of 4 defined risk factors: 201‡ and 186§ | Daily until discharge, then after discharge (week 6 and 90 days) | Cefuroxime 1·5 g (single dose), then cefuroxime 750 mg at reversal of anticoagulation, 8 and 16 h after surgery | Rifampicin 600 mg (single dose), then gentamicin 2 mg/kg + vancomycin 15 mg/kg on induction of anaesthesia. Postoperative vancomycin 7·5 mg/kg at 12, 24 and 36 h | Second‐generation¶ cephalosporin versus gentamicin combined with rifampicin and vancomycin to prevent sternal wound infection | Cost‐benefit analysis | Longer and broader‐ spectrum preoperative antibiotic prophylaxis advocated. Cost‐effective |
| Dijksman et al.39 (2012) | Intestinal resection with primary anastomosis, with or without a diverting ileostomy or closure of a temporary colostomy: 289 | 1 year | Placebo for 2 days before surgery, then parenteral perioperative cefuroxime 1500 mg + metronidazole 500 mg 30 min before surgery. Cefuroxime 1500 mg + metronidazole 500 mg continued 8‐hourly for 24 h | SDD (polymyxin B sulphate100 mg + tobramycin 80 mg + amphotericin B 500 mg) for 2 days before surgery and continued for at least 3 days after surgery or until normal bowel function. Parenteral perioperative antibiotic cefuroxime 1500 mg + metronidazole 500 mg 30 min before surgery. Cefuroxime 1500 mg + metronidazole 500 mg continued 8‐hourly for 24 h | Perioperative selective decontamination of digestive tract (polymyxin B sulphate with tobramycin and amphotericin B) versus placebo to reduce infection | Cost‐effectiveness analysis | Selective decontamination of digestive tract advocated. Cost‐effective |
| Garcia‐Rodriguez et al.40 (1989) | Gastroduodenal or biliary surgery with at least 1 of 11 defined risk factors: 1451 | 16 days | Cefoxitin 2 g (single i.v. dose), then cefoxitin 2 g 6, 12 and 18 h after surgery | Cefotaxime 1 g (single dose) | Second‐ and third‐generation cephalosporin¶ to prevent postoperative infection | Cost‐benefit analysis | Cefotaxime antibiotic prophylaxis advocated. Cost‐effective |
| Jones et al.41 (1987) | Obstetrics and gynaecology, gastrointestinal; orthopaedics and other (total joint replacement and open reduction of fractures) surgical procedures: 812 | 30 days | Cefotaxime 1·0 g (slow i.v. bolus after anaesthesia but 30 min before incision). Additional cefotaxime 1·0 g given during surgery if procedure duration 2 h or more. For bowel surgery, standard bowel preparation before prophylaxis | Cefoperazone 1·0 g (slow i.v. bolus after anaesthesia but 30 min before incision). For bowel surgery, standard bowel preparation before prophylaxis | Two third‐generation cephalosporins to prevent perioperative infection | Cost containment | Both cefoperazone and cefotaxime antibiotic prophylaxis advocated. Both cost‐effective |
| Marroni et al.42 (1999) | Abdominal aortic or lower limb prosthetic vascular surgery: 238 | Daily until discharge, then after discharge (3 monthly for 1 year, then at 24 months) | Cefazolin 2 g (single i.v. dose) | Teicoplanin 400 mg (single dose) | Efficacy and tolerability of first‐generation cephalosporin and a glycopeptide to prevent postoperative infection | Cost‐benefit analysis | Cefazolin antibiotic prophylaxis advocated. Cost‐effective |
| Matkaris et al.43 (1991) | Abdominal hysterectomy: 200 | 4–5 days if no SSI, otherwise kept in hospital until infection resolved | No prophylaxis | Ceftriaxone 2 g (single dose). Additional dose if postoperative infection | Efficacy and safety of three third‐generation cephalosporins to prevent postoperative infection | Cost‐benefit analysis | Single dose of any of the three antibiotic prophylaxes advocated. Cefotaxime was most cost‐effective |
| Cefotaxime 2 g (single dose). Additional dose if postoperative infection | |||||||
| Ceftazidime 2 g (single dose). Additional dose if postoperative infection | |||||||
| Matsui et al.44 (2014) | Laparoscopic cholecystectomy for gallbladder stones or polyps: 437 | 8 days after surgery in outpatient setting | No prophylaxis | Cefazolin 1 g (3 doses before skin incision, then 12 and 24 h after surgery). Additional cefazolin 1 g in theatre if duration of surgery more than 3 h | First‐generation† cephalosporin to reduce postoperative complications, including SSI and distant infection | Cost‐ effectiveness analysis | Antibiotic prophylaxis advocated. Cost‐effective |
| Sisto et al.45 (1994) | CABG: 551 | Daily until discharge (10–12 days) or to another hospital (6–7 days) | Ceftriaxone 2 g (single dose) | Cefuroxime 1·5 g (single dose), then cefuroxime 1·5 g (8‐hourly to end of postoperative day 2) | Efficacy and side‐effects of single‐dose third‐generation cephalosporin versus multiple doses of second‐generation cephalosporin to prevent postoperative infection | Cost‐benefit analysis | Efficacy of ceftriaxone and cefuroxime equivalent. Ceftriaxone cheaper and simpler to use |
| Wilson et al.46 (2008) | Colorectal surgery: 672# | 4 weeks after surgery | Ertapenem 1 g (single dose) | Cefotetan 2 g (single dose) | Preoperative prophylaxis of second‐generation cephalosporin and a β‐lactam to reduce postoperative infectious complications | Cost‐benefit analysis | Ertapenem antibiotic prophylaxis advocated. Cost‐effective |
*
Prophylactic antibiotic dose not stated;
†
antibiotic trade name or generation of the cephalosporin not stated;
‡
intention‐to‐treat data for antibiotic efficacy;
§
per‐protocol data for costs38;
¶
blinding not stated;
#
per‐protocol data. n.s., Not stated; CABG, coronary artery bypass graft; SDD, selective decontamination of digestive tract; i.v., intravenous; SSI, surgical‐site infection. A more detailed version of this table is available as Table S3, supporting information47,48.