The usage of antibiotic therapy for septic complications in colorectal surgery

Over the past few decades, surgeons have made many attempts to reduce the incidence of surgical site infections (SSI) after elective colorectal surgery. Routine faecal diversion is no longer practiced in elective colonic surgery and mechanical bowel preparation is on the verge of being eliminated altogether. Intravenous antibiotics have become the standard of care as prophylaxis against SSI for elective colorectal operations. However, the role of antibiotics is still being debated. The aim of the study was to reduce the proportion of antibiotic-resistant strains of pathogens of infectious complications in colorectal surgery by optimizing the use of antimicrobial drugs. Method: We analyzed data of 135 patients who were operated for colorectal cancer in our general surgery department in between 2019 and 2021. Age, gender, body mass index, presence of chronic pulmonary disease, surgery duration, disease location (colon or rectum), and surgeon volume were evaluated for associations with the development of superficial or deep surgical site infection. Results: All parameters were found to be significant for the development surgical site infection except sex. Cut-off values were 63.5 years for age, 167.5 minutes for surgery duration. Conclusion. The introduction of strict monitoring of compliance with the protocols of antibiotic prophylaxis and antibiotic therapy at the level of a separate surgical unit in a multidisciplinary hospital improves conditions for the rational use of antimicrobial drugs.

Preoperative mechanical bowel preparation combined with oral antibacterials in the prevention of complications of surgery for rectal and rectosigmoid junction cancer

Aim: To evaluate the efficacy of mechanical bowel preparation (MBP) combined with oral antibacterials for the prevention of postoperative complications when preparing a patient for anterior rectal resection.Materials and methods: We analyzed shortterm results in 77 patients who had undergone anterior rectal resection for rectal and rectosigmoid junction cancer. Forty five (45) patients were prepared for surgery only with MBP. In 32 patients, in addition to MBP, oral antibacterial agents ciprofloxacin and metronidazole were used preoperatively.Results: The overall rate of postoperative complications was 6.25% (2/32 patients) in the group of combined preparation for surgery and 15.5% (7/45) in the group using only MBP. Surgical wound infection occurred in 1 patient in the combined preparation group and in 4 patients in the MBP only group. There was no anastomotic leak in the combined preparation group, whereas in the MBP only group, anastomotic leak occurred in 2 patients.Conclusion: Combined use of oral antibacterials and MBP before anterior rectal resection makes it possible to achieve an extremely low rate of the colorectal anastomosis leak. Further studies into the efficacy of this preparation regimen are needed, along with their discussion in the professional communities.

Interventions to reduce the incidence of surgical site infection in colorectal resections: systematic review with multicomponent network meta-analysis (INTRISSI): study protocol

ObjectiveTo assess the relative contribution of intravenous antibiotic prophylaxis, mechanical bowel preparation, oral antibiotic prophylaxis, and combinations thereof towards the reduction of surgical site infection (SSI) incidence in elective colorectal resections.Methods and analysisA systematic search of randomised controlled trials comparing interventions to reduce SSI incidence will be conducted with predefined search terms in the following databases: MEDLINE, LILACS, Cochrane Central Register of Controlled Trials (CENTRAL) and the Cochrane Database of Systematic Reviews (CDSR). Additionally, several online databases will be searched for ongoing trials, and conference proceedings and reference lists of retrieved articles will be hand searched. The title–abstract screening will be partly performed by means of a semiautomated supervised machine learning approach, which will be trained on a subset of the identified titles and abstracts identified through traditional screening methods.The primary analysis will be a multicomponent network meta-analysis, as we expect to identify studies that investigate combinations of interventions (eg, mechanical bowel preparation combined with oral antibiotics) as well as studies that focus on individual components (mechanical bowel preparation or oral antibiotics). By means of a multicomponent network meta-analysis, we aim at estimating the effects of the separate components along the effects of the observed combinations. To account for between-trial heterogeneity, a random-effect approach will be combined with inverse variance weighting for estimation of the treatment effects. Associated 95% CIs will be calculated as well as the ranking for each component in the network using P scores. Results will be visualised by network graphics and forest plots of the overall pairwise effect estimates. Comparison-adjusted funnel plots will be used to assess publication bias.Ethics and disseminationEthical approval by the Ethical Committee of the Medical Faculty of the Martin-Luther-University Halle-Wittenberg (ID of approval: 2021–148). Results shall be disseminated directly to decision-makers (eg, surgeons, gastroenterologists, wound care specialists) by means of publication in peer-reviewed journals, presentation at conferences and through the media (eg, radio, TV, etc).PROSPERO registration numberCRD42021267322.

Are preoperative oral antibiotics effective in reducing the incidence of anastomotic leakage after Colorectal cancer surgery: Study protocol for a prospective, multicentre, randomized controlled study

Introduction The optimal preoperative preparation for elective colorectal cancer surgery has been debated in academic circles for decades. Previously, many expert teams have conducted studies on whether preoperative mechanical bowel preparation and preoperative oral antibiotics can effectively reduce the incidence of postoperative complications, such as surgical site infections and anastomotic leakage. Most of the results of these studies have suggested that preoperative mechanical bowel preparation for elective colon surgery has no significant effect on the occurrence of surgical site infections and anastomotic leakage. Methods/design This study will examine whether oral antibiotic bowel preparation (OABP) influences the incidence of anastomotic leakage after surgery in a prospective, multicentre, randomized controlled trial that will enrol 1500 patients who need colon surgery. The primary endpoint, incidence of anastomotic leakage, is based on 2.3% in the OABP ± mechanical bowel preparation (MBP) group in the study by Morris et al. The patients will be randomized (1:1) into two groups: the test group will be given antibiotics (both neomycin 1 g and metronidazole 1 g) the day before surgery, and the control group will not have any special intestinal preparation before surgery, including oral antibiotics or mechanical intestinal preparation. All study-related clinical data, such as general patient information, past medical history, laboratory examination, imaging results, and surgery details, will be recorded before surgery and during the time of hospitalization. The occurrence of postoperative fistulas, including anastomotic leakage, will be recorded as the main severe postoperative adverse event and will represent the primary endpoint. Ethics and dissemination Ethics and dissemination Ethics approval has been obtained from the Ethics Committee at the Chinese Ethics Committee of Registering Clinical Trials(ChiECRCT20200173). The results of this study will be disseminated at several research conferences and as published articles in peer-reviewed journals. Trial registration: ChiCTR2000035550. Registered on 13 Aug 2020.

TP7.2.16 Systematic review and meta analysis of pre operative antibiotics and bowel preparation on ileus following colorectal resection

Aims Pre-operative oral antibiotics (OAB) and mechanical bowel preparation (MBP) may reduce rates of post-operative infectious complications following colorectal surgery but their effects on post-operative ileus (POI) are not well-established. We conducted a systematic review and meta-analysis to address this question. Methods Medline and Embase databases were searched to identify randomised controlled trials and cohort studies comparing pre-operative MBP or OAB to control in patients undergoing elective colorectal resection and reporting the rate of POI as an outcome. Risk ratios were pooled using a random-effects model to generate a summary risk ratio and 95% confidence interval. Results Five randomised trials and three cohort studies were included which reported the effect of pre-operative MBP on POI. Some 29056 patients received MBP compared to 13077 who did not. The rates of POI were 10.0% vs 12.0% respectively. Meta-analysis gave a risk ratio of 0.85 (0.80-0.91, p < 0.0001) for the development of POI with MBP versus control. Four randomised trials and four cohort studies were included which reported the effect of pre-operative OAB on POI. Some 9.5% of 19,903 patients receiving OAB developed POI compared to 11.8% of 23,884 control patients. The pooled risk ratio for the development of POI with OAB compared to control was 0.86 (0.81-0.91, p < 0.0001). However, when limiting analyses to randomised trials alone, neither MBP (RR 1.13, 0.67-1.90) nor OAB 1.01, 0.75-1.35) had a significant effect on the rate of POI. Conclusions Pre-operative MBP or OAB may reduce POI following colorectal resection but this has not been confirmed in randomised trials.

EP.TH.965Use of Oral Antibiotics as Adjunct to Systemic Antibiotics and Mechanical Bowel Preparation for Left Sided Colorectal Surgery. It is the time to trust the best available evidence and change the practice

Aims To prospectively evaluate the clinical efficacy of oral antibiotics as an adjunct to intravenous antibiotics and mechanical bowel preparation (MBP) in patients undergoing left sided colorectal surgery. Methods All participants aged 18 years or older and of any gender undergoing an elective open or laparoscopic left sided colorectal resection for benign or malignant colorectal pathologies were considered. The intervention of interest was oral neomycin 1g every 4 hours combined with oral metronidazole 400mg every 8 hours from 24 hours before the proposed surgery. Surgical site infections (SSIs), anastomotic leak, paralytic ileus, need for intervention, and mortality were the evaluated outcome parameters. Results Forty-two consecutive patients received oral antibiotics as an adjunct to intravenous antibiotics and MBP before left sided colorectal surgery. The mean age was 58.8 ± 11.5. There were 23 males (54.8%) and 19 females (45.2%). Use of oral antibiotics was associated with SSI infection rate of 2.4% (1 patient). The rates of clinically significant and non-significant anastomotic leak were 0% and 2.9%, respectively. Moreover, postoperative ileus happened in 11.9% of patients. Furthermore, there was no mortality or need for re-intervention. Conclusions Use of oral antibiotics as an adjunct to intravenous antibiotics and MBP in patients undergoing left-sided colorectal surgery was associated with a surprisingly low rate of SSIs and no significant anastomotic leak. It is time to trust the best available evidence and incorporate the use of oral antibiotics as an adjunct to intravenous antibiotics and MBP in colorectal surgery protocols in the UK hospitals.

EP.TU.582Impact of enteral prophylactic antibiotic course on the trends of inflammatory markers following laparoscopic colorectal cancer surgery

Introduction The study aimed to assess the effect of oral prophylactic antibiotic (OAB) with mechanical bowel preparation (MBP) on the serial measurement of postoperative inflammatory markers and clinical outcomes of the patients undergoing laparoscopic colorectal cancer resection surgery. Methods A retrospective data collection was carried out from January 2019 to March 2020 for the patients undergoing laparoscopic colorectal cancer resection. Daily measurements of inflammatory markers were obtained upto 7 days following surgery. The measurements of inflammatory markers were compared between patients who received a 1 week course of OAB along with MBP to those who only received MBP. Results There were a total of 110 patients that were divided into 2 groups: patients who received OAB and MBP (n = 44, 40%) and those who had MBP only (n = 66, 60%). There was no significant difference between the patient characteristics and preoperative staging of the cancer between the 2 groups. The overall length of stay was significantly lower in the patients who received OAB (9.09 days [SD 7.94] vs. 6.63 days [SD 4.96], P 0.02). The patients with OAB and MAP had persistently and significantly low levels of white blood cell count, CRP, and neutrophil count throughout the postoperative period as compared to those who only had MBP. Conclusion The study demonstrated reduction in serial measurement of inflammatory markers throughout postoperative stay for the patients receiving preoperative OAB. The use of OAB helps in physiological recovery of the patient by reducing the inflammatory process postoperatively.

Oral Antibiotic Prophylaxis Reduces Surgical Site Infection and Anastomotic Leakage in Patients Undergoing Colorectal Cancer Surgery

Background: Surgical-site infection (SSI) and anastomotic leakage (AL) are major complications following surgical resection of colorectal carcinoma (CRC). The beneficial effect of prophylactic oral antibiotics (OABs) on AL in particular is inconsistent. We investigated the impact of OABs on AL rates and on SSI. Methods: A systematic review and meta-analysis of recent RCTs and cohort studies was performed including patients undergoing elective CRC surgery, receiving OABs with or without mechanical bowel preparation (MBP). Primary outcomes were rates of SSI and AL. Secondarily, rates of SSI and AL were compared in broad-spectrum OABs and selective OABs (selective decontamination of the digestive tract (SDD)) subgroups. Results: Eight studies (seven RCTs and one cohort study) with a total of 2497 patients were included. Oral antibiotics combined with MBP was associated with a significant reduction in SSI (RR = 0.46, 95% confidence interval (CI) 0.31–0.69), I2 = 1.03%) and AL rates (RR = 0.58, 95% CI 0.37–0.91, I2 = 0.00%), compared to MBP alone. A subgroup analysis demonstrated that SDD resulted in a significant reduction in AL rates compared to broad-spectrum OABs (RR = 0.52, 95% CI 0.30 to 0.91), I2 = 0.00%). Conclusion: OABs in addition to MBP reduces SSI and AL rates in patients undergoing elective CRC surgery and, more specifically, SDD appears to be more effective compared to broad-spectrum OABs in reducing AL.