Orelio Claudia C, van Hessen Coen, Sanchez-Manuel Francisco Javier, Aufenacker Theodorus J, Scholten Rob Jpm
Diakonessenhuis Utrecht, Research Support, Bosboomstraat 1, Utrecht, Netherlands, 3582 KE.
Diakonessenhuis Utrecht, Liesbreukcentrum Nederland, Bosboomstraat 1, Utrecht, Netherlands, 3582 KE.
Cochrane Database Syst Rev. 2020 Apr 21;4(4):CD003769. doi: 10.1002/14651858.CD003769.pub5.
Inguinal or femoral hernia is a tissue protrusion in the groin region and has a cumulative incidence of 27% in adult men and of 3% in adult women. As most hernias become symptomatic over time, groin hernia repair is one of the most frequently performed surgical procedures worldwide. This type of surgery is considered 'clean' surgery with wound infection rates expected to be lower than 5%. For clean surgical procedures, antibiotic prophylaxis is not generally recommended. However after the introduction of mesh-based hernia repair and the publication of studies that have high wound infection rates the debate as to whether antibiotic prophylaxis is required to prevent postoperative wound infections started again.
To determine the effectiveness of antibiotic prophylaxis in reducing postoperative (superficial and deep) wound infections in elective open inguinal and femoral hernia repair.
We searched several electronic databases: Cochrane Registry of Studies Online, MEDLINE Ovid, Embase Ovid, Scopus and Science Citation Index (search performed on 12 November 2019). We also searched two trial registers and the reference list of included studies.
We included randomised controlled trials comparing any type of antibiotic prophylaxis versus placebo or no treatment for preventing postoperative wound infections in adults undergoing inguinal or femoral open hernia repair surgery (tissue repair and mesh repair).
Two review authors independently selected studies, extracted data and assessed risk of bias. We separately analysed results for two different surgical methods (herniorrhaphy and hernioplasty). Several studies revealed infection rates that were higher than the expected 5% for clean surgery and we therefore divided studies into two subgroups: high infection risk environments (≥ 5% infection rate); and low infection risk environments (< 5% infection rate). We performed meta-analyses with random-effects models. We analysed three outcomes: superficial surgical site infections (SSSI); deep surgical site infections (DSSI); and all postoperative wound infections (SSSI + DSSI).
In this review update we identified and included 10 new studies. In total, we included 27 studies with 8308 participants in this review. It is uncertain whether antibiotic prophylaxis as compared to placebo (or no treatment) prevents all types of postoperative wound infections after herniorrhaphy surgery (risk ratio (RR) 0.86, 95% confidence interval (CI) 0.56 to 1.33; 5 studies, 1865 participants; very low quality evidence). Subgroup analysis did not change these results. We could not perform meta-analyses for SSSI or DSSI as these outcomes were not reported separately. Twenty-two studies related to hernioplasty surgery (total of 6443 participants) and we analysed three outcomes: SSSI; DSSI; SSSI + DSSI. Within the low infection risk environment subgroup, antibiotic prophylaxis as compared to placebo probably makes little or no difference for the outcomes 'prevention of all wound infections' (RR 0.71, 95% CI 0.44 to 1.14; moderate-quality evidence) and 'prevention of SSSI' (RR 0.71, 95% CI 0.44 to 1.17, moderate-quality evidence). Within the high infection risk environment subgroup it is uncertain whether antibiotic prophylaxis reduces all types of wound infections (RR 0.58, 95% CI 0.43 to 0.77, very low quality evidence) or SSSI (RR 0.56, 95% CI 0.41 to 0.77, very low quality evidence). When combining participants from both subgroups, antibiotic prophylaxis as compared to placebo probably reduces the risk of all types of wound infections (RR 0.61, 95% CI 0.48 to 0.78) and SSSI (RR 0.60, 95% CI 0.46 to 0.78; moderate-quality evidence). Antibiotic prophylaxis as compared to placebo probably makes little or no difference in reducing the risk of postoperative DSSI (RR 0.65, 95% CI 0.26 to 1.65; moderate-quality evidence), both in a low infection risk environment (RR 0.67, 95% CI 0.11 to 4.13; moderate-quality evidence) and in the high infection risk environment (RR 0.64, 95% CI 0.22 to 1.89; low-quality evidence).
AUTHORS' CONCLUSIONS: Evidence of very low quality shows that it is uncertain whether antibiotic prophylaxis reduces the risk of postoperative wound infections after herniorrhaphy surgery. Evidence of moderate quality shows that antibiotic prophylaxis probably makes little or no difference in preventing wound infections (i.e. all wound infections, SSSI or DSSI) after hernioplasty surgery in a low infection risk environment. Evidence of low quality shows that antibiotic prophylaxis in a high-risk environment may reduce the risk of all wound infections and SSSI, while evidence of very low quality shows that it is uncertain whether antibiotic prophylaxis reduces DSSI after hernioplasty surgery.
腹股沟疝或股疝是腹股沟区的组织突出，成年男性的累积发病率为27%，成年女性为3%。随着大多数疝随着时间推移出现症状，腹股沟疝修补术是全球最常开展的外科手术之一。这类手术被视为“清洁”手术，伤口感染率预计低于5%。对于清洁手术，一般不建议预防性使用抗生素。然而，在引入基于补片的疝修补术以及发表了伤口感染率较高的研究后，关于是否需要预防性使用抗生素来预防术后伤口感染的争论再次兴起。
确定预防性使用抗生素在择期开放性腹股沟疝和股疝修补术中减少术后（浅表和深部）伤口感染的有效性。
我们检索了多个电子数据库：Cochrane在线研究注册库、MEDLINE Ovid、Embase Ovid、Scopus和科学引文索引（检索于2019年11月12日进行）。我们还检索了两个试验注册库以及纳入研究的参考文献列表。
我们纳入了随机对照试验，这些试验比较了任何类型的抗生素预防与安慰剂或不治疗，以预防接受腹股沟或股部开放性疝修补手术（组织修补和补片修补）的成年人术后伤口感染。
两位综述作者独立选择研究、提取数据并评估偏倚风险。我们分别分析了两种不同手术方法（疝修补术和疝成形术）的结果。多项研究显示感染率高于清洁手术预期的5%，因此我们将研究分为两个亚组：高感染风险环境（感染率≥5%）；和低感染风险环境（感染率<5%）。我们使用随机效应模型进行荟萃分析。我们分析了三个结局：浅表手术部位感染（SSSI）；深部手术部位感染（DSSI）；以及所有术后伤口感染（SSSI + DSSI）。
在本次综述更新中，我们识别并纳入了10项新研究。本综述总共纳入了27项研究，8308名参与者。与安慰剂（或不治疗）相比，预防性使用抗生素是否能预防疝修补术后所有类型的术后伤口感染尚不确定（风险比（RR）0.86，95%置信区间（CI）0.56至1.33；5项研究，1865名参与者；极低质量证据）。亚组分析未改变这些结果。由于这些结局未分别报告，我们无法对SSSI或DSSI进行荟萃分析。22项研究涉及疝成形术（共6443名参与者），我们分析了三个结局：SSSI；DSSI；SSSI + DSSI。在低感染风险环境亚组中，与安慰剂相比，预防性使用抗生素对于“预防所有伤口感染”（RR 0.71，95% CI 0.44至1.14；中等质量证据）和“预防SSSI”（RR 0.71，95% CI 0.44至1.17，中等质量证据）的结局可能几乎没有差异或没有差异。在高感染风险环境亚组中，预防性使用抗生素是否能减少所有类型的伤口感染（RR 0.58，95% CI 0.43至0.77，极低质量证据）或SSSI（RR 0.56，95% CI 0.41至0.77，极低质量证据）尚不确定。当合并两个亚组的参与者时，与安慰剂相比，预防性使用抗生素可能会降低所有类型伤口感染的风险（RR 0.61，95% CI 0.48至0.78）和SSSI（RR 0.60，95% CI 0.46至0.78；中等质量证据）。与安慰剂相比，预防性使用抗生素在降低术后DSSI风险方面可能几乎没有差异或没有差异（RR 0.65，95% CI 0.26至1.65；中等质量证据），在低感染风险环境（RR 0.67，95% CI 0.11至4.13；中等质量证据）和高感染风险环境（RR 0.64，95% CI 0.22至1.89；低质量证据）中均如此。
极低质量的证据表明，预防性使用抗生素是否能降低疝修补术后的术后伤口感染风险尚不确定。中等质量的证据表明，在低感染风险环境下，预防性使用抗生素在预防疝成形术后的伤口感染（即所有伤口感染、SSSI或DSSI）方面可能几乎没有差异或没有差异。低质量的证据表明，在高风险环境下预防性使用抗生素可能会降低所有伤口感染和SSSI的风险，而极低质量的证据表明，预防性使用抗生素是否能降低疝成形术后的DSSI尚不确定。
