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

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

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.

Conflict of interest statement

Conflict of Interest Disclosures: None reported.

Figures

Figure 1.. Network Plots of the 8…
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.. League Tables of the 8…
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.. Rankograms of the 8 Outcomes…
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.. Forest Plots of the 8…
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]).

References

    1. Holubar SD, Hedrick T, Gupta R, et al. ; Perioperative Quality Initiative (POQI) I Workgroup . American Society for Enhanced Recovery (ASER) and Perioperative Quality Initiative (POQI) joint consensus statement on prevention of postoperative infection within an enhanced recovery pathway for elective colorectal surgery. Perioper Med (Lond). 2017;6:. doi:10.1186/s13741-017-0059-2
    1. Systematic Review Report for question PRP2-5,7. Clinical question: can peri operative management be optimised? . Accessed November 7, 2017.
    1. Devane LA, Proud D, O’Connell PR, Panis Y. A European survey of bowel preparation in colorectal surgery. Colorectal Dis. 2017;19(11):O402-. doi:10.1111/codi.13905
    1. Güenaga KF, Matos D, Wille-Jørgensen P. Mechanical bowel preparation for elective colorectal surgery. Cochrane Database Syst Rev. 2011;(9):CD001544.
    1. Chen M, Song X, Chen LZ, Lin ZD, Zhang XL. Comparing mechanical bowel preparation with both oral and systemic antibiotics versus mechanical bowel preparation and systemic antibiotics alone for the prevention of surgical site infection after elective colorectal surgery: a meta-analysis of randomized controlled clinical trials. Dis Colon Rectum. 2016;59(1):70-78. doi:10.1097/DCR.0000000000000524
    1. Dahabreh IJ, Steele DW, Shah N, Trikalinos TA. Oral mechanical bowel preparation for colorectal surgery: systematic review and meta-analysis. Dis Colon Rectum. 2015;58(7):698-707. doi:10.1097/DCR.0000000000000375
    1. Nelson RL, Gladman E, Barbateskovic M. Antimicrobial prophylaxis for colorectal surgery. Cochrane Database Syst Rev. 2014;(5):CD001181.
    1. Nelson RL, Glenny AM, Song F. Antimicrobial prophylaxis for colorectal surgery. Cochrane Database Syst Rev. 2009;(1):CD001181.
    1. Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group . Preferred Reporting Items for Systematic Reviews and Meta-Analyses: the PRISMA statement. PLoS Med. 2009;6(7):e1000097. doi:10.1371/journal.pmed.1000097
    1. Phan K, Tian DH, Cao C, Black D, Yan TD. Systematic review and meta-analysis: techniques and a guide for the academic surgeon. Ann Cardiothorac Surg. 2015;4(2):112-122.
    1. Zmora O, Mahajna A, Bar-Zakai B, et al. . Colon and rectal surgery without mechanical bowel preparation: a randomized prospective trial. Ann Surg. 2003;237(3):363-367. doi:10.1097/01.SLA.0000055222.90581.59
    1. Zmora O, Mahajna A, Bar-Zakai B, et al. . Is mechanical bowel preparation mandatory for left-sided colonic anastomosis? results of a prospective randomized trial. Tech Coloproctol. 2006;10(2):131-135. doi:10.1007/s10151-006-0266-1
    1. University of Melbourne Colorectal Group Clinical trial of prophylaxis of wound sepsis in elective colorectal surgery comparing ticarcillin with tinidazole. Aust N Z J Surg. 1986;56(3):209-213. doi:10.1111/j.1445-2197.1986.tb06137.x
    1. University of Melbourne Colorectal Group Systemic Timentin is superior to oral tinidazole for antibiotic prophylaxis in elective colorectal surgery. Dis Colon Rectum. 1987;30(10):786-789. doi:10.1007/BF02554628
    1. Horan TC, Gaynes RP, Martone WJ, Jarvis WR, Emori TG. CDC definitions of nosocomial surgical site infections, 1992: a modification of CDC definitions of surgical wound infections. Infect Control Hosp Epidemiol. 1992;13(10):606-608. doi:10.1017/S0195941700015241
    1. Turner RM, Davey J, Clarke MJ, Thompson SG, Higgins JP. Predicting the extent of heterogeneity in meta-analysis, using empirical data from the Cochrane Database of Systematic Reviews. Int J Epidemiol. 2012;41(3):818-827. doi:10.1093/ije/dys041
    1. Ali M. Randomized prospective clinical trial of no preparation versus mechanical bowel preparation before elective colorectal surgery. Med Channel. 2007;13:32-35.
    1. Bertani E, Chiappa A, Biffi R, et al. . Comparison of oral polyethylene glycol plus a large volume glycerine enema with a large volume glycerine enema alone in patients undergoing colorectal surgery for malignancy: a randomized clinical trial. Colorectal Dis. 2011;13(10):e327-e334. doi:10.1111/j.1463-1318.2011.02689.x
    1. Bhat AP, Parray FQ, Chowdri NA, et al. Mechanical bowel preparation versus no preparation in elective colorectal surgery: a prospective randomized study. Int J Surg Open. 2016;2:26-30. doi:10.1016/j.ijso.2016.02.010
    1. Bhattacharjee PK, Chakraborty S. An open-label prospective randomized controlled trial of mechanical bowel preparation vs nonmechanical bowel preparation in elective colorectal surgery: personal experience. Indian J Surg. 2015;77(suppl 3):1233-1236. doi:10.1007/s12262-015-1262-3
    1. Bretagnol F, Panis Y, Rullier E, et al. ; French Research Group of Rectal Cancer Surgery (GRECCAR) . Rectal cancer surgery with or without bowel preparation: the French GRECCAR III multicenter single-blinded randomized trial. Ann Surg. 2010;252(5):863-868. doi:10.1097/SLA.0b013e3181fd8ea9
    1. Bucher P, Gervaz P, Soravia C, Mermillod B, Erne M, Morel P. Randomized clinical trial of mechanical bowel preparation versus no preparation before elective left-sided colorectal surgery [published correction appears in Br J Surg. 2005;92(8):1051]. Br J Surg. 2005;92(4):409-414. doi:10.1002/bjs.4900
    1. Burke P, Mealy K, Gillen P, Joyce W, Traynor O, Hyland J. Requirement for bowel preparation in colorectal surgery. Br J Surg. 1994;81(6):907-910. doi:10.1002/bjs.1800810639
    1. Contant CM, Hop WC, van’t Sant HP, et al. . Mechanical bowel preparation for elective colorectal surgery: a multicentre randomised trial. Lancet. 2007;370(9605):2112-2117. doi:10.1016/S0140-6736(07)61905-9
    1. Fa-Si-Oen P, Roumen R, Buitenweg J, et al. . Mechanical bowel preparation or not? outcome of a multicenter, randomized trial in elective open colon surgery. Dis Colon Rectum. 2005;48(8):1509-1516. doi:10.1007/s10350-005-0068-y
    1. Khan SA, Hadi A, Ahmad S, et al. . Mechanical bowel preparation in elective colorectal surgery. J Med Sci. 2011;19(1):31-34.
    1. Miettinen RP, Laitinen ST, Mäkelä JT, Pääkkönen ME. Bowel preparation with oral polyethylene glycol electrolyte solution vs. no preparation in elective open colorectal surgery: prospective, randomized study. Dis Colon Rectum. 2000;43(5):669-675. doi:10.1007/BF02235585
    1. Pena-Soria MJ, Mayol JM, Anula R, Arbeo-Escolar A, Fernandez-Represa JA. Single-blinded randomized trial of mechanical bowel preparation for colon surgery with primary intraperitoneal anastomosis. J Gastrointest Surg. 2008;12(12):2103-2108. doi:10.1007/s11605-008-0706-5
    1. Platell C, Barwood N, Makin G. Randomized clinical trial of bowel preparation with a single phosphate enema or polyethylene glycol before elective colorectal surgery. Br J Surg. 2006;93(4):427-433. doi:10.1002/bjs.5274
    1. Ram E, Sherman Y, Weil R, Vishne T, Kravarusic D, Dreznik Z. Is mechanical bowel preparation mandatory for elective colon surgery? a prospective randomized study. Arch Surg. 2005;140(3):285-288. doi:10.1001/archsurg.140.3.285
    1. Saha AK, Chowdhury F, Jha AK, Chatterjee S, Das A, Banu P. Mechanical bowel preparation versus no preparation before colorectal surgery: a randomized prospective trial in a tertiary care institute. J Nat Sci Biol Med. 2014;5(2):421-424. doi:10.4103/0976-9668.136214
    1. Santos JC Jr, Batista J, Sirimarco MT, Guimarães AS, Levy CE. Prospective randomized trial of mechanical bowel preparation in patients undergoing elective colorectal surgery. Br J Surg. 1994;81(11):1673-1676. doi:10.1002/bjs.1800811139
    1. Sasaki J, Matsumoto S, Kan H, et al. . Objective assessment of postoperative gastrointestinal motility in elective colonic resection using a radiopaque marker provides an evidence for the abandonment of preoperative mechanical bowel preparation. J Nippon Med Sch. 2012;79(4):259-266. doi:10.1272/jnms.79.259
    1. Reddy BS, Macfie J, Gatt M, Larsen CN, Jensen SS, Leser TD. Randomized clinical trial of effect of synbiotics, neomycin and mechanical bowel preparation on intestinal barrier function in patients undergoing colectomy. Br J Surg. 2007;94(5):546-554. doi:10.1002/bjs.5705
    1. Beggs FD, Jobanputra RS, Holmes JT. A comparison of intravenous and oral metronidazole as prophylactic in colorectal surgery. Br J Surg. 1982;69(4):226-227. doi:10.1002/bjs.1800690419
    1. Dion YM, Richards GK, Prentis JJ, Hinchey EJ. The influence of oral versus parenteral preoperative metronidazole on sepsis following colon surgery. Ann Surg. 1980;192(2):221-226. doi:10.1097/00000658-198008000-00016
    1. Espin-Basany E, Sanchez-Garcia JL, Lopez-Cano M, et al. . Prospective, randomised study on antibiotic prophylaxis in colorectal surgery: is it really necessary to use oral antibiotics? Int J Colorectal Dis. 2005;20(6):542-546. doi:10.1007/s00384-004-0736-8
    1. Hata H, Yamaguchi T, Hasegawa S, et al. . Oral and Parenteral Versus Parenteral Antibiotic Prophylaxis in Elective Laparoscopic Colorectal Surgery (JMTO PREV 07-01): a phase 3, multicenter, open-label, randomized trial. Ann Surg. 2016;263(6):1085-1091. doi:10.1097/SLA.0000000000001581
    1. Ikeda A, Konishi T, Ueno M, et al. . Randomized clinical trial of oral and intravenous versus intravenous antibiotic prophylaxis for laparoscopic colorectal resection. Br J Surg. 2016;103(12):1608-1615. doi:10.1002/bjs.10281
    1. Ishida H, Yokoyama M, Nakada H, Inokuma S, Hashimoto D. Impact of oral antimicrobial prophylaxis on surgical site infection and methicillin-resistant Staphylococcus aureus infection after elective colorectal surgery: results of a prospective randomized trial. Surg Today. 2001;31(11):979-983. doi:10.1007/s005950170006
    1. Kling PA, Dahlgren S. Oral prophylaxis with neomycin and erythromycin in colorectal surgery: more proof for efficacy than failure. Arch Surg. 1989;124(6):705-707. doi:10.1001/archsurg.1989.01410060075015
    1. Kobayashi M, Mohri Y, Tonouchi H, Miki C, Nakai K, Kusunoki M; Mie Surgical Infection Research Group . Randomized clinical trial comparing intravenous antimicrobial prophylaxis alone with oral and intravenous antimicrobial prophylaxis for the prevention of a surgical site infection in colorectal cancer surgery. Surg Today. 2007;37(5):383-388. doi:10.1007/s00595-006-3410-7
    1. Lau WY, Chu KW, Poon GP, Ho KK. Prophylactic antibiotics in elective colorectal surgery. Br J Surg. 1988;75(8):782-785. doi:10.1002/bjs.1800750819
    1. Lazorthes F, Legrand G, Monrozies X, et al. . Comparison between oral and systemic antibiotics and their combined use for the prevention of complications in colorectal surgery. Dis Colon Rectum. 1982;25(4):309-311. doi:10.1007/BF02553603
    1. Lewis RT. Oral versus systemic antibiotic prophylaxis in elective colon surgery: a randomized study and meta-analysis send a message from the 1990s. Can J Surg. 2002;45(3):173-180.
    1. Oshima T, Takesue Y, Ikeuchi H, et al. . Preoperative oral antibiotics and intravenous antimicrobial prophylaxis reduce the incidence of surgical site infections in patients with ulcerative colitis undergoing IPAA. Dis Colon Rectum. 2013;56(10):1149-1155. doi:10.1097/DCR.0b013e31829f71a0
    1. Playforth MJ, Smith GM, Evans M, Pollock AV. Antimicrobial bowel preparation: oral, parenteral, or both? Dis Colon Rectum. 1988;31(2):90-93. doi:10.1007/BF02562635
    1. Raahave D, Hesselfeldt P, Pedersen TB. Cefotaxime i.v. versus oral neomycin-erythromycin for prophylaxis of infections after colorectal operations. World J Surg. 1988;12(3):369-373. doi:10.1007/BF01655676
    1. Sadahiro S, Suzuki T, Tanaka A, et al. . Comparison between oral antibiotics and probiotics as bowel preparation for elective colon cancer surgery to prevent infection: prospective randomized trial. Surgery. 2014;155(3):493-503. doi:10.1016/j.surg.2013.06.002
    1. Stellato TA, Danziger LH, Gordon N, et al. . Antibiotics in elective colon surgery: a randomized trial of oral, systemic, and oral/systemic antibiotics for prophylaxis. Am Surg. 1990;56(4):251-254.
    1. Weaver M, Burdon DW, Youngs DJ, Keighley MR. Oral neomycin and erythromycin compared with single-dose systemic metronidazole and ceftriaxone prophylaxis in elective colorectal surgery. Am J Surg. 1986;151(4):437-442. doi:10.1016/0002-9610(86)90097-8
    1. Yabata E, Okabe S, Endo M. A prospective, randomized clinical trial of preoperative bowel preparation for elective colorectal surgery: comparison among oral, systemic, and intraoperative luminal antibacterial preparations. J Med Dent Sci. 1997;44(4):75-80.
    1. Bhattacharjee PK, Chakraborty S. An open-label prospective randomized controlled trial of mechanical bowel preparation vs nonmechanical bowel preparation in elective colorectal surgery: personal experience. Indian J Surg. 2015;77(suppl 3):1233-1236. doi:10.1007/s12262-015-1262-3
    1. Bhat AH, Parray FQ, Chowdri NA, et al. . Mechanical bowel preparation versus no preparation in elective colorectal surgery: a prospective randomized study. Int J Surg Open. 2016;2(suppl C):26-30. doi:10.1016/j.ijso.2016.02.010
    1. Slim K, Vicaut E, Launay-Savary MV, Contant C, Chipponi J. Updated systematic review and meta-analysis of randomized clinical trials on the role of mechanical bowel preparation before colorectal surgery. Ann Surg. 2009;249(2):203-209. doi:10.1097/SLA.0b013e318193425a
    1. Slim K, Vicaut E, Panis Y, Chipponi J. Meta-analysis of randomized clinical trials of colorectal surgery with or without mechanical bowel preparation. Br J Surg. 2004;91(9):1125-1130. doi:10.1002/bjs.4651
    1. Bucher P, Mermillod B, Gervaz P, Morel P. Mechanical bowel preparation for elective colorectal surgery: a meta-analysis. Arch Surg. 2004;139(12):1359-1364. doi:10.1001/archsurg.139.12.1359
    1. Moghadamyeghaneh Z, Hanna MH, Carmichael JC, et al. . Nationwide analysis of outcomes of bowel preparation in colon surgery. J Am Coll Surg. 2015;220(5):912-920. doi:10.1016/j.jamcollsurg.2015.02.008
    1. Kiran RP, Murray AC, Chiuzan C, Estrada D, Forde K. Combined preoperative mechanical bowel preparation with oral antibiotics significantly reduces surgical site infection, anastomotic leak, and ileus after colorectal surgery. Ann Surg. 2015;262(3):416-425. doi:10.1097/SLA.0000000000001416
    1. Scarborough JE, Mantyh CR, Sun Z, Migaly J. Combined mechanical and oral antibiotic bowel preparation reduces incisional surgical site infection and anastomotic leak rates after elective colorectal resection: an analysis of colectomy-targeted ACS NSQIP. Ann Surg. 2015;262(2):331-337. doi:10.1097/SLA.0000000000001041
    1. Morris MS, Graham LA, Chu DI, Cannon JA, Hawn MT. Oral antibiotic bowel preparation significantly reduces surgical site infection rates and readmission rates in elective colorectal surgery. Ann Surg. 2015;261(6):1034-1040. doi:10.1097/SLA.0000000000001125
    1. Young Tabusso F, Celis Zapata J, Berrospi Espinoza F, Payet Meza E, Ruiz Figueroa E. Mechanical preparation in elective colorectal surgery, a usual practice or a necessity? [in Spanish]. Rev Gastroenterol Peru. 2002;22(2):152-158.
    1. Kale TI, Kuzu MA, Tekeli A, Tanik A, Aksoy M, Cete M. Aggressive bowel preparation does not enhance bacterial translocation, provided the mucosal barrier is not disrupted: a prospective, randomized study. Dis Colon Rectum. 1998;41(5):636-641. doi:10.1007/BF02235274
    1. Cao F, Li J, Li F. Mechanical bowel preparation for elective colorectal surgery: updated systematic review and meta-analysis. Int J Colorectal Dis. 2012;27(6):803-810. doi:10.1007/s00384-011-1361-y
    1. Klinger AL, Green H, Monlezun DJ, et al. The role of bowel preparation in colorectal surgery: results of the 2012-2015 ACS-NSQIP data [published online October 23, 2017]. Ann Surg. doi:10.1097/SLA.0000000000002568
    1. Atkinson SJ, Swenson BR, Hanseman DJ, et al. . In the absence of a mechanical bowel prep, does the addition of pre-operative oral antibiotics to parenteral antibiotics decrease the incidence of surgical site infection after elective segmental colectomy? Surg Infect (Larchmt). 2015;16(6):728-732. doi:10.1089/sur.2014.215
    1. Garfinkle R, Abou-Khalil J, Morin N, et al. . Is there a role for oral antibiotic preparation alone before colorectal surgery? ACS-NSQIP analysis by coarsened exact matching. Dis Colon Rectum. 2017;60(7):729-737. doi:10.1097/DCR.0000000000000851

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