Is Antibiotic Prophylaxis in Surgery a Generally Effective Intervention? Testing a Generic Hypothesis Over a Set of Meta-Analyses

Department of Public Health and Epidemiology, School of Medicine, University of Birmingham, Edgbaston, Birmingham, United Kingdom.
Annals of surgery (Impact Factor: 7.19). 05/2009; 249(4):551-6. DOI: 10.1097/SLA.0b013e318199f202
Source: PubMed

ABSTRACT While the main focus of a meta-analysis is often to assess the effectiveness of a particular intervention in managing or curing a specific condition, there exists a substantial amount of information within published systematic reviews that could be used to assess the validity of a generic hypothesis about the effectiveness of an intervention across a range of different but related conditions.
To systematically search for and then collate the results of meta-analyses for the effectiveness of antibiotic prophylaxis in preventing postoperative wound infection across various types of surgery in order to assess generic hypotheses about the effectiveness of this intervention in surgery as a whole. With the relative risk of wound infection used as the measure of clinical effectiveness, the hypotheses to be assessed were first that antibiotic prophylaxis would be an effective intervention for preventing wound infection over a broad range of different surgical procedures, and second that there would be a substantial difference in the effectiveness of antibiotic prophylaxis between "clean" and "contaminated" surgical procedures.
Medline and the Cochrane Database of Systematic Reviews.
Eligible meta-analyses were meta-analyses published between 1990 and 2006 of randomized controlled trials that looked at the effectiveness of prophylactic antibiotics versus no antibiotic or placebo in preventing postoperative wound infections.
Independent data extraction by multiple observers.
The first hypothesis was strongly supported by the data as evidenced by the fact that the estimates of the relative risk of infection for the 23 types of surgery that were included in the study were all less than 1. However, there was no real evidence supporting the second hypothesis that the relative risk of wound infection would substantially vary over different levels of surgery cleanliness.
: As well as antibiotic prophylaxis being a generally effective intervention for preventing postoperative wound infection, the level of this effectiveness would appear to be reasonably independent of what type of surgery is being considered. Therefore, the general prevailing attitude that antibiotic prophylaxis should be assumed to be ineffective unless its effectiveness has been experimentally proven beyond doubt for the specific type of surgery being considered, perhaps should be revised. In particular, perhaps a sensible philosophy would be to assume that antibiotic prophylaxis is effective in reducing the risk of wound infection for all types of surgery, even ones where no clinical trial data exists and make exceptions to this rule if, for certain types of surgery, it can be proved to the contrary.

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    • "Case reports, technical notes, expert opinions, tutorials, nonsystematic reviews, and RCTs Animal or laboratory studies Neurosurgical case load High-risk patients (RTx, CTx, and ICP) Therapeutic administration of antibiotics should only be omitted if they are demonstrated to lack any value [6]. This paper gives a brief overview of the current evidence based recommendations regarding antibiotic prophylaxis for elective and emergency procedures in the noninfected operating field in the healthy patient. "
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    ABSTRACT: Antibiotic prophylaxis is commonly used to decrease the rate of infections in head and neck surgery. The aim of this paper is to present the available evidence regarding the application of antibiotic prophylaxis in surgical procedures of the head and neck region in healthy patients. A systemic literature review based on Medline and Embase databases was performed. All reviews and meta-analyses based on RCTs in English from 2000 to 2013 were included. Eight out of 532 studies fulfilled all requirements. Within those, only seven different operative procedures were analyzed. Evidence exists for the beneficial use of prophylactic antibiotics for tympanostomy, orthognathic surgery, and operative tooth extractions. Unfortunately, little high-level evidence exists regarding the use of prophylactic antibiotics in head and neck surgery. In numerous cases, no clear benefit of antibiotic prophylaxis has been shown, particularly considering their potential adverse side effects. Antibiotics are often given unnecessarily and are administered too late and for too long. Furthermore, little research has been performed on the large number of routine cases in the above-mentioned areas of specialization within the last few years, although questions arising with respect to the treatment of high-risk patients or of specific infections are discussed on a broad base.
    BioMed Research International 07/2014; 2014:879437. DOI:10.1155/2014/879437 · 2.71 Impact Factor
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    • "The odds ratio for SSI per 100 operations was 7.1 for dirty procedures and 2.1 for clean procedures. Therefore, SAP is essential to prevent SSI and its complications; thereby it helped to improve wound healing process and eventually reduce the overall hospital stay [10]. Most of the published guidelines clearly recommend discontinuation of SAP after wound closure, and many studies which compared single dose prophylaxis versus multiple doses failed to show any benefits of the multiple doses [11]. "
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    ABSTRACT: Objectives. To assess the standard practice of care of surgeons regarding surgical antibiotic prophylaxis, to identify gaps, and to set recommendations. Methods. A retrospective analysis of data obtained from different surgical units in a single center in Qatar over a 3-month period in 2012. A total of 101 patients who underwent surgery and followed regimes for surgical prophylaxis as per hospital guidelines were included in the study. Results. The overall use of antibiotic was 89%, whereas the current practice did not match the recommended hospital protocols in 53.5% of cases. Prolonged antibiotics use (59.3%) was the commonest reason for nonadherence followed by the use of an alternative antibiotic to that recommended in the protocol (31.5%) and no prophylaxis was used in 9.2% of cases. The rate of compliance was significantly higher among clean surgery than clean contaminated group (P = 0.03). Forty-four percent of clean and 65% of clean-contaminated procedures showed noncompliance with the recommended surgical antimicrobial prophylaxis hospital guidelines. Conclusion. Lack of adherence to hospital protocols is not uncommon. This finding remains a challenge to encourage clinicians to follow hospital guidelines appropriately and to consistently apply the surgical antibiotic prophylaxis. The role of clinical pharmacist may facilitate this process across all surgical disciplines.
    Advances in Pharmacological Sciences 12/2013; 2013:842593. DOI:10.1155/2013/842593
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    • "In France, the first work on the ''rational practice of preventive antibiotic therapy'' was by François Vachon, in 1986 [3]. There has since formed an international consensus that antimicrobial prophylaxis reduces the rate of postoperative infection, as was recently confirmed a meta-analysis of the literature for the period 1990—2006 [4]. The Infectious Diseases Society of America, however, reported that prescriber practice still needed assessment in terms of risk-benefit and cost-benefit analysis [5]. "
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    ABSTRACT: Antimicrobial prophylaxis is one of the main safety measures to be enforced when implanting any medical device; surveys of practice, however, have found poor compliance. This study is based on analysis of 153 dedicated in-depth analysis forms sent to orthopedic surgeons who had reported an antimicrobial prophylaxis-related near-miss event (NME) during the year 2008 as part of their certification report to the official organization, Orthorisq (orthopaedic Patient safety risk management agency). Antimicrobial prophylaxis guidelines exist in 95% of French centers, but in 14% are not available in the right place. 88% of orthopedic surgeons consider them well-adapted to their practice. Most declarations follow fortuitous discovery by the surgeon of an immediate peri-operative malfunction. Human causes were found in 92% of declarations, general organizational causes in 50% and material causes in 28%. Regarding corrective action, 65% of respondents reported implementing a second-order procedure, and only 20% were able to resume truly regular antimicrobial prophylaxis. The main reason for poor or non-performance of antimicrobial prophylaxis was "omission by negligence or oversight", reported in 56% of declarations. Proposals for improvement were: revised antimicrobial prophylaxis guidelines specifying "who does what"; guideline awareness checks on new, temporary and locum-tenens staff; patient involvement in personal data collection; and implementation of a check-list in line with WHO and French Health Authority recommendations. These improvement proposals were taken on board in the antimicrobial prophylaxis consensus update currently being drawn up by the French Society for Anesthesia and Intensive Care. Level IV, Decision Analyses Study.
    Orthopaedics & Traumatology Surgery & Research 06/2010; 96(5):493-9. DOI:10.1016/j.otsr.2010.03.014 · 1.17 Impact Factor
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