Oral Antibiotic Bowel Preparation Significantly Reduces Surgical Site Infection Rates and Readmission Rates in Elective Colorectal

SurgeryMelanie S. Morris, MD, Laura A. Graham, MPH, Daniel I. Chu, MD, Jamie A. Cannon, MD, and Mary T. Hawn, MD, MPHDepartment of Surgery at the University of Alabama, Birmingham, AL.Annals of Surgery Volume 261, Number 6, June 2015

Introduction Mechanical bowel preparation (MBP) with the

use of oral antibiotics is effective in reducing surgical site infection (SSI)

More recent trials and a Cochrane meta-analysis show that omitting bowel preparation before colorectal surgery was not associated with increased complications

Recently, several large retrospective studies have demonstrated that oral antibiotic bowel preparation (OABP), but not MBP is associated with reduced SSI rates after elective colorectal surgery

These conflicting findings on OABP, MBP, and no preparation

emphasis on omitting preparation in enhanced recovery protocols (ERPs)

patient preference and intolerance to preparations have likely led to decreased usage of bowel preparation in recent years.

field of colorectal surgery has experienced revolutionary change minimallyinvasive approach

increased emphasis on reducing the length of stay (LOS) has led to the adoption of ERP

ERPs were developed to improve efficiency and reduce complications after colorectal surgery

ERPs minimize surgical stress and organ dysfunction during the perioperative period by using multimodal strategies such as nonopioid analgesia, minimizing intravenous fluids, early postoperative feeding, early ambulation, and omitting bowel preparations

ERPs in colorectal surgery have demonstrably reduced LOS

criteria for discharge include return of bowel function, which occurs more quickly if MBPis avoided.

Although use of OABP has been associated with lower SSI and readmission rates in open approaches , it is not clear whether OABP will have similar effects in patients undergoing minimally invasive surgical (MIS)

This journal study : OABP was associated with reduced postoperative SSI rates, LOS and readmission rates after elective colorectal surgery

METHODS study population consisted of all colectomy cases

collected by the American College of Surgeons NSQIP in 2011 and 2012 , all 8415 case

Excluded - missing information- non-elective or emergent

outcomes measured- postoperative surgical site infection (SSI)- in-hospital LOS- all-cause re-admission within 30 days after

colectomy

postoperative SSI was defined as the occurrence of a superficial, deep incisionalwithin the 30 days after colectomy

Readmission was defined readmission resulting postoperative wound disruption, anastomotic leak, ileus, acute renal failure

RESULTS 8415 patients who had a colorectal operation

from 2011 to 2012. - 25.6% had no preoperative bowel

preparation- 44.9% had an MBP alone- 29.5% had both an oral antibiotic with or

without anMBP.

The majority of patients (92%) receiving oral antibiotics had both an OABP and an MBP

8% received oral antibiotics alone Nearly two thirds (62.9%) underwent a

minimally invasive colectomy. Indications for surgery included

neoplasm 43.2%diverticulitis 24.6%benign disease 12.6%inflammatory bowel disease (IBD) 6.6%. other 13.0%

Operation partial colectomy 47.6%left-sided or rectal operation 29.7%ileocolic resection 19.0%,total colectomy 3.7%

SSI 934 (11.1%) had a postoperative SSI537 (6.4%)superficial SSI 95 (1.1%) deep SSI343 (4.1%) organ space SSI.

The SSI rate differed significantly by type of bowel preparation: (P < 0.001).

14.9% no preparation12.0% MBP6.5% OABP

OABP with MBP was associated with a slightly lower but not significant rate than OABP alone (6.3% vs 9.4%, P = 0.09);

OABP was associated with the lowest hospital LOS

Readmission rates were the lowest in patients receiving OABP (8.1%) and highest in the group receiving no preparation (11.8%).

SSIs were more likely to occur after discharge in patients with an OABP (59.8% vs 54.2% for MBP and 50.5% for no preparation(P = 0.16)

use of a minimally invasive approach for surgery was associated with a significant reduction in SSI

DISCUSSION OABP is associated with significantly improved

outcomes including decreased wound-related complications such as SSIs, shortened LOS, and decreased readmissions.

SSIs are costly and lead to readmissions study found that both SSI rates and readmission rates were different based on the type of bowel

preparation used. The lowest readmission rates are seen

- OABP group (8.0%)- highest in no bowel preparation (11.8%)

patients receiving mechanical and OABP were also less likely to develop postoperative C difficile colitis when compared with patients receiving no bowel preparation(0.5% vs 1.8%, P = 0.01).

OABP was associated with decreased organ space infections and returns to the operating room

LIMITATIONS retrospective review of the association

between bowel preparation category and colorectal outcomes and may be bias.

First, bowel preparation was likely abstracted from the medical record

Second, we do not have access to which oral antibiotics were prescribed and cannot recommend a specific antibioticregimen based on these data.

Third, study is restricted to hospitals that participated in the ACS NSQIP

CONCLUSIONS Our study supports the continued use of OABP

for elective colorectal surgery and even in the era of MIS colectomy

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