Antibiotics versus placebo for prevention of postoperative infection after appendicectomy.: Cochrane systematic review
Assessed as up to date: 2005/04/19
Appendicitis is the most common cause of acute abdominal pain requiring surgical intervention. The cause of appendicitis is unclear and the mechanism of pathogenesis continues to be debated. Despite improved asepsis and surgical techniques, postoperative complications, such as wound infection and intraabdominal abscess, still account for a significant morbidity. Several studies implicate that postoperative infections are reduced by administration of antimicrobial regimes.Objectives
This review evaluated the use of antibiotics compared to placebo or no treatment in patients undergoing appendectomy. Will these patients benefit from antimicrobial prophylaxis? The outcomes were described according to the nature of the appendix, as either simple appendicitis (including the non-infectious stage) and complicated appendicitis. The efficacy of different antibiotic regimens were not evaluated.Search strategy
We searched The Cochrane Central Register of Controlled Trials (Cochrane Library 2005 issue 1); Pubmed ; EMBASE; and the Cochrane Colorectal Cancer Group Specialised Register (April 2005). In addition, we manually searched the reference lists of the primary identified trials.Selection criteria
We evaluated Randomised Controlled Trials (RCTs) and Controlled Clinical Trials (CCTs) in which any antibiotic regime were compared to placebo in patients suspected of having appendicitis, and undergoing appendectomy. Both studies on children and adults were reviewed. The outcome measures of the studies were: Wound infection, intra abdominal abscess, length of stay in hospital, and mortality.Data collection and analysis
Eligibility and trial quality were assessed, recorded and cross-checked by two reviewers.Main results
Forty-five studies including 9576 patients were included in this review. The overall result is that the use of antibiotics is superior to placebo for preventing wound infection and intraabdominal abscess, with no apparant difference in the nature of the removed appendix. Studies exclusively on children and studies examining topical application reported results in favour to the above, although the results were not significant.Authors' conclusions
Antibiotic prophylaxis is effective in the prevention of postoperative complications in appendectomised patients, whether the administration is given pre-, peri- or post-operatively, and could be considered for routine in emergency appendectomies.
Andersen Betina Ristorp, Kallehave Finn Lasse, Andersen Henning Keinke
Antibiotic prophylaxis could be considered for routine in emergency appendectomies.
Appendicitis is the most common cause of acute abdominal pain requiring surgical intervention. This is associated with increased risk of postoperative complications, wound infection being the most commonly reported. Standard prophylaxis is an anti-bacterial treatment. In order to reduce cost, toxicity and the risk of developing bacterial resistance, it is desirable to establish the shortest and most effective prophylaxis for postoperative complications. This review reports that antibiotic prophylaxis is effective in the prevention of postoperative complications in people who had the appendix removed. Regardless whether the antibiotic was given before, during or after the surgery.
Implications for practice
It seems reasonable to conclude that antibiotic prophylaxis is effective in the prevention of post-operative complications in appendectomied patients, whether the administration is given pre-, per- or post-operatively, and should be considered for routine use in emergency appendicectomy. The overall strategy (type of antibiotics and/or preferred time of administration) needs to be evaluated in another systematic review.
Our results indicate that single doses have the same impact as multiple doses. In order to reduce cost, toxicity and the risk of developing bacterial resistance, it is desirable to establish the shortest, effective prophylaxis for post-operative complications, and from the meta-analysis it seem that single doses have the same impact as multiple doses.
The general assumption is that it is better to treat patients with complicated appendicitis with antibiotics than with placebo, in contrast to patients with simple appendicitis. Yet other studies have questioned the use of antibiotics at all in appendectomised patients.
Implications for research
Despite the presented meta-analysis indicate similar results on single dose efficacy and multiple dose efficacy, we did not compare these outcome parameters. In addition, the time for administration did not seem to have any significant impact at all, but weren't compared either. Conclusively these parameters should therefore be reviewed. Other strategies such as irrigation and delayed closure could alternatively have positive effects on reduction of postoperative complications, but need further examination in another systematic review. This review confirms the effect of antibiotics in reducing wound infection and abscess formation in all pato-anatomic subgroup and after removal of a normal appendix. Recommendations to the use of antibiotics in all cases of appendectomies patients is still controversy regarding the general accepted recommendations prescribing only use of antibiotics in case of complicated appendicitis. On the other hand the literature stated superior effects following preoperatively administration incompatible to per operatively verifying (by visualisation) of the disease severity as condition for initialisation of antibiotic treatment.Get full text at The Cochrane Library
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