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TECHNICAL REPORTSystematic review and evidence-based guidance on perioperative antibiotic prophylaxisAdequate duration of PAPFive systematic reviews analysing short-term versus long-term antibiotic prophylaxis were identified [103,105,107-109].A systematic review by Gillespie et al. included two small studies in which 224 participants undergoing hip fracturesurgery were randomised to receive multiple doses of parenteral antibiotics either administered over ≤24 hours ora longer period [103]. Data for deep SSI were pooled from these two studies and demonstrated no evidence ofdifference between the two types of regimen for the outcomes of deep (RR 1.10, 95% CI 0.22 to 5.34) orsuperficial surgical site infection (RR 0.57, 95% CI 0.17 to 1.93).A second systematic review by Stewart et al. compared short versus longer PAP in 531 patients undergoingperipheral arterial reconstruction [107]. Continuing prophylactic antibiotics for longer than 24 h did not reduce SSIssignificantly (RR 1.28; 95% CI: 0.82, 1.98). In their systematic review, Stewart et al. analysed three trials, whichwere published between 1984 and 1998 and revealed variable risks in respect to selection, performance anddetection bias.The systematic review by Zani et al. analysed short- (one day) versus long-term (three days) PAP in patientsundergoing transrectal prostate biopsy in six trials [105]. The authors demonstrated that long-course treatment isnot superior to short-course treatment for the outcomes: fever (RR 2.84, 95% CI 0.99–8.16), bacteraemia (RRfavouring short course: 0.33, 95% CI 0.01–7.86) and urinary tract infection (RR 1.40, 95% CI 0.73–2.68). Only forthe outcome bacteriuria the authors found that long-course treatment – in three trials with considerableheterogeneity (I2=34%) – was associated with a lower risk of bacteriuria (RR 2.09, 95% CI 1.17–3.73).Thus, the authors concluded that there is no definitive data to confirm that antibiotics for long-course treatments(three days) are superior to short-course treatments (one day), or that multiple-dose treatment is superior tosingle dose treatment.A prospective cohort study by Harbarth et al. compared short-term (≤ 48 h) with long-term (>48 h) PAP in 2 641patients undergoing coronary artery bypass graft (CABG) surgery with or without valve replacement [110]. Afteradjustment for possible confounding factors (i.e. obesity, co-morbidities, ASA score IV, duration of surgery, etc.)prolonged PAP was not associated with a decreased risk of SSI (adjusted OR: 1.2; 95% CI: 0.8–1.6) but wascorrelated with an increased risk of acquiring antibiotic resistance (adjusted OR: 1.6; 95% CI 1.1–2.6). The authorsconcluded that the maximum clinical benefit of prophylaxis is achieved by administration of antibiotics 48 hourspost-surgery; the administration of antibiotics for more than 48 hours is ineffective in further reducing SSI. Thestudy reveals some limitations. The incidence of mediastinitis was not reported. There was no mention of adifference in mortality or length of stay in the two groups. In addition, the choice of antibiotics had not beenidentical in the two groups [110].Mertz et al. showed the opposite in a systematic review and meta-analysis comparing the efficacy of short-term(≤24 h) versus long-term (>24 h) antibiotic prophylaxis in open heart surgery [108]. In this review, the selected12 RCTs involving 7 893 patients were published between 1972 and 2008. The meta-analysis demonstrated a riskreduction of sternal SSI in the long-term compared to the short-term antibiotic prophylaxis (RR=1.38 [95% CI:1.13–1.69]). However, the findings are limited due to the heterogeneity of the antibiotic regimen used and also bythe fact that more than 50% of the 12 studies revealed a severe risk of selection, performance and detection bias.Thus, the authors stated that no definitive conclusion can be drawn from the evidence available and theyrecommend the need for a rigorous, large RCT [108].De Chiara et al. observed in a methodologically well-performed prospective cohort study with 358 patientsundergoing clean and clean and clean-contaminated general surgery that prolonged PAP did not reduce the SSIrate in patients with risk factors. If PAP was applied longer than 24 hours, it was an independent risk factor forintra-hospital or post-hospital SSI, regardless of the presence of patients’ risk factors (OR 3.39; 95% CI 1.11–10.35;p=0.032 and OR 5.39; 95% CI 1.64–17.75; p=0.006, respectively) [111].Summary of evidence for Objective 4: Do selection, timing, dosage or duration of PAP as processindicators have an influence on the incidence of SSIs?The following list summarises the effect of appropriate selection, timing, dosage and duration of PAP on SSIprevention.PAP should be applied 30 to 60 minutes before incision (120 minutes before incision if a glycopeptide isadministered) [59,73,85,97,101,112].If surgery lasts
Systematic review and evidence-based guidance on perioperative antibiotic prophylaxisTECHNICAL REPORTObjective 5: Does the use of PAP have an effect on the incidence of Clostridiumdifficile-associated diarrhoea (CDAD) or the development of antimicrobialresistance?The number of well-designed studies about the association of perioperative antibiotic prophylaxis is limited andincidence rates for CDAD and/or MDROs are rarely reported. One systematic review [89], two RCTs [120-122],three cohort study [110,123,124] and one non-CBA study were included [125] (Table 8).Table 8. Distribution of included study design and geographical location of included studies,Objective 5Type of studyDistribution (world regions)Observational cohort studies: n=3 (42.8%) North America: n=4RCTs: n=2 (14.3%) Asia: n=3Systematic reviews/meta-analyses: n=1 (14.3%)Non-CBAs: n=1 (14.3%)Total: N=7Two RCTs reported on incidence of CDAD in patients undergoing colorectal surgery [120,121].Itani et al. assessed the efficacy and safety of PAP with ertapenem compared with cefotetan in 901 patientsundergoing elective colorectal surgery [120,122]. The study measured the occurrence of CDAD and looked at SSIas a primary outcome. Although ertapenem was more effective than cefotetan in the prevention of SSI, the overallincidence of CDAD was 1.7% in the ertapenem group and 0.6% in the cefotetan group (p=0.02). The study was awell-designed RCT and showed low risk of bias [120,122].The second RCT by Fujita et al. compared single dose versus multiple doses of cefmetazole as antibioticprophylaxis in 384 patients. Two patients (1.1%) with postoperative CDAD were in the multiple dose groups andnone in the single dose group [121]. Although randomisation was performed adequately, the quality of the studywas poor due to high risk of bias (performance bias, selection bias and reporting bias) [121].In a well-designed retrospective cohort study with good methodological quality, Carignan et al. reported asignificant increase in the occurrence of CDAD due to PAP from 2003 to 2005 as compared with 1999 to 2002(14.9 cases/1000 procedures versus 0.7 cases/1000 procedures; p
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