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Tang XF, Bin X, Qu KY, Liu HJ, Lei H, Li WF, Min Z, Xia Y, Dai LH, Yu SY, Bao YP, Zhu JQ, Bing T. Antibiotic prophylaxis for surgical wound infections in clean and clean-contaminated surgery: an updated systematic review and meta-analysis. Int J Surg 2024; 110:5818-5832. [PMID: 38935088 PMCID: PMC11392186 DOI: 10.1097/js9.0000000000001882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Accepted: 06/17/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND The efficacy and necessity of prophylactic antibiotics in clean and clean-contaminated surgery remains controversial. METHODS The studies were screened and extracted using databases including PubMed, Embase, Cochrane Library, Web of Science, and Clinical Trials.gov according to predefined eligibility criteria. Randomized controlled trials (RCTs) comparing the effect of preoperative and postoperative prophylactic antibiotic use on the incidence of surgical site infections (SSIs) in patients undergoing any clean or clean-contaminated surgery. RESULTS A total of 16 189 participants in 48 RCTs were included in the primary meta-analysis following the eligibility criteria. The pooled odds ratio (OR) for SSI with antibiotic prophylaxis versus placebo was 0.60 (95% CI: 0.53-0.68). The pooled OR among gastrointestinal, oncology, orthopedics, neurosurgery, oral, and urology surgery was 3.06 (95% CI: 1.05-8.91), 1.16 (95% CI: 0.89-1.50), 2.04 (95% CI: 1.09-3.81), 3.05 (95% CI: 1.25-7.47), 3.55 (95% CI: 1.78-7.06), and 2.26 (95% CI: 1.12-4.55), respectively. Furthermore, the summary mean difference (MD) for patients' length of hospitalization was -0.91 (95% CI: -1.61, -0.16). The results of sensitivity analyses for all combined effect sizes showed good stability. CONCLUSION Antibiotics are both effective, safe, and necessary in preventing surgical wound infections in clean and clean-contaminated procedures, attributed to their reduction in the incidence of surgical site infections as well as the length of patient hospitalization.
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Affiliation(s)
- Xiao-Fei Tang
- Department of Pharmaceutical, Fengdu People's Hospital, Chongqing
| | - Xiang Bin
- Department of Otolaryngology, Fengdu People's Hospital, Chongqing
| | - Ke-Yi Qu
- Department of Stomatology, Fengdu People's Hospital, Chongqing
| | - Hong-Jun Liu
- Department of Cardiovascular, Fengdu People's Hospital, Chongqing
| | - Haike Lei
- Chongqing Cancer Multi-omics Big Data Application Engineering Research Center, Chongqing University Cancer Hospital, Chongqing
| | - Wei-Fan Li
- Department of Pharmaceutical, Fengdu People's Hospital, Chongqing
| | - Zhou Min
- Department of Education, Fengdu People's Hospital & Science, Chongqing
| | - Yu Xia
- Department of Education, Fengdu People's Hospital & Science, Chongqing
| | - Li-Hua Dai
- Department of Pharmaceutical, Fengdu People's Hospital, Chongqing
| | - Su-Ying Yu
- Department of Nursing, Fengdu People's Hospital, Chongqing
| | - Yun-Ping Bao
- Department of Stomatology, Fengdu People's Hospital, Chongqing
| | - Jia-Quan Zhu
- Department of Pharmaceutical, Fengdu People's Hospital, Chongqing
| | - Tan Bing
- Department of Medical Equipment, Fengdu People's Hospital, Chongqing, China
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Elkasaby MH, Elsayed H, Charo DC, Rashed MA, Elkoumi O, Elhaddad IM, Gadallah A, Ramadan A. Antibiotic prophylaxis in emergency cholecystectomy for mild to moderate acute cholecystitis: a systematic review and meta-analysis of randomized controlled trials. Perioper Med (Lond) 2024; 13:87. [PMID: 39123238 PMCID: PMC11312388 DOI: 10.1186/s13741-024-00441-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Accepted: 07/16/2024] [Indexed: 08/12/2024] Open
Abstract
BACKGROUND Emergency cholecystectomy is the mainstay in treating acute cholecystitis (AC). In actual practice, perioperative prophylactic antibiotics are used to prevent postoperative infectious complications (PIC), but their effectiveness lacks evidence. We aim to investigate the efficacy of prophylactic antibiotics in emergency cholecystectomy. METHODS We searched PubMed, Embase, Cochrane CENTRAL, Web of Science (WOS), and Scopus up to June 14, 2023. We included randomized controlled trials (RCTs) that involved patients diagnosed with mild to moderate AC according to Tokyo guidelines who were undergoing emergency cholecystectomy and were administered preoperative and/or postoperative antibiotics as an intervention group and compared to a placebo group. For dichotomous data, we applied the risk ratio (RR) and the 95% confidence interval (CI), while for continuous data, we used the mean difference (MD) and 95% CI. RESULTS We included seven RCTs encompassing a collective sample size of 1747 patients. Our analysis showed no significant differences regarding total PIC (RR = 0.84 with 95% CI (0.63, 1.12), P = 0.23), surgical site infection (RR = 0.79 with 95% CI (0.56, 1.12), P = 0.19), distant infections (RR = 1.01 with 95% CI (0.55, 1.88), P = 0.97), non-infectious complications (RR = 0.84 with 95% CI (0.64, 1.11), P = 0.22), mortality (RR = 0.34 with 95% CI (0.04, 3.23), P = 0.35), and readmission (RR = 0.69 with 95% CI (0.43, 1.11), P = 0.13). CONCLUSION Perioperative antibiotics in patients with mild to moderate acute cholecystitis did not show a significant reduction of postoperative infectious complications after emergency cholecystectomy. (PROSPERO registration number: CRD42023438755).
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Affiliation(s)
- Mohamed Hamouda Elkasaby
- Faculty of Medicine, Al-Azhar University, Cairo, Egypt.
- Medical Research Group of Egypt (MRGE), Cairo, Egypt.
| | - Hesham Elsayed
- Faculty of Medicine, Tanta University, Tanta, Egypt
- Medical Research Group of Egypt (MRGE), Cairo, Egypt
| | - Dilawer Chofan Charo
- General Surgery Department, Ministry of Health, Latakia, Syria
- Medical Research Group of Egypt (MRGE), Cairo, Egypt
| | - Mohamed Abdalla Rashed
- Faculty of Medicine, Al-Azhar University, Cairo, Egypt
- Medical Research Group of Egypt (MRGE), Cairo, Egypt
| | - Omar Elkoumi
- Faculty of Medicine, Suez University, Suez, Egypt
- Medical Research Group of Egypt (MRGE), Cairo, Egypt
| | - Islam Mohsen Elhaddad
- Faculty of Medicine, Al-Azhar University, Damietta, Egypt
- Medical Research Group of Egypt (MRGE), Cairo, Egypt
| | - Ahmed Gadallah
- Faculty of Medicine, Ain Shams University, Cairo, Egypt
- Medical Research Group of Egypt (MRGE), Cairo, Egypt
| | - Alaa Ramadan
- Faculty of Medicine, South Valley University, Qena, Egypt
- Medical Research Group of Egypt (MRGE), Cairo, Egypt
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Chuklin S, Chooklin S. Laparoscopic cholecystectomy in calculous cholecystitis: are antibiotics necessary? EMERGENCY MEDICINE 2024; 20:77-84. [DOI: 10.22141/2224-0586.20.2.2024.1668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/02/2024]
Abstract
Laparoscopic cholecystectomy in patients with cholecystitis is considered the best, appropriate and safe method of treatment for gallstone disease. However, the role of antibiotic administration before or after cholecystectomy to reduce infectious complications, particularly surgical site infections, or mortality is less clear. Many patients receive empiric antibiotics, but the feasibility of their use has not been proven. Some guidelines suggest the use of antibiotic prophylaxis for all cholecystectomies, although current evidence does not indicate any benefit to this practice in the absence of risk factors. This review examines the results of antibiotic use in laparoscopic cholecystectomy for chronic and acute calculous cholecystitis. Most studies argue against the need to use prophylactic antibiotics during elective surgery in low-risk patients. In cases of mild and moderate acute cholecystitis, the use of antibiotics to prevent postoperative infectious complications has no evidence of effectiveness, although these recommendations are also ambiguous. It is not recommended to use postoperative antibiotics after elective laparoscopic cholecystectomy, as well as for mild or moderate acute cholecystitis. However, additional studies with well-defined patient populations and comparable outcomes are needed to better assess the most appropriate timing and duration of antibiotic use in patients undergoing laparoscopic cholecystectomy. We used MedLine database on the PubMed platform and the Cochrane library to search for literature sources.
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Meretsky CR, Krumbach B, Schiuma AT. A Comparative Analysis of Prophylactic Antibiotic Administration in Emergency Surgery Versus Elective Surgery: A Comprehensive Review. Cureus 2024; 16:e57338. [PMID: 38690454 PMCID: PMC11060617 DOI: 10.7759/cureus.57338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2024] [Indexed: 05/02/2024] Open
Abstract
Surgical site infections (SSIs) contribute to increased patient morbidity, prolonged hospital stays, and substantial healthcare costs. Prophylactic antibiotics play a pivotal role in mitigating the risk of SSIs, with their administration being a standard practice before both emergency and elective surgeries. This paper provides a comprehensive review and comparative analysis of the benefits of prophylactic antibiotic administration in emergency surgery versus elective surgery. Through a systematic literature review and analysis of relevant studies identified through PubMed searches, this paper highlights the specific benefits of prophylactic antibiotics between emergency and elective surgeries. The findings underscore the importance of tailored antibiotic regimens and administration protocols to optimize patient care and promote successful surgical outcomes in diverse clinical settings. Further research is warranted to refine guidelines and enhance understanding of the relationship between prophylactic antibiotics and surgical outcomes across different surgical contexts.
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Affiliation(s)
| | - Brandon Krumbach
- Surgery, St. George's University School of Medicine, Great River, USA
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de Miguel-Palacio M, González-Castillo AM, Membrilla-Fernández E, Pons-Fragero MJ, Pelegrina-Manzano A, Grande-Posa L, Morera-Casaponsa R, Sancho-Insenser JJ. Impact of empiric antibiotic therapy on the clinical outcome of acute calculous cholecystitis. Langenbecks Arch Surg 2023; 408:345. [PMID: 37644336 PMCID: PMC10465626 DOI: 10.1007/s00423-023-03063-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Accepted: 08/14/2023] [Indexed: 08/31/2023]
Abstract
PURPOSE Although mortality and morbidity of severe acute calculous cholecystitis (ACC) are still a matter of concern, the impact of inadequate empirical antibiotic therapy has been poorly studied as a risk factor. The objective was to assess the impact of the adequacy of empirical antibiotic therapy on complication and mortality rates in ACC. METHODS This observational retrospective cohort chart-based single-center study was conducted between 2012 and 2016. A total of 963 consecutive patients were included, and pure ACC was selected. General, clinical, postoperative, and microbiological variables were collected, and risk factors and consequences of inadequate treatment were analyzed. RESULTS Bile, blood, and/or exudate cultures were obtained in 76.3% of patients, more often in old, male, and severely ill patients (P < 0.001). Patients who were cultured had a higher overall rate of postoperative complications (47.4% vs. 29.7%; P < 0.001), as well as of severe complications (11.6% vs. 4.7%; P = 0.008). Patients with positive cultures had more overall complications (54.8% vs. 39.6%; P = 0.001), more severe complications (16.3% vs. 6.7%; P = 0.001), and higher mortality rates (6% vs. 1.9%; P = 0.012). Patients who received inadequate empirical antibiotic therapy had a fourfold higher mortality rate than those receiving adequate therapy (n = 283; 12.8% vs. 3.4%; P = 0.003). This association was especially marked in severe ACC TG-III patients (n = 132; 18.2 vs. 5.1%; P = 0.018) and remained a predictor of mortality in a binary logistic regression (OR 4.4; 95% CI 1.3-15.3). CONCLUSION Patients with positive cultures developed more complications and faced higher mortality. Adequate empirical antibiotic therapy appears to be of paramount importance in ACC, particularly in severely ill patients.
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Affiliation(s)
- Maite de Miguel-Palacio
- Department of Surgery, Autonomous University of Barcelona, Barcelona, Spain.
- Department of General Surgery, Hospital del Mar, Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain.
| | - Ana-María González-Castillo
- Department of General Surgery, Hospital del Mar, Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
- Department of Medicine and Life Sciences, Pompeu Fabra University, Barcelona, Spain
| | - Estela Membrilla-Fernández
- Department of General Surgery, Hospital del Mar, Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
- Department of Medicine and Life Sciences, Pompeu Fabra University, Barcelona, Spain
| | - María-José Pons-Fragero
- Department of General Surgery, Hospital del Mar, Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | - Amalia Pelegrina-Manzano
- Department of General Surgery, Hospital del Mar, Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
- Department of Medicine and Life Sciences, Pompeu Fabra University, Barcelona, Spain
| | - Luis Grande-Posa
- Department of Surgery, Autonomous University of Barcelona, Barcelona, Spain
- Department of General Surgery, Hospital del Mar, Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | | | - Juan-José Sancho-Insenser
- Department of Surgery, Autonomous University of Barcelona, Barcelona, Spain
- Department of General Surgery, Hospital del Mar, Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
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Satheeskaran M, Hussan A, Anto A, de Preux L. Cost-effectiveness analysis of antibiotic prophylaxis versus no antibiotic prophylaxis for acute cholecystectomy. BMJ Open Gastroenterol 2023; 10:e001162. [PMID: 37562856 PMCID: PMC10423775 DOI: 10.1136/bmjgast-2023-001162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 07/22/2023] [Indexed: 08/12/2023] Open
Abstract
OBJECTIVE For acute cholecystitis, the treatment of choice is laparoscopic cholecystectomy. In mild-to-moderate cases, the use of antibiotic prophylaxis for the prevention of postoperative infectious complications (POICs) lacks evidence regarding its cost-effectiveness when compared with no prophylaxis. In the context of rising antimicrobial resistance, there is a clear rationale for a cost-effectiveness analysis (CEA) to determine the most efficient use of National Health Service resources and antibiotic routine usage. DESIGN 16 of 226 patients (7.1%) in the single-dose prophylaxis group and 29 of 231 (12.6%) in the non-prophylaxis group developed POICs. A CEA was carried out using health outcome data from thePerioperative antibiotic prophylaxis in the treatment of acute cholecystitis (PEANUTS II) multicentre, randomised, open-label, non-inferiority, clinical trial. Costs were measured in monetary units using pound sterling, and effectiveness expressed as POICs avoided within the first 30 days after cholecystectomy. RESULTS This CEA produced an incremental cost-effectiveness ratio of -£792.70. This suggests a modest cost-effectiveness of antibiotic prophylaxis being marginally less costly and more effective than no prophylaxis. Three sensitivity analyses were executed considering full adherence to the antibiotic, POICs with increased complexity and break-point analysis suggesting caution in the recommendation of systematic use of antibiotic prophylaxis for the prevention of POICs. CONCLUSION The results of this CEA point to greater consensus in UK-based guidelines surrounding the provision of antibiotic prophylaxis for mild-to-moderate cases of acute cholecystitis.
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Affiliation(s)
- Maya Satheeskaran
- Imperial College Business School, Imperial College London, London, UK
| | - Aminah Hussan
- Imperial College Business School, Imperial College London, London, UK
| | - Ailin Anto
- Imperial College Business School, Imperial College London, London, UK
| | - Laure de Preux
- Imperial College Business School, Imperial College London, London, UK
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Park SE, Choi HJ, You YK, Hong TH. Clinical significance of preoperative antibiotic use in mild to moderate acute inflammatory gallbladder disease: A randomized controlled trial. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2023; 30:482-492. [PMID: 36050816 DOI: 10.1002/jhbp.1237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 08/10/2022] [Accepted: 08/11/2022] [Indexed: 04/28/2023]
Abstract
BACKGROUND Many patients receive empirical antibiotics for the prevention of postoperative infectious complications following cholecystectomy due to acute cholecystitis (AC). The purpose of this study was to investigate the clinical significance of preoperative antibiotics in mild to moderate AC patients undergoing emergency laparoscopic cholecystectomy. METHODS This was a double-blind, placebo-controlled, randomized study. Patients with AC eligible for emergency laparoscopic cholecystectomy were randomly assigned to an antibiotic or a placebo group. Clinical outcomes including infectious complications were reviewed. RESULTS An imputed per-protocol analysis of 234 patients showed that the postoperative infection rate was 8.6% (10 of 116 patients) in the antibiotic group and 7.6% (9 of 118 patients) in the placebo group (absolute difference, 1%; 95% CI: -8.1% to 6.1%; P = .815). Based on a noninferiority margin of 10%, the lack of preoperative antibiotic treatment was not associated with worse clinical outcomes than antibiotic treatment. Surgical site infection was the most common complication among the infectious complications, and there was no significant difference between the two groups (7.8% in the antibiotic group vs 7.6%, in the placebo group, P = .53). CONCLUSIONS The absence of prophylactic antibiotics has no significant impact on the incidence of infectious complications in mild to moderated AC.
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Affiliation(s)
- Sung Eun Park
- Division of Hepato-Biliary and Pancreas Surgery, Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Ho Jung Choi
- Division of Hepato-Biliary and Pancreas Surgery, Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Young Kyoung You
- Division of Hepato-Biliary and Pancreas Surgery, Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Tae Ho Hong
- Division of Hepato-Biliary and Pancreas Surgery, Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Barie PS, Kao LS, Moody M, Sawyer RG. Infection or Inflammation: Are Uncomplicated Acute Appendicitis, Acute Cholecystitis, and Acute Diverticulitis Infectious Diseases? Surg Infect (Larchmt) 2023; 24:99-111. [PMID: 36656157 DOI: 10.1089/sur.2022.363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Background: It is recognized increasingly that common surgical infections of the peritoneal cavity may be treated with antibiotic agents alone, or source control surgery with short-course antimicrobial therapy. By extension, testable hypotheses have emerged that such infections may not actually be infectious diseases, but rather represent inflammation that can be treated successfully with neither surgery nor antibiotic agents. The aim of this review is to examine extant data to determine which of uncomplicated acute appendicitis (uAA), uncomplicated acute calculous cholecystitis (uACC), or uncomplicated mild acute diverticulitis (umAD) might be amenable to management using supportive therapy alone, consistent with the principles of antimicrobial stewardship. Methods: Review of pertinent English-language literature and expert opinion. Results: Only two small trials have examined whether uAA can be managed with observation and supportive therapy alone, one of which is underpowered and was stopped prematurely because of challenging patient recruitment. Data are insufficient to determine the safety and efficacy of non-antibiotic therapy of uAA. Uncomplicated acute calculous cholecystitis is not primarily an infectious disease; infection is a secondary phenomenon. Even when bactibilia is present, there is no high-quality evidence to suggest that mild disease should be treated with antibiotic agents. There is evidence to indicate that antibiotic prophylaxis is indicated for urgent/emergency cholecystectomy for uACC, but not in the post-operative period. Uncomplicated mild acute diverticulitis, generally Hinchey 1a or 1b in current nomenclature, does not benefit from antimicrobial agents based on multiple clinical studies. The implication is that umAD is inflammatory and not an infectious disease. Non-antimicrobial management is reasonable. Conclusions: Among the considered disease entities, the evidence is strongest that umAD is not an infectious disease and can be treated without antibiotic agents, intermediate regarding uACC, and lacking for uAA. A plausible hypothesis is that these inflammatory conditions are related to disruption of the normal microbiome, resulting in dysbiosis, which is defined as an imbalance of the natural microflora, especially of the gut, that is believed to contribute to a range of conditions of ill health. As for restorative pre- or probiotic therapy to reconstitute the microbiome, no recommendation can be made in terms of treatment, but it is not recommended for prevention of primary or recurrent disease.
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Affiliation(s)
- Philip S Barie
- Department of Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Lillian S Kao
- Department of Surgery, UTHealth Houston John P. and Kathrine G. McGovern Medical School, Houston, Texas, USA
| | - Mikayla Moody
- Department of Surgery, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, Michigan, USA
| | - Robert G Sawyer
- Department of Surgery, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, Michigan, USA
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Sandblom G. Surgical Infection Society guidelines on antibiotic use in gallstone surgery: high time we crack down on prophylactic antibiotics. Hepatobiliary Surg Nutr 2022; 11:893-895. [PMID: 36523940 PMCID: PMC9745614 DOI: 10.21037/hbsn-22-482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 10/26/2022] [Indexed: 08/29/2023]
Affiliation(s)
- Gabriel Sandblom
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
- Department of Surgery, Södersjukhuset, Stockholm, Sweden
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