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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
Intervention Studied (Focus
of the Meta-analysis)
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
Intervention Studied (Focus
of the Meta-analysis)
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.
Meta-analysis on Surgical Infections 415
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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
Gurusamy and Samraj,200759
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
Gurusamy and Samraj,200662
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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