Influence of a Shorter Duration of Post-Operative Antibiotic Prophylaxis on Infectious Complications in Patients Undergoing Elective Liver Resection

What Is the Ideal Duration for Surgical Antibiotic Prophylaxis?

Background: Surgical antibiotic prophylaxis practice became common in the 1970s and has since become almost universal. The earliest articles used three doses over 12 hours with the first being administered before the start of the operation. Conclusions: The duration of prophylaxis has varied widely in practice over time, but an increasing body of evidence has supported shorter durations, most recently with recommendations in influential guidelines to avoid administration after the incision is closed.

Routine Postoperative Antibiotic Prophylaxis Offers No Benefit after Hepatectomy-A Systematic Review and Meta-Analysis

BACKGROUND

Prophylactic antibiotics are frequently administered after major abdominal surgery including hepatectomies aiming to prevent infective complications. Yet, excessive use of antibiotics increases resistance in bacteria. The aim of this systematic review and meta-analysis is to assess the efficacy of prophylactic antibiotics after hepatectomy (postoperative antibiotic prophylaxis, POA).

METHOD

This systematic review and meta-analysis were completed according to the current PRISMA guidelines. The protocol has been registered prior to data extraction (PROSPERO registration Nr: CRD42021288510). MEDLINE, Web of Science and CENTRAL were searched for clinical reports on POA in hepatectomy restrictions. A random-effects model was used for synthesis. Methodological quality was assessed with RoB2 and ROBINS-I. GRADE was used for the quality of evidence assessment.

RESULTS

Nine comparative studies comprising 2987 patients were identified: six randomized controlled trials (RCTs) and three retrospectives. POA did not lead to a reduction in postoperative infective complications or have an effect on liver-specific complications-post-hepatectomy liver failure and biliary leaks. POA over four or more days was associated with increased rates of deep surgical site infections compared to short-term administration for up to two days (OR 1.54; 95% CI [1.17;2.03]; p = 0.03). Routine POA led to significantly higher MRSA incidence as a pathogen (p = 0.0073). Overall, the risk of bias in the studies was low and the quality of evidence moderate.

CONCLUSION

Routine POA cannot be recommended after hepatectomy since it does not reduce postoperative infection or liver-specific complications but contributes to resistance in bacteria. Studies into individualized risk-adapted antibiotic prophylaxis strategies are needed to further optimize perioperative treatment in liver surgery.

Infected hepatic echinococcosis. Clinical, therapeutic, and prognostic aspects. A systematic review

Infected hepatic echinococcosis (IHE), defined as a cystic infection, and the development of a liver abscess may be a complication in the natural history of hepatic echinococcosis. The aim of this study was to review the evidence available related to clinical, therapeutic, and prognostic aspects of IHE. We conducted a systematic review. Trip Database, BIREME-BVS, SciELO, LILACS, IBECS, PAHO-WHO; WoS, EMBASE, SCOPUS and PubMed were consulted. Studies related to IHE in humans, without language restriction, published between 1966 and 2020 were considered. Variables studied were publication year, geographical origin of the samples, number of patients, therapeutic and prognosis aspects, and methodological quality (MQ) for each article. Descriptive statistics was applied. Subsequently, weighted averages (WA) of the MQ of each article were calculated for each variable of interest. 960 related articles were identified; 47 fulfilled selection criteria, including 486 patients with a median age of 48 years, 51.6% being male. The largest proportion of articles were from Spain, India, and Greece (36.1%). Mean cyst diameter was 14.1 cm, and main location was right liver lobe (74.0%). WA for morbidity, mortality, hospital stay, and follow-up were 28.5%, 7.4%, 8.5 days and 14.8 months, respectively. The most common causative microorganisms of superinfection isolated were Enterobacteriaceae. An association with cholangitis was reported in 13.4% of cases. Mean MQ of the 47 articles included was 7.6 points. We can conclude that the information related to IHE is scarce and scattered throughout articles of small casuistry and poor quality, and consequently does not provide strong evidence.

Controversies in Perioperative Antimicrobial Prophylaxis

Although clinical guidelines for antibiotic prophylaxis across a wide array of surgical procedures have been proposed by multidisciplinary groups of physicians and pharmacists, clinicians often deviate from recommendations. This is particularly true when recommendations are based on weak data or expert opinion. The goal of this review is to highlight certain common but controversial topics in perioperative prophylaxis and to focus on the data that does exist for the recommendations being made.

Acute wound infections management: the 'Don'ts' from a multidisciplinary expert panel

Introduction: The management of acute wounds may be affected by malpractices leading to poor outcome, prolonged hospital stay and inappropriate use of antibiotic therapy.Areas covered: Acute wound infections are represented by surgical site and post-traumatic infections. The aim of this expert opinion is to identify a list of inadvisable actions and to provide a guide for an optimal management of acute wound infections. A literature search using Pubmed/MEDLINE database was performed. Articles pertaining to areas covered published until December 2019 were selected. We identified the most common malpractices in this setting and, using the Choosing Wisely methodology, we proposed a list of "Don'ts" for an easy use in clinical practice.Expert opinion: Malpractices may occur from the surgical prophylaxis to the discharge of patient. A prolonged surgical prophylaxis, the underestimation of signs and symptoms, the omission of source control, the inappropriate collection of wound swab, the improper use of clinical microbiology and pharmacology, the lack of hygiene measures and the delay of discharge are all factors that may lead to unfavorable outcome. A multidisciplinary approach is needed to optimally manage these patients. The "Don'ts" refer to all professional figures involved in the management of patients with acute wound infections.

Giving short-term prophylactic antibiotics in patients undergoing open and laparoscopic hepatic resection

AIM

The 2016 guidelines of the Japan Society for Surgical Infection and the Japan Society of Chemotherapy advocate giving prophylactic antibiotics 1 hour before surgery and until 24 hours after surgery in patients undergoing elective hepatic resection. However, the efficacy of short-term antimicrobial prophylaxis has not been evaluated according to surgical approach. We evaluated the efficacy of giving prophylactic antibiotics in patients undergoing open or laparoscopic hepatic resection.

METHODS

The study comprised 218 and 185 patients undergoing open and pure laparoscopic hepatic resection, respectively. Incidence rates of postoperative infectious complications were compared between patients who received flomoxef sodium as the prophylactic antibiotic before and until 24 hours after surgery (short-term group) and those who received flomoxef sodium until 72 hours after surgery (long-term group) among patients undergoing open or laparoscopic hepatic resection. Propensity score matching analysis was carried out to adjust for confounding factors between the short- and long-term groups.

RESULTS

There was no significant difference in the postoperative infectious complication incidence between the short- and long-term groups among patients undergoing open (18.9% vs 12.2%; P = 0.36) or laparoscopic (3.3% vs 1.7%; P > 0.99) hepatic resection after propensity score matching. Incidence rate of surgical site infections was comparable between the short- and long-term groups among patients undergoing open (13.5% vs 10.8%; P = 0.80) or laparoscopic (3.3% vs 1.7%; P > 0.99) hepatic resection.

CONCLUSION

Giving short-term prophylactic antibiotics might be sufficient in preventing postoperative infectious complications in patients undergoing open and laparoscopic hepatic resection.

Adverse oncological outcome of surgical site infection after liver resection for colorectal liver metastases

PURPOSES

Postoperative complications are associated with poor overall and cancer-specific survival after resection of various types of cancer, including primary colorectal cancer. However, the oncological impact of surgical site infection (SSI) after liver resection for colorectal liver metastases (CLM) is unclear. The aim of this study was to investigate the oncological impact of SSI after liver resection for CLM.

METHODS

We reviewed data from 367 consecutive patients treated by curative liver resection for CLM between 1994 and 2015. Patients who underwent simultaneous resection of colorectal cancer and synchronous liver metastases (n = 86) were excluded from the analysis. Short- and long-term outcomes were analyzed.

RESULTS

SSI developed in 18 (6.4%) of the 281 patients in the analytic cohort (SSI group). The remaining 93.6% (n = 263) did not suffer this complication (no-SSI group). The operative duration was significantly longer in the SSI group than in the No-SSI group (p = 0.002). The overall survival rates 5 years after liver resection for CLM were 33.3% in the SSI group vs. 50.7% in the No-SSI group (p = 0.043). Multivariate analysis indicated that a liver tumor size ≥ 5 cm, R1 resection, and SSI were independently associated with overall survival after liver resection.

CONCLUSIONS

SSI after liver resection for CLM is associated with adverse oncological outcomes.