Table 3.
Evidence of efficacy of preoperative prophylactic antibiotics
| Preoperative prophylaxis | Sample size | Postoperative infections | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Reference | Surgical procedure | Definition of postoperative infection | Control | Intervention | Total (M : F) | Control* | Intervention* | Control* | Intervention* | P |
| Blair et al.35 † | Neck dissection | Wound infection: based on wound grading scale developed by Johnson et al.49 | No prophylaxis | Cefazolin 600 mg | 192 (139 : 53) | 99 (51·6) | 58 (30·2) | 10 (10·0) | 3 (3·3) | 0·08 |
| Clindamycin 2 g | 13 (6·8) | |||||||||
| Penicillin | 17 (8·6) | |||||||||
| Drug n.s. | 5 (2·6) | |||||||||
| Bold et al.36 | Axillary lymph node dissection | Infection of surgical wound in the absence of any other site of infection | Placebo (normal saline) | Cefonicid 1 g | 178 (24 : 154) | 90 (50·6) | 88 (49·4) | 12 (13·0) | 5 (6·0) | 0·08‡ |
| Davey et al.37 § | AH or VH | Infected wound; pelvic infection | Placebo (normal saline) | Cephradine 2 g | 400 (0 : 400) | AH 102 (25·5) | AH 97 (24·3) | Hospital wound | ||
| Pelvic | ||||||||||
| VH 29 (7·2) | VH 34 (8·5) | AH 20 (19·6) | AH 6 (6) | < 0·05 | ||||||
| VH 6 (21) | VH 1 (3) | < 0·05 | ||||||||
| Hospital total | ||||||||||
| AH 42 (41·2) | AH 16 (16) | < 0·01 | ||||||||
| VH 10 (34) | VH 8 (24) | 0·41 | ||||||||
| Home wound | ||||||||||
| Pelvic | ||||||||||
| AH 9 (8·8) | AH 10 (10) | 0·81 | ||||||||
| VH 2 (7) | VH 1 (3) | VH 0·59 | ||||||||
| Home total | ||||||||||
| AH 15 (14·7) | AH 25 (26) | AH 0·05 | ||||||||
| VH 7 (24) | VH 10 (29) | VH 0·02 | ||||||||
| Mezlocillin 5 g | AH 102 (25·5) | AH 101 (25·3) | Hospital wound | |||||||
| Pelvic | ||||||||||
| VH 29 (7·2) | VH 37 (9·2) | AH 20 (19·6) | AH 18 (17·8) | 0·86 | ||||||
| VH 6 (21) | VH 0 (0) | < 0·01 | ||||||||
| Hospital total | ||||||||||
| AH 42 (41·2) | AH 30 (29·7) | 0·11 | ||||||||
| VH 10 (34) | VH 6 (16) | 0·15 | ||||||||
| Home wound | ||||||||||
| Pelvic | ||||||||||
| AH 9 (8·8) | AH 4 (4·0) | 0·25 | ||||||||
| VH 2 (7) | VH 0 (0) | 0·19 | ||||||||
| Home total | ||||||||||
| AH 15 (14·7) | AH 14 (13·9) | 1·000 | ||||||||
| VH 7 (24) | VH 2 (5) | 0·04 | ||||||||
| Dhadwal et al.38 | CABG | NNIS infection risk score35 CDC sternal wound50 | Cefuroxime 1·5 g | Rifampicin 600 mg; gentamicin 2 mg/kg; vancomycin 15 mg/kg | 201 (165 : 36) | 106 (52·8) | 95 (47·2) | NNIS 30‐day infection | ||
| 12 (11·3) | 4 (4) | 0·063 | ||||||||
| Sternal wound (90 days) | ||||||||||
| 25 (23·6) | 8 (8) | 0·004¶ | ||||||||
| Superficial | ||||||||||
| 11 (10·4) | 4 (4) | 0·097 | ||||||||
| Deep | ||||||||||
| 8 (7·5) | 2 (2) | 0·15# | ||||||||
| Organ space | ||||||||||
| 6 (5·7) | 2 (2) | 0·36# | ||||||||
| Deep + organ space | ||||||||||
| 14 (13·2) | 4 (4) | 0·03 | ||||||||
| Sternal debridement | ||||||||||
| 19 (17·9) | 4 (4) | 0·002 | ||||||||
| Harvest site infection | ||||||||||
| 7 (6·6) | 45 (5) | 0·69 | ||||||||
| Dijksman et al.39 | Digestive tract surgery | Wound infection, intra‐abdominal abscess and anastomotic leak47,51. Calculated event rate was percentage of patients who suffered at least 1 infectious complication | Placebo. Parenteral perioperative antibiotic cefuroxime 1500 mg + metronidazole 500 mg | SDD (polymyxin B sulphate100 mg + tobramycin 80 mg + amphotericin B 500 mg). Parenteral perioperative antibiotic cefuroxime 1500 mg + metronidazole 500 mg | 289 (156 : 133) | 146 (50·5) | 143 (49·5) | 45 (30·8) | 28 (19·6) | 0·03¶ |
| Garcia‐Rodriguez et al.40 ** | Gastroduodenal or biliary surgery | Surgical wound infection: cellulitis with purulent secretion, with or without dehiscence (NRC52) | Cefoxitin 2 g | Cefotaxime 1 g | 1451 (624 : 827) | 716 (50·2) | 722 (49·8) | Wound infection | ||
| 54 (7·5) | 24 (3·3) | < 0·002 | ||||||||
| Jones et al.41 †† | Gastrointestinal; gynaecological, orthopaedic (total joint replacement and open reduction of fractures) and other surgery | Postoperative surgical incision or peritoneal cavity infection | Cefotaxime 1 g | Cefoperazone 1 g | 812 (42 : 770) | 401 (49·4) | 411 (50·6) | Wound infection | ||
| 12 (3·0) | 9 (2·2) | > 0·05 | ||||||||
| Total general | 96 | 89 | 1 (1) | 2 (2) | 1·000 | |||||
| UGIT | 72 | 66 | 0 (0) | 0 (0) | ||||||
| Colorectal | 24 | 23 | 1 (4) | 2 (9) | 1·000 | |||||
| Total O+G | 168 | 168 | 9 (5·4) | 6 (3·6) | 0·60 | |||||
| Hysterectomy | 119 | 125 | 8 (6·7) | 6 (4·8) | 0·59 | |||||
| C‐section | 19 | 18 | 1 (5) | 0 (0) | 1·000 | |||||
| Other O+G | 30 | 25 | 0 (0) | 0 (0) | ||||||
| Total orthopaedic | 74 | 77 | 1 (1) | 0 (0) | 0·49 | |||||
| Total joints | 51 | 59 | 0 (0) | 0 (0) | ||||||
| Other orthopaedic | 23 | 18 | 1 (4) | 0 (0) | 1·000 | |||||
| Other surgery | 61 | 77 | 1 (2) | 1 (1) | 1·000 | |||||
| Marroni et al.42 ‡‡ | Abdominal aortic or lower limb prosthetic vascular surgery | Surgical wound infection; deep wound infection (CDC53) | Cefazolin 2 g | Teicoplanin 400 mg | 238 (220 : 18) | 119 (50·0) | 119 (50·0) | SSI | ||
| 2 (1·7) | 7 (5·9) | 0·19 | ||||||||
| Graft | ||||||||||
| 2 (1·7) | 0 (0·0) | 0·49 | ||||||||
| Wound | ||||||||||
| 5 (4·2) | 2 (1·7) | 0·46 | ||||||||
| Matkaris et al.43 | AH | Fever > 38°C for 24 h, blood analysis, urine analysis, clinical evaluation | No prophylaxis | Ceftriaxone 2 g | 200 (0 : 200) | 50 (25·0) | 50 (25·0) | 15 (30) | 3 (6) | < 0·01§§ |
| Cefotaxime 2 g | 50 (25·0) | 4 (8) | ||||||||
| Ceftazidime 2 g | 50 (25·0) | 4 (8) | ||||||||
| Matsui et al.44 ¶¶ | Laparoscopic cholecystectomy for removal of gallbladder stones or polyps | SSI (surgical wound and subhepatic abscess) | No prophylaxis | Cefazolin 1 g | 1037 (490 : 547) | 519 (50·0) | 518 (50·0) | SSI | ||
| 19 (3·7) | 4 (0·8) | 0·001 | ||||||||
| Wound | ||||||||||
| 16 (3·1) | 4 (0·8) | 0·005 | ||||||||
| Subhepatic | ||||||||||
| 3 (0·6) | 0 (0·0) | 0·249 | ||||||||
| All infections | ||||||||||
| 35 (6·7) | 6 (1·2) | < 0·001 | ||||||||
| Sisto et al.45 ## | CABG | Superficial and deep sternal wound infection; donor‐site infection | Ceftriaxone 2 g | Cefuroxime 1·5 g, then cefuroxime 1·5 g 8‐hourly until end of day 2 after surgery | 551 (437 : 114) | 274 (49·7) | 277 (50·3) | Superficial | ||
| 4 (1·5) | 7 (2·5) | 0·56 | ||||||||
| Deep | ||||||||||
| 8 (2·9) | 8 (2·9) | 1·00 | ||||||||
| Donor site | ||||||||||
| 3 (1·1) | 4 (1·4) | 1·00 | ||||||||
| Wilson et al.46 *** | Colorectal surgery | SSI (organ space; deep incisional; either superficial infection or anastomotic leak) (NNIS54,55) | Ertapenem 1 g | Cefotetan 2 g | 672 (365 : 307) | 338 (50·3) | 334 (49·7) | SSI | ||
| 62 (18·3) | 104 (31·1) | < 0·001 | ||||||||
| Organ/space | ||||||||||
| 4 (1·2) | 12 (3·6) | 0·05 | ||||||||
| Deep | ||||||||||
| 13 (3·8) | 17 (5·1) | 0·46 | ||||||||
| Superficial | ||||||||||
| 45 (13·3) | 75 (22·5) | 0·002 | ||||||||
| Anastomotic leak | ||||||||||
| 10 (3·0) | 14 (4·2) | 0·41 | ||||||||
Values in parentheses are percentages.
Intervention failure results for cefazolin, clindamycin and cefoperazone were pooled as individual results were not stated; statistical method was not stated, but assumed to be Fisher's exact test.
Fisher's exact test (P < 0·050 was considered significant with 80 per cent confidence level).
Analysis of significance in fourfold tables was done with the χ2 test with Yates' correction unless the total number of observations was less than 60 or the number in any cell was zero, when Fisher's exact test was used; threefold or greater tables were analysed with the χ2 test.
χ2 or Fisher's exact test with two‐sided significance level of 0·05.
χ2 test with Yates' correction.
Intention‐to‐treat data; statistical analysis with Fisher's exact test; infection data were missing for six patients in the control group and seven in the intervention group.
Per‐protocol data; statistical analysis with Fisher's exact test or χ2 test; P < 0·050 considered significant;
χ2 test with a two‐sided significance level of 0·05 when expected frequencies were less than 5.
Statistical method not stated.
χ2 test with significance level of 0·05; Fisher's exact test used for subhepatic comparison as expected frequencies in cells were less than 5.
Student's t test for parametric data and Mann–Whitney or χ2 test for non‐parametric data; significance level of 0·05.
Per‐protocol data; absolute difference and 95 per cent c.i. for percentage prophylactic failure were determined in a statistical model adjusting for surgical procedure; 95 per cent c.i. that did not overlap zero indicated significant difference between groups at P < 0·050. n.s., Not stated; AH, abdominal hysterectomy; VH, vaginal hysterectomy; CABG, coronary artery bypass graft; NNIS, National Nosocomial Infections Surveillance; CDC, Centers for Disease Control and Prevention; SDD, selective decontamination of digestive tract; NRC, National Research Council; UGIT, upper gastrointestinal tract; O+G, obstetrics and gynaecology; C‐section, caesarean section; SSI, surgical‐site infection.