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M e t a - a n a l y si son Surgic al Infe ctions

Dimitrios K. Matthaiou, MDa,b, George Peppas, MD, PhDa,c,

Matthew E. Falagas, MD, MSc, DSca,d,e,*

Surgical infections are a set of different infections that are roughly divided into two

major groups: surgical site infections (SSIs) and other infections that require surgical

intervention to resolve along with antibiotic treatment. SSIs are further divided into

superficial incisional, deep incisional, and organ/space infections.1

Surgical infections are an important clinical entity, as almost 3% of the operations

performed in the United States are complicated by SSIs.2 Patients in whom SSIs

develop are more likely to be admitted to an intensive care unit, return to the hospital

after discharge, or even die than patients who do not.3 Specific types of surgical infec-

tions, such as intra-abdominal infections or bone and joint infections, may furthercontribute to mortality and morbidity.

Meta-analysis is a statistical approach that was first used during the late 1980s in

the field of psychology and social sciences4 and soon found its place in medical

research. It combines the findings of similar studies regarding the outcomes of various

treatments in certain populations and settings using quantitative methods. In this

regard, the pooling of data included in different studies confers a larger sample size

and consequently a more accurate estimate of the outcomes of different interventions.

Thus, an adequately powered quantitative conclusion is frequently derived, which may

be used in the formation of guidelines and the promotion of medical practice.

Under this perspective, we sought to conduct a review focusing on the application

of this analytical tool and its potential contribution to the field of surgical infections.

a Alfa Institute of Biomedical Sciences (AIBS), 9 Neapoleos Street, 151 23 Marousi, Athens,Greeceb Department of Medicine, G. Gennimatas General Hospital, 41 Ethnikis Amynis Street, 54635 Thessaloniki, Greecec Department of Surgery, Henry Dunant Hospital, 107 Mesogeion Avenue, 115 26 Athens,Greeced

Department of Medicine, Tufts University School of Medicine, Boston, MA 02111, USAe Department of Medicine, Henry Dunant Hospital, 107 Mesogeion Avenue, 115 26 Athens,Greece* Corresponding author.E-mail address: [email protected] (M.E. Falagas).

KEYWORDS

Intra-abdominal infections Prophylaxis Mortality Wound infections Surgical site infections Appendicitis Pancreatitis

Infect Dis Clin N Am 23 (2009) 405430doi:10.1016/j.idc.2009.01.012 id.theclinics.com0891-5520/09/$ see front matter 2009 Elsevier Inc. All rights reserved.
mailto:[email protected]://id.theclinics.com/http://id.theclinics.com/mailto:[email protected]

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LITERATURE SEARCH

The literature was systematically reviewed to identify meta-analyses focusing on

surgical infections. One reviewer (DKM) performed the literature search in PubMed

until 30/09/2008 using the search terms meta-analysis AND (appendicitis OR perito-

nitis OR diverticulitis OR intra-abdominal infection OR intra-abdominal infections ORcholecystitis OR necrotizing pancreatitis OR surgical infection OR surgical infections

OR surgical site infection OR surgical site infections OR abscess OR empyema).

STUDY SELECTION AND EXTRACTION

An article was considered eligible to be included in this review if it was a meta-analysis

including randomized controlled trials with a focus on surgical infections and (1) it

compared different surgical procedures for the treatment of diseases requiring

surgical intervention and reported data on SSIs and other surgical complications,

(2) it evaluated antimicrobial prophylaxis for different surgical procedures and reportedoutcomes of SSIs, (3) it compared different antimicrobial regimens used for the treat-

ment of patients with surgical infections and reported data on effectiveness, and/or

(4) it compared different preventive procedures and reporting data on SSIs and other

surgical complications. Additionally, the outcomes of interest should have been

considered as primary outcomes and consistent with the outcomes of interest of

this review. Meta-analyses that included patients with mixed infections reporting

separate outcomes on surgical infections were also included. Consecutive updates

of the same meta-analysis (except for the most recent version), meta-analyses

including less than 100 patients in total, duplicate publications, as well as conference

abstracts were excluded. There was no language limitation for an article to be included

in this review.

Data extracted and tabulated from each meta-analysis were: author name, year of

publication, intervention studied (focus of the meta-analysis), number of included

studies, number of included patients, and effect on primary outcomes.

The total number of the retrieved articles was 693, of which, 518 were excluded at

first screening of title and abstract. After excluding 85 for other various reasons, 90

meta-analyses were considered eligible to be included in the review and are presented

in Tables 1 and 2 .

META-ANALYSES FOCUSING ON ANTIBIOTIC PROPHYLAXIS FOR SURGICAL INFECTIONS

Table 1 summarizes 45 meta-analyses with a focus on antibiotic prophylaxis for

surgical infections.549 Specifically, 19 of these 45 (42.2%)523 focused on antibiotic

prophylaxis in abdominal surgery, 6 (13.3%)36,37,40,42,45,49 on perioperative prophy-

laxis in surgery, 5 (11.19%)2731 on antibiotic prophylaxis in thoracic and vascular

surgery, 4 (8.9%)35,44,46,47 on prophylaxis in neurosurgery, 3 (6.7%)38,39,48 on prophy-

laxis in breast surgery, 3 (6.7%)3234 on obstetrics and gynecology, 3 (6.7%)2426 on

antibiotic prophylaxis in orthopedics, and 2 (4.4%)41,43 on other topics.

Meta-analyses Focusing on Antibiotic Prophylaxis in Abdominal Surgery

Seven of 19 abdominal surgery meta-analyses (36.8%)5,7,8,1416,19 focused on acute

pancreatitis requiring surgery (six on necrotizing pancreatitis [31.6%]5,7,8,14,15,19 and

one nonnecrotizing [5.3%]16). Five of these seven meta-analyses (26.3%)5,1416,19

found no advantage in the use of prophylaxis, whereas two (10.5%)7,8 found antibiotic

prophylaxis to be superior regarding pancreatic infection rates. In terms of mortality,

Matthaiou et al406

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four meta-analyses (21.1%)5,7,14,16 found no advantage in the use of prophylaxis,

whereas three (15.8%)8,15,19 found prophylaxis to be superior.

Four of 19 abdominal meta-analyses (21.1%)6,1012 focused on hernia surgery, three

of which (15.8%)6,10,11 found antibiotic prophylaxis to be superior regarding wound

infection rates. The remaining meta-analysis12 found no difference between the proto-

cols. Two of these meta-analyses10,12 included studies focusing on mesh hernia

repair, whereas the remaining ones6,11 included both studies using prosthetic material

or not. No data were provided regarding the types of meshes used.

Three of 19 meta-analyses (15.8%)9,13,20 studied the use of antibiotic prophylaxis in

percutaneous endoscopic gastrostomy. All of them (15.8%) found antibiotic prophy-

laxis to be superior regarding wound infection rates.

Two of 19 meta-analyses (10.5%)18,23 focused on biliary surgery. The more recent

meta-analysis (5.3%)18 found no benefit in the use of antibiotic prophylaxis, whereas

the other (5.3%)23 found prophylaxis to be superior regarding wound infection rates.

Of the remaining three meta-analyses (15.8%), one (5.3%)22 focused on colorectal

surgery, one (5.3%)17 on antimicrobial prophylaxis after appendicectomy, and one

(5.3%)21 on prophylaxis for the prevention of infections in cirrhotic patients with

gastrointestinal bleeding. All of them found antibiotic prophylaxis to be superior

regarding wound infection rates.

Meta-analyses Focusing on Antibiotic Prophylaxis in Thoracic and Vascular Surgery

Four of 5 (80%)2831 meta-analyses concerning thoracic and vascular surgery focused

on thoracic surgery. Two of them (40%)28,31 examined the effect of antibiotic prophy-

laxis in isolated chest trauma and in tube thoracostomy for trauma, both of which

favored the use of antibiotic prophylaxis. Two of them (40%)29,30

focused on cardio-thoracic surgery, one on the comparison of glycopeptides with b-lactams as prophy-

laxis against wound infection after cardiac surgery,29 and the other on the use of

prophylaxis for permanent pacemaker implantation.30 The remaining meta-analysis

(20%)27 focused on the use of antimicrobial prophylaxis in arterial reconstruction.

Meta-analyses Focusing on Antibiotic Prophylaxis in Peri-Operative Prophylaxis

in Surgery

Three of six meta-analyses (50%)42,45,49 focusing on perioperative prophylaxis in

surgery compared ceftriaxone with other drugs,42 ceftriaxone with other cephalospo-

rins,45

and amoxicillin-clavulanate with other drugs,49

respectively. Two of six meta-analyses (33.3%)36,40 examined the prophylactic effect of mupirocin in developing

wound infections after surgery, of which, one found mupirocin to be superior regarding

postoperative Staphylococcus aureus infection rates,36 whereas the other was consis-

tent with the former only regarding wound infection rates in nongeneral surgery.40 The

remaining study examined the prophylactic effect of antiseptic bathing with chlorhex-

idine gluconate, in which no difference was found between antiseptic bathing and

other methods for prevention of SSIs.37

Meta-analyses Focusing on Antibiotic Prophylaxis in Neurosurgery, Obstetrics

and Gynecology, and Breast SurgeryAll four meta-analyses (100%)35,44,46,47 focusing on antimicrobial prophylaxis in

neurosurgical procedures found prophylaxis to be superior regarding wound infection

rates. All three meta-analyses (100%)3234 focusing on antimicrobial prophylaxis in

obstetrics and gynecology, of which, two (66.7%)32,34 concerned cesarean delivery

and one (33.3%)33 abdominal hysterectomy, found antimicrobial prophylaxis to be

superior regarding wound infection. All three meta-analyses (100%)38,39,48 focusing

Meta-analysis on Surgical Infections 407

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Table1

Meta-analyses focusing on antibiotic prophylaxis

Study

Intervention Studied (Focus

of the Meta-analysis)

Studies

Included

Patients

Included

Intra-abdominal

Bai et al, 20085 Prophylactic antibiotics in acutenecrotizing pancreatitis(antibiotics versus placebo/no treatment)

7 467

Gravante et al, 20086 Single-dose antibiotic prophylaxisversus placebo in openinguinal repair

10 4336

Xu and Cai, 20087

Prophylactic antibiotic treatmentin acute necrotizing pancreatitis

8 540

Dambrauskas et al, 20078 Prophylactic antibiotics in acutenecrotizing pancreatitis

10 1079

Jafri et al, 20079 Antibiotic prophylaxis to preventperistomal infection afterpercutaneous endoscopic

gastrostomy (antibioticsversus placebo/no intervention)

10 1059

Sanabria et al, 200710 Prophylactic antibiotics for meshinguinal hernioplasty antibioticsversus placebo/no treatment)

6 2507

Sanchez-Manuel et al, 200711 Antibiotic prophylaxis for herniarepair

12 6705

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Aufenacker et al, 200612 Antibiotic prophylaxis in preventionof wound infection after meshrepair of abdominal wall hernia(antibiotics versus placebo)

8 2861

Lipp and Lusardi, 200613 Systemic antimicrobial prophylaxis forpercutaneous endoscopic gastrostomy

(prophylaxis versus no prophylaxis)

10 1100

Mazaki et al, 200614 Prophylactic antibiotic use in acutenecrotizing pancreatitis

6 329

Villatoro et al, 200615 Antibiotic therapy for prophylaxisagainst infection of pancreaticnecrosis in acute pancreatitis

5 294

Xiong et al, 200616 Prophylactic antibioticadministration in severe acutepancreatitis (antibiotics versusplacebo)

6 338

Andersen et al, 200517 Antibiotics versus placebo forprevention of postoperativeinfection after appendicectomy

71 8812

Catarci et al, 200418 Antibiotic prophylaxis in electivelaparoscopic cholecystectomy

6 974

Sharma and Howden,200119

Antibiotic prophylaxis in acutenecrotizing pancreatitis (prophylaxisversus no prophylaxis)

3 160

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Table1

(continued)

Study



Studies

Included

Patients

Included Sharma and Howden,

200020Antibiotic prophylaxis before

percutaneous endoscopicgastrostomy (antibioticsversus placebo/no treatment)

7 777

Bernard et al, 199921 Antibiotic prophylaxis for theprevention of bacterial infectionsin cirrhotic patients withgastrointestinal bleeding(prophylaxis versus noprophylaxis)

5 534

Glenny and Song, 199922 Antimicrobial prophylaxis incolorectal surgery (antibioticsversus no antibiotics)

4 293

Meijer et al, 199023 Antibiotic prophylaxis inbiliary tract surgery(antibiotics versusno antibiotics)

42 4129

Orthopedic

AlBuhairan et al, 200824

Antibiotic prophylaxis forwound infections in totaljoint arthroplasty (prophylaxisversus no prophylaxis)

7 3065

Slobogean et al, 200825 Single- versus multiple-doseantibiotic prophylaxis inthe surgical treatmentof closed fractures

7 3808

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Southwell-Keely et al,200426

Antibiotic prophylaxis in hipfracture surgery

10 2417

Thoracic surgery/vascular

Stewart et al, 200727 Prevention of infection inperipheral arterial

reconstruction (antibioticsversus placebo)

10 1297

Sanabria et al, 200628 Prophylactic antibiotics inisolated chest trauma(antibiotics versusplacebo)

5 614

Bolon et al, 200429 Glycopeptides versus b-lactamsfor prevention of surgical siteinfection after cardiac surgery

7 5761

Da Costa et al, 199830 Antibiotic prophylaxis forpermanent pacemaker

implantation (prophylaxisversus no prophylaxis)

7 2023

Fallon and Wears, 1992 31 Antibiotic prophylaxis intube thoracostomy fortrauma

6 507

Obstetric

Martins and Krauss-Silva,200632

Antibiotic prophylaxis incesarean sections (antibioticsversus placebo)

27 4470

Costa and Krauss-Silva,

200433

Antibiotic prophylaxis in

abdominal hysterectomy(antibiotics versus placebo)

20 2456

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Table1

(continued)

Study



Studies

Included

Patients

Included

Chelmow et al, 200134

Prophylactic use of antibioticsfor nonlaboring patientsundergoing cesareandelivery with intactmembranes (antibioticsversus placebo)

7 446

Other

Ratilal et al, 200835 Antibiotic prophylaxis forsurgical introduction ofintracranial ventricularshunts (antibiotics versus

placebo/no antibiotics)

17 2134

van Rijen et al, 200836 Prevention of S aureusinfections in nasal S aureuscarriers after surgery (nasal mupirocinversus placebo/no treatment)

4 1372

Webster and Osborne, 200737 Preoperative antiseptic bathingfor prevention of surgical siteinfection (chlorhexidine gluconateversus placebo/bar soap/nowashing)

6 10,007

Cunningham et al,200638 Antibiotic prophylaxis afterbreast cancer surgery 6

Tejirian et al, 200639 Antibiotic prophylaxis afterbreast surgery (antibioticsversus placebo)

5 1307

Kallen et al, 200540 Perioperative intranasalmupirocin versus no mupirocinfor the preventionof surgical site infections

7 11,088

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Vardakas et al, 200541 Perioperative teicoplanin comparedwith cephalosporins in orthopedicand vascular surgery involvingprosthetic material

6 2886

Esposito et al, 200442 Ceftriaxone versus otherantibiotics for surgicalprophylaxis

48 17,565

Strippoli et al, 200443 Antimicrobial agents for preventingperitonitis in peritoneal dialysispatients

19 1949

Barker, 200244 Prophylactic antibiotictherapy in spinal surgery(antibiotics versusplacebo/no intervention)

6 843

Dietrich et al, 200245 Ceftriaxone versus othercephalosporins forperioperative antibiotic

prophylaxis

43 13,482

Barker, 199446 Prophylactic antibiotics forcraniotomy (antibioticsversus placebo)

8 2075

Langley et al, 199347 Antimicrobial prophylaxis inplacement of cerebrospinalfluid shunts (prophylaxisversus no prophylaxis)

12 1359

Platt et al, 199348 Perioperative antibioticprophylaxis in breastsurgery

2587

Wilson et al, 199249 Amoxicillin-clavulanate insurgical prophylaxis

21 4905

Abbreviations: RCTs, Randomized clinical trials; RR, Risk ratio; OR, Odds ratio; ARR, Absolute risk reduction.

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on antimicrobial prophylaxis in breast surgery found prophylaxis to be superior

regarding wound infection rates.

Meta-analyses Focusing on Antibiotic Prophylaxis in Orthopedics

Two of three meta-analyses (66.7%)25,26

focusing on orthopedics examined the use ofprophylaxis in fracture surgery, of which, one (33.3%)26 compared prophylaxis with no

prophylaxis, and one (33.3%)25 compared single- with multiple-dose antibiotic prophy-

laxis. In the former study, an absolute risk reduction by 8% and relative risk reduction by

81% for wound infection was found, whereas in the latter, no difference was found

between single- and multiple-dose prophylaxis. In the remaining meta-analysis

(33.3%)24 comparing prophylaxis with no prophylaxis in total joint arthroplasty, prophy-

laxis was found to be superior regarding wound infection rates.

Meta-analyses Focusing on Antibiotic Prophylaxis in Other Patient Settings

The remaining two meta-analyses examined the use of prophylaxis in peritoneal dial-

ysis patients43 and the comparison of teicoplanin with cephalosporins in orthopedic

and vascular surgery involving prosthetic material,41 respectively. In both meta-anal-

yses, no difference was found between the two antibiotic regimens regarding SSI

rates.

META-ANALYSES FOCUSING ON TOPICS OTHER THAN ANTIBIOTIC PROPHYLAXIS

Table 2 summarizes 44 meta-analyses5093 (one was not reported in the table

because of the large number of outcomes of interest)94 that focused on other aspects

of surgical infections apart from antibiotic prophylaxismostly comparisons of

different surgical techniques and procedures, as well as comparisons of the efficacy

of different antibiotics for the treatment of surgical infections. Thirty-one of them

(68.9%)5079,94 regarded techniques and procedures used in abdominal surgery,

four (8.9%)8083 concerned cardiothoracic and vascular surgery, three (6.7%)8587

focused on orthopedics, two (4.4%)84,85 regarded obstetrics and gynecology, and

five (11.1%)8993 dealt with various other topics.

Meta-analyses Focusing on Abdominal Surgery

Nine of the 31 (29%)61,64,67,70,7478 abdominal surgery meta-analyses focused onappendicitis, nine (29%)5254,56,63,66,69,71,72 on colorectal surgery, five (16.1%) on

biliary surgery, five (16.1%)50,55,65,73,79 on comparing different antibiotic regimens

for the treatment of intra-abdominal infections, one (3.2%)68 on gastrointestinal

surgery, and one (3.2%)60 on the use of drainage for uncomplicated liver resection,

respectively. The meta-analysis not reported in the table because of the large number

of primary analyses94 focused on the comparison of 16 different antibiotic regimens

for the treatment of secondary peritonitis of gastrointestinal origin in adults. None of

the comparisons favored any of the compared regimens in terms of clinical success

or mortality.

Six of nine meta-analyses (66.7%)61,70,74,7678 concerning appendicitis comparedlaparoscopic with conventional techniques for appendectomy, four (44.4%)70,74,76,77

of which found laparoscopic techniques to be superior regarding wound infection

rates, whereas one61 found no difference between the techniques. All meta-analyses

reporting relevant data found no difference between the techniques regarding the rate

of intra-abdominal abscesses. Three of 9 (33.3%)64,67,75 meta-analyses compared

different wound closure methods during appendectomy.

Matthaiou et al414

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Three of 9 (33.3%)66,69,72 meta-analyses concerning colorectal surgery compared

mechanical bowel preparation with no preparation. In two of these69,72 anastomotic

leakage was less in mechanical bowel preparation, whereas in the remaining one,66

no difference was found regarding the anastomotic leakage rate. In two of three

meta-analyses69,72 in which wound infection and intra-abdominal abscess rates

were reported, no difference between the two methods was found. The remaining

six meta-analyses (66.7%) compared (1) laparoscopic with open surgery for resection

of colorectal cancer,52 in which laparoscopic techniques were associated with fewer

wound infections; (2) different methods for ileocolic anastomoses,53 in which anasto-

motic leaks were significantly fewer with stapled method; (3) supplemental perioper-

ative oxygen versus no oxygen in colorectal surgery patients,54 in which no

difference was found between the protocols; (4) ileostomy with colostomy for colo-

rectal anastomotic decompression,56 in which no difference was found in terms of

wound infection or mortality; (5) drainage with no drainage in elective colorectal

surgery,63 in which no advantage was found in the use of drainage; and (6) primary

repair versus fecal diversion for penetrating colon injuries,71 in which primary repair

was associated with fewer complications in general, but not with less mortality of

infectious complications.

Three of five meta-analyses (60%)5759 concerning biliary surgery compared the use

of different types of drainage in various types of cholecystectomy with mixed results.

The remaining meta-analyses (40%)51,62 compared early with delayed laparoscopic

cholecystectomy, in which no difference was found between the two techniques

regarding complication rates.

The five meta-analyses studying different antibiotic regimens for the treatment of

intra-abdominal infections compared ertapenem with other antibiotic regimens,50

clin-damycin/aminoglycoside with b-lactam monotherapy,55 ciprofloxacin/metronidazole

with b-lactam based regimens,65 aminoglycosides with other antibiotic regimens,73

and meropenem with other antimicrobials.79 Ertapenem was found to be as effective

as other antimicrobials for the treatment of complicated intra-abdominal infections.

Ciprofloxacin/metronidazole65 and aminoglycosides73 were found to be more effec-

tive, whereas clindamycin/aminoglycoside was less effective than comparators for

the treatment of intra-abdominal infections. No difference regarding the response

rates was found between meropenem and other antibiotic regimens. The meta-anal-

ysis focusing on the treatment of secondary peritonitis of gastrointestinal origin in

adults94

compared virtually each available antibiotic class with all the other for variousoutcomes, of which the primary outcomes were clinical success and mortality.

Of the remaining two meta-analyses concerning abdominal surgery, one focused on

the use of drainage for uncomplicated liver resection,60 and 1 on the comparison of

different techniques for the treatment of perforated peptic ulcer.68

Meta-analyses Focusing on Cardiothoracic and Vascular Surgery

Three of 4 meta-analyses (75%)80,81,83 concerning cardiothoracic and vascular

surgery focused on vascular surgery. Two of them (50%)81,83 compared minimallyinvasive with conventional vein harvesting, in which minimally invasive vein harvesting

was superior regarding wound infection rates. The remaining one (25%)80 compared

closed suction drainage with no drainage in lower limb arterial surgery, in which no

difference was found between the two techniques regarding various outcomes. One

meta-analysis (25%)82 focused on the comparison of off-pump surgery with traditional

coronary artery bypass grafting, in which off-pump surgery was superior.


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Table 2

Meta-analyses focusing on the effect of various interventions (other than antimicrobial prophylaxis) on surgical infecti

StudyIntervention Studied (Focus of theMeta-analysis)

StudiesIncluded

PatientsIncluded Effe

Intra-abdominal

Falagas et al, 200850 Ertapenem versus other antimicrobial regimensfor complicated intra-abdominal infections

6 2691 Clin

Siddiqui et al, 200851 Early versus delayed laparoscopiccholecystectomy for acute cholecystitis

4 375 ComCon

Yamamoto et al, 200852 Laparoscopic versus open surgery for resectionof colorectal cancer

10 3821 Wo

Choy et al, 200753 Stapled versus handsewn methods for ileocolic

anastomoses

6 955 Ana

Chura et al, 200754 Supplemental perioperative oxygen versus nooxygen in colorectal surgery patients

4 943 Surg

Falagas et al, 200755 Treatment of intra-abdominal infections(clindamycin/aminoglycoside versus b-lactammonotherapy)

28 4518 Clin

Guenaga et al, 200756 Ileostomy versus colostomy for temporarydecompression of colorectal anastomosis

5 334 MoWoReoCol

(0

Gurusamy and Samraj,200757

Primary closure versus T-tube drainageafter open common bile duct exploration

5 324 PosWo

Gurusamy et al, 200758 Routine abdominal drainage versus no drainagefor uncomplicated laparoscopiccholecystectomy

6 741 Wo


Routine abdominal drainage versus no drainagefor uncomplicated open cholecystectomy

28 3659 MoBile

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Gurusamy et al, 200760 Routine abdominal drainage versus no drainagefor uncomplicated liver resection

5 465 Mo(0

Reo(0

ReoO

Aziz et al, 2006

61

Laparoscopic versus open appendectomyin children 7 1237 WoIntrPost


Early versus delayed laparoscopiccholecystectomy for acute cholecystitis

5 451 BileBileIntr

OSupDee

Karliczek et al, 200663 Drainage versus nondrainage in electivecolorectal anastomosis

6 1140 MoAna

Kazemier et al, 200664

Endoscopic linear stapling versus loopligatures of the stump duringlaparoscopic appendectomy for acuteappendicitis

4 427 Sup(0

PostIntr

Matthaiou et al, 200665 Treatment of intra-abdominalinfections(ciprofloxacin/metronidazole versusb-lactambased antibiotics)

5 1431 Clin

Guenaga et al, 200566 Mechanical bowel preparation versus nopreparation for elective colorectal surgery

9 1592 AnaLow

(0Colo

Ove(1

Henry and Moss, 200567 Primary versus delayed wound closure incomplicated appendicitis

6 347 Wo

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Table 2

(continued)

Study

Intervention Studied (Focus of the

Meta-analysis)

Studies

Included

Patients

Included Effe

Sanabria et al, 200568 Laparoscopic versus open surgical treatment inpatients with perforated peptic ulcer

2 214 IntrAnaSurg

Bucher et al, 200469 Mechanical bowel preparation versus

nonmechanical bowel preparation forelective colorectal surgery

7 1297 Ana

IntrWoReoGenMo

Sauerland et al, 200470 Laparoscopic versus open surgery forsuspected appendicitis

45 5366 Lapa

WoIntrLap

a

WoIntr

(0Dia

ao

WoIntr

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Nelson and Singer, 200371 Primary repair versus fecal diversion forpenetrating colon injuries

6 705 MoComTota

(0Abd

OAbd

PeWo

PWo

P

Wille-Jrgensen et al,200372

Mechanical bowel preparation versus nopreparation in patients undergoing electivecolorectal surgery

6 1204 AnaRecColoOvePeriWo

Bailey et al, 200273 Aminoglycosides versus other antibiotics inintra-abdominal infections

47 7772 Effi

Eypasch et al, 200274 Laparoscopic versus open surgery forsuspected appendicitis

45 >4000 WoIntr

(1

Rucinski et al, 200075 Primary versus delayed closure for gangrenousor perforated acute appendicitis

27 2532 WoPrimDela

Meynaud-Kraemer et al,199976

Laparoscopic versus open appendectomy 8 907 Wo

Temple et al, 199977 Laparoscopic versus open appendectomy insuspected acute appendicitis

12 1383 WoIntr

Sauerland et al, 199878 Laparoscopic versus conventionalappendectomy

28 2877 OpeTotaWoDee

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Orthopedic

Parker and Gurusamy,200686

Internal fixation versus arthroplasty forintracapsular proximal femoral fractures inadults

36 5464 All Dee

Parker et al, 200487 Closed suction drainage versus no drainagefor hip and knee arthroplasty

18 3495 WoWo

ReoR

Parker and Pryor, 199688 DHS versus Gamma nailing for extracapsularfemoral fractures

10 1794 PercWoMo

Other

McCallum et al, 200889 Healing by primary closure versus open healingafter surgery for pilonidal sinus

18 1573 SurRec

Rabindranath et al, 200790 Continuous ambulatory peritoneal dialysisversus automated peritoneal dialysis forend-stage renal disease

3 139 MoPer

Webster and Alghamdi,200791

Plastic adhesive drapes (iodine-impregnated ornot) versus no drape during surgery

7 4195 SurAdh

Iodd

Delaney et al, 200692 Percutaneous dilatational tracheostomy versussurgical tracheostomy in critically ill patients

17 1212 WoBleeMo

Tanner et al, 200693 Preoperative hair removal to reduce surgicalsite infection

11 4501 WoSha

Cre

Abbreviations: RCTs, Randomized controlled trials; OR, Odds ratio; RR, Risk ratio; RD, Risk difference.

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Meta-analyses Focusing on Orthopedics

Two of 3 meta-analyses (66.7%)86,88 concerning orthopedics compared different

procedures for the treatment of femoral fractures; none of the compared techniques

was found to be superior in terms of wound infection rates or mortality. The remaining

meta-analysis (33.3%)87

focused on the use of closed suction drainage versus nodrainage for hip and knee arthroplasty, in which no difference was found between

the two techniques for the examined outcomes.

Meta-analyses Focusing on Obstetrics

Both meta-analyses (100%)84,85 concerning obstetrics focused on the use of drainage

versus no drainage for cesarean section. No difference was found between the

compared techniques regarding the various outcomes.

Meta-analyses Focusing on Other Topics

Of the remaining meta-analyses (20% each), one focused on the comparison of

different techniques for the treatment of pilonidal sinus,89 in which primary closure

was associated with lower recurrence rates; one on the comparison of continuous

ambulatory dialysis with automated peritoneal dialysis for end-stage renal diseases,90

in which no difference was found between the types of dialysis in terms of mortality or

peritonitis; one on the use of plastic adhesive drapes versus no drape during

surgery,91 in which no advantage was found in the use of drapes regarding the surgical

site infection rates; one on the comparison of different techniques of tracheostomy,92

in which percutaneous dilatational tracheostomy was superior to surgical tracheos-

tomy in terms of wound infections rates; and one on the comparison of differenthair removal techniques to reduce SSIs,93 in which no advantage was found in preop-

erative hair removal of any type.

DISCUSSION

Meta-analysis is a useful statistical approach, which offers quantitative measures of

studied outcomes and can be applied in virtually any field of science. As such, it

has also been used in the study of surgical infections. According to our findings,

meta-analyses regarding surgical infections may be divided in studies focusing on

the use of antimicrobial prophylaxis, and in studies focusing on the comparison ofdifferent techniques and procedures or therapeutic regimens for the treatment of

surgical infections.

Administration of antibiotics may have an impact on the postoperative course

regarding the wound infection rates. This depends on the type of surgery or infection

for which they are used. Thus, in acute necrotizing pancreatitis, it is not clear if antibi-

otic prophylaxis has a role in the reduction of pancreatic necrosis or mortality.

Although the majority of meta-analyses focusing on the subject show no benefit

from the administration of prophylaxis regarding the infected necrosis rates, the

most recent studies suggest that prophylaxis may be superior. Safe conclusions

regarding mortality are even more difficult to be drawn, as merely half of the meta-analyses found prophylaxis to be superior. The same results may be observed in

meta-analyses regarding SSI rates in biliary surgery. However, all meta-analyses

that have been conducted in other patient settings, such as percutaneous endoscopic

gastrostomy, thoracic surgery, neurosurgery, obstetrics and gynecology, and breast

surgery, as well as the majority of meta-analysis regarding hernia surgery, suggest

an advantage in the use of antibiotic prophylaxis.

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in intra-abdominal infections.96 General factors, which are independently associated

with clinical failure, are the isolation of an organism resistant to the treatment regimen,

including Pseudomonas spp, being on antibiotic therapy at the time of admission, and

diagnosis of a complicated intra-abdominal infection.97

Given the size of the field of surgical infections, one would expect meta-analysis

to have been used in the study of virtually every type of surgical infection.

However, the topics that have been studied are limited. More than half of the

included meta-analyses focused on surgical infections in abdominal surgery (50

of 90, 55.6%). Furthermore, many meta-analyses with similar topics include prac-

tically the same studies. This is expected to some extent, because the conduction

of a randomized controlled trial is a costly and time-consuming process. Thus, in

the short interval between two meta-analyses on the same topic, few new

randomized trials may have been published to substantially alter the former

meta-analyses outcomes.

It should be noted that, although the topic of two meta-analyses may be the same and

the included studies are similar, the outcome estimates are different. Apart from the

additional inclusion of a small number of more recent, if any, studies, there are other

factors that may also influence the outcome estimates. Such factors may be the analyt-

ical methodology that has been used, and the variability in the number of patients of

each evaluable trial that are included in the analyses. Although discrepancies among

the point estimates of meta-analyses on the same topic may be expected to some

extent, scores calculating the overall quality of each meta-analysis should be devel-

oped, as for other types of studies. Thus, quality of meta-analyses may be quantified

to help in the evaluation of findings and correct application of conclusions.

It is interesting that the retrieved meta-analyses focusing exclusively on surgicalinfections most often concern antibiotic prophylaxis or the comparison of specific

techniques and procedures but not comparisons of different antibiotic regimens for

the treatment of surgical infections. Antibiotics as therapeutic regimens are more

easily evaluated in patients with various infections. Prospective studies are designed

to include patients from broad settings, because the applicability and extrapolation of

the findings are greater, whereas the cost of the study and the time needed to find the

appropriate participants are smaller.

Furthermore, few meta-analyses (15 of 90, 16.7%) report data on mortality as

primary outcomes. All but four (11 of 15, 73.3%) were meta-analyses focusing on

surgical infections in abdominal surgery. One would expect this outcome to bereported more often, because mortality is a crucial determinant in the evaluation of

different treatments, as it encompasses both efficacy and safety.

According to the definition by the Centers for Disease Control, surgical infections

are very common, but also diverse clinical entities and cannot be considered as

a whole. Data regarding wound infections, among other numerous outcomes, were

reported in a large number of meta-analyses, which included studies evaluating or

comparing various types of interventions, but they were not considered primary

outcomes, resulting in their exclusion. However, practically any surgical procedure

may have an SSI as a possible complication. Although this may be a methodologic

limitation of the review, presenting all these diverse data would make a meaningfulinterpretation difficult.

SUMMARY

Meta-analysis on surgical infections may be a useful tool that can provide more

accurate outcome estimates than other conventional types of studies. Published

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meta-analyses in surgical infections tend to focus mainly on the use of antimicrobial

prophylaxis and on the comparison of different procedures or techniques for the treat-

ment of surgical infections. The majority concern surgical infections in abdominal

surgery. However, mortality is reported as primary outcome in few meta-analyses.

Meta-analyses focusing exclusively on surgical infections, reporting data on mortality

as a primary outcome, and comparing different antibiotic regimens for the treatment of

surgical infections should be conducted.

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