EDITORIAL
Should a Scheduled Colorectal Operation Have a Mechanical Bowel Prep, Preoperative Oral Antibiotics, Both, or Neither? E. Patchen Dellinger, MD
M
orris and colleagues1 in this issue provide us with the latest good information in an area regarding colorectal surgery that has been evolving now for more than 40 years and continues to be an area of profound misunderstanding of what the evidence tells us. When I began my surgical training more than 40 years ago, any patient scheduled for a colectomy was admitted to the hospital several days in advance and had an extensive mechanical bowel prep. In most cases, oral antibiotics were not used, and we had just seen the landmark article by Polk and Lopez-Mayor2 showing the efficacy of prophylactic parenteral antibiotics. We had a recent publication showing that mechanical bowel prep did not change bacterial numbers in the colon,3 and this was shortly followed by 2 powerful articles showing an average 79%4 to 88%5 reduction in surgical site infections (SSIs) compared with placebo (all with mechanical prep) when preoperative oral antibiotics were used. The article by Washington et al5 also had a trial arm with oral neomycin alone (no anaerobic activity) that had the same infection rate as placebo. Within 5 years, 2 more studies showed similar results.6,7 It soon became standard to use both oral antibiotics with mechanical bowel prep and parenteral antibiotics, but some asked whether both were necessary or whether one was more effective than the other. An influential but flawed study from Great Britain comparing oral-only with parenteralonly antibiotics appeared to show a lack of efficacy with oral antibiotics, but in an effort to avoid any systemic effects of the oral antibiotic, the investigators stopped the oral antibiotic 2 days preoperatively, rendering it ineffective.8 Sometime during the 1980s, most American and Canadian surgeons adopted oral antibiotics with a mechanical bowel prep combined with parenteral prophylaxis whereas many European surgeons abandoned oral antibiotics. This was followed by a number of studies comparing mechanical bowel prep with no prep, with both groups treated with parenteral antibiotics alone,9–11 and these trials showed no benefit from the mechanical prep. This continued for some time, and as more articles were published suggesting the lack of value for mechanical bowel prep, this was dropped by some surgeons in North America along with the oral antibiotics that had been given after the mechanical prep and before the operation. Certainly, patients do not like bowel preps, and the gradual spread of the concepts of enhanced recovery after surgery also promoted the abandonment of mechanical bowel preps. With this as background, Lewis12 conducted a prospective trial in 2002 comparing parenteral antibiotics alone with the combination of parenteral antibiotics and preoperative oral antibiotics, with both groups receiving a mechanical bowel prep. In this article, he demonstrated a lower incidence of bacteria in the surgical incision at the end of the operation and a dramatically lower rate of SSI (relative risk 0.29; P < 0.01) in the patients who received both oral and parenteral antibiotics. Lewis went on to perform a meta-analysis of existing articles comparing parenteral prophylaxis alone with combined oral and parenteral prophylaxis, demonstrating a 50% reduction with the combined approach. In 2009, 2 Cochrane meta-analyses were published in the same year, one comparing mechanical bowel prep with no prep,13 with most patients getting parenteral antibiotics alone, whereas the other14 compared patients who received only parenteral antibiotic prophylaxis with those who received both oral and parenteral prophylaxis, with both groups receiving a mechanical bowel prep. The analysis by Guenaga et al13 showed no advantage for mechanical bowel prep, with slightly lower, but not statistically significant, SSI rates in the group without a prep. The analysis by Nelson et al14 showed a highly significant lower rate of SSI in patients who had received both oral and parenteral antibiotic prophylaxis than in those who received parenteral antibiotics alone (relative risk = 0.55) or oral antibiotics alone (relative risk = 0.34).14 This was followed by several observational studies from the Michigan Surgical Quality Collaborative15,16 and a large VASQIP (Veterans Affairs Surgical Quality Improvement Program) study,17 both of which demonstrated a 50% or more reduction in SSI with the combined use of oral and parenteral antibiotics compared with parenteral antibiotics alone. These articles also confirmed the lack of benefit of mechanical bowel preparation when not combined with
From the Department of Surgery, University of Washington, Seattle, WA. Disclosure: The author declares no conflicts of interest. Reprints: E. Patchen Dellinger, MD, Department of Surgery, University of Washington, Box 356410, Room BB 441, 1959 NE Pacific St, Seattle, WA 98195. E-mail: [email protected]. C 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright ISSN: 0003-4932/15/26106-1041 DOI: 10.1097/SLA.0000000000001124
Annals of Surgery r Volume 261, Number 6, June 2015
www.annalsofsurgery.com | 1041
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Annals of Surgery r Volume 261, Number 6, June 2015
Dellinger
oral antibiotics.15,17 In addition, they showed no increase in Clostridium difficile infections with the use of oral antibiotics and a statistically significant reduction in postoperative ileus with the use of oral antibiotics. This was confirmed in a follow-up study.18,19 About the same time, investigators in Texas proposed the introduction of an “evidence-based” bundle of perioperative care for colorectal surgical care that eliminated mechanical bowel prep and oral antibiotics, and in a prospective randomized trial, they achieved an increase in their SSI rate from 24% to 45% (P = 0.003).20 In the 1960s and 1970s, it was assumed that cleaning the colon of its contents was necessary for a safe operation, but experience in trauma colectomies21 and later prospective trials22 showed that this was not necessarily the case. Similarly, many assumed that for oral antibiotics to be effective in preventing infection, the bulk of feces would have to be cleared from the colon, but we have learned over the years that our assumptions, when tested with well-designed studies, sometimes turn out to be wrong. A fascinating bit of information buried in the VASQIP study is that 7% of the patients were recorded as receiving oral antibiotics without evidence of a bowel prep, and their SSI rate (8%) was essentially the same as that of patients who received both a bowel prep and oral antibiotics (9%), whereas patients without oral antibiotics had the same rate regardless of bowel prep (20%) or no prep (18%).17 The one weakness of this observation is that bowel prep was identified by the prescription of a laxative in the VA system, so we don’t actually know if those without a prescription really did not get a prep. Both the Guenaga et al22 and Nelson et al23 Cochrane analyses have been updated since the 2009 publications and continue to show the same results. Thus, the data so far indicate that a bowel prep without oral antibiotics does not benefit the patient but oral antibiotics combined with a bowel prep cut the SSI risk by about 50% compared with no oral antibiotics either with or without a bowel prep. However, a careful reading of the most recent Guenaga et al22 analysis reveals that although the great majority of the trials cited omitted oral antibiotics in both the prep and no prep arms, 3 of the published articles24–26 did administer oral antibiotics to both arms in the trial, although in the Jung et al25 article, they were given to only 46% of the patients. The results for SSI when you separate the articles with and without oral antibiotics can be seen in Table 1.22 These data contain the hint that oral antibiotics, even without a mechanical bowel prep, may reduce the SSI rate (6.0% vs 10.3%). The article by Morris and colleagues1 in this issue brings new, highly reliable data on this question, derived from real-world practice in NSQIP hospitals where standardized data recording allows us to see how these issues play out in the real world. They provide data on 8415 colorectal operations from 121 hospitals in the years 2011 and 2012. They provide data on both open (37%) and laparoscopic (63%) operations reflective of modern surgical practice. What is intriguing about their data is the fact that 45% of their patients had a mechanical bowel prep without oral antibiotics, a practice that has conclusively been shown to have no benefit whatsoever for the patient. As have all other publications in this area, they demonstrate a clinically and statistically significant 50% reduction in SSI rates with the use of oral antibiotics (6.5%) compared with no oral antibiotics (13%). But
TABLE 1. SSI Results With and Without Oral Antibiotics All patients No oral antibiotics Oral antibiotics
Mechanical Prep
No Mechanical Prep
223/2305 = 9.7% 145/1336 = 10.9% 78/969 = 8.0%
196/2290 = 8.6% 140/1353 = 10.3% 56/937 = 6.0%
1042 | www.annalsofsurgery.com
another hint is found in their article. They combined patients who did or did not have a mechanical bowel prep but did get oral antibiotics into one group, but in the text of their article, they report that 8% of the patients who received oral antibiotics did not have a documented mechanical bowel prep and that there was a lower, but not statistically significant, SSI rate in those patients without a documented prep (6.3% vs 9.4%; P = 0.09). These data combined with those from Cannon et al17 and the data excerpted earlier from Guenaga et al22 suggest to me that it is high time to conduct a 4-arm trial that would randomize patients into mechanical bowel prep versus no prep and to preoperative oral antibiotics versus no oral antibiotics while all patients get effective parenteral prophylaxis. In the meantime, until the results of this trial are available, if I need my colon operated on, I will suffer through the bowel prep and take preoperative oral antibiotics.
REFERENCES 1. Morris M, Graham LA, Chu DI, et al. Oral antibiotic bowel prep significantly reduces surgical site infection rates and readmission rates in elective colorectal surgery. Ann Surg. 2015;261:1034–1040. 2. Polk HC, Jr, Lopez-Mayor JF. Postoperative wound infection: a prospective study of determinant factors and prevention. Surgery. 1969;66:97–103. 3. Nichols RL, Gorbach SL, Condon RE. Alteration of intestinal microflora following preoperative mechanical preparation of the colon. Dis Colon Rectum. 1971;14:123–127. 4. Clarke JS, Condon RE, Bartlett JG, et al. Preoperative oral antibiotics reduce septic complications of colon operations: results of prospective, randomized, double-blind clinical study. Ann Surg. 1977;186:251–259. 5. Washington JA, II, Dearing WH, Judd ES, et al. Effect of preoperative antibiotic regimen on development of infection after intestinal surgery: prospective, randomized, double-blind study. Ann Surg. 1974;180:567–572. 6. Matheson DM, Arabi Y, Baxter-Smith D, et al. Randomized multicentre trial of oral bowel preparation and antimicrobials for elective colorectal operations. Br J Surg. 1978;65:597–600. 7. Wapnick S, Guinto R, Reizis I, et al. Reduction of postoperative infection in elective colon surgery with preoperative administration of kanamycin and erythromycin. Surgery. 1979;85:317–321. 8. Keighley MR, Arabi Y, Alexander-Williams J, et al. Comparison between systemic and oral antimicrobial prophylaxis in colorectal surgery. Lancet. 1979;1:894–897. 9. Burke P, Mealy K, Gillen P, et al. Requirement for bowel preparation in colorectal surgery. Br J Surg. 1994;81:907–910. 10. Santos JC, Jr, Batista J, Sirimarco MT, et al. Prospective randomized trial of mechanical bowel preparation in patients undergoing elective colorectal surgery. Br J Surg. 1994;81:1673–1676. 11. Miettinen RP, Laitinen ST, Makela JT, et al. Bowel preparation with oral polyethylene glycol electrolyte solution vs. no preparation in elective open colorectal surgery: prospective, randomized study. Dis Colon Rectum. 2000;43:669–675; discussion 675–677. 12. Lewis RT. Oral versus systemic antibiotic prophylaxis in elective colon surgery: a randomized study and meta-analysis send a message from the 1990s. Can J Surg. 2002;45:173–180. 13. Guenaga KK, Matos D, Wille-Jorgensen P. Mechanical bowel preparation for elective colorectal surgery. Cochrane Database Syst Rev. 2009:CD001544. 14. Nelson RL, Glenny AM, Song F. Antimicrobial prophylaxis for colorectal surgery. Cochrane Database Syst Rev. 2009:CD001181. 15. Englesbe MJ, Brooks L, Kubus J, et al. A statewide assessment of surgical site infection following colectomy: the role of oral antibiotics. Ann Surg. 2010;252:514–519; discussion 519–520. 16. Waits SA, Fritze D, Banerjee M, et al. Developing an argument for bundled interventions to reduce surgical site infection in colorectal surgery. Surgery. 2014;155:602–606. 17. Cannon JA, Altom LK, Deierhoi RJ, et al. Preoperative oral antibiotics reduce surgical site infection following elective colorectal resections. Dis Colon Rectum. 2012;55:1160–1166. 18. Kim EK, Sheetz KH, Bonn J, et al. A statewide colectomy experience: the role of full bowel preparation in preventing surgical site infection. Ann Surg. 2014;259:310–314. 19. Krapohl GL, Phillips LR, Campbell DA, Jr, et al. Bowel preparation for colectomy and risk of Clostridium difficile infection. Dis Colon Rectum. 2011;54:810–817.
C 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Annals of Surgery r Volume 261, Number 6, June 2015
20. Anthony T, Murray BW, Sum-Ping JT, et al. Evaluating an evidence-based bundle for preventing surgical site infection: a randomized trial. Arch Surg. 2011;146:263–269. 21. Conrad JK, Ferry KM, Foreman ML, et al. Changing management trends in penetrating colon trauma. Dis Colon Rectum. 2000;43:466–471. 22. Guenaga KF, Matos D, Wille-Jorgensen P. Mechanical bowel preparation for elective colorectal surgery [update of: Cochrane Database Syst Rev. 2009:CD001544]. Cochrane Database Syst Rev. 2011:CD001544. 23. Nelson RL, Gladman E, Barbateskovic M. Antimicrobial prophylaxis for colorectal surgery. Cochrane Database Syst Rev. 2014:CD001181.
C 2015 Wolters Kluwer Health, Inc. All rights reserved.
The Confusion Over Bowel Prep and Oral Antibiotics
24. Alcantara Moral M, Serra Aracil X, Bombardo Junca J, et al. A prospective, randomised, controlled study on the need to mechanically prepare the colon in scheduled colorectal surgery. Cir Esp. 2009;85: 20–25. 25. Jung B, Pahlman L, Nystrom PO, et al. Multicentre randomized clinical trial of mechanical bowel preparation in elective colonic resection. Br J Surg. 2007;94:689–695. 26. Zmora O, Mahajna A, Bar-Zakai B, et al. Colon and rectal surgery without mechanical bowel preparation: a randomized prospective trial. Ann Surg. 2003;237:363–367.
www.annalsofsurgery.com | 1043
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Should a Scheduled Colorectal Operation Have a Mechanical Bowel Prep, Preoperative Oral Antibiotics, Both, or Neither? E. Patchen Dellinger, MD
M
orris and colleagues1 in this issue provide us with the latest good information in an area regarding colorectal surgery that has been evolving now for more than 40 years and continues to be an area of profound misunderstanding of what the evidence tells us. When I began my surgical training more than 40 years ago, any patient scheduled for a colectomy was admitted to the hospital several days in advance and had an extensive mechanical bowel prep. In most cases, oral antibiotics were not used, and we had just seen the landmark article by Polk and Lopez-Mayor2 showing the efficacy of prophylactic parenteral antibiotics. We had a recent publication showing that mechanical bowel prep did not change bacterial numbers in the colon,3 and this was shortly followed by 2 powerful articles showing an average 79%4 to 88%5 reduction in surgical site infections (SSIs) compared with placebo (all with mechanical prep) when preoperative oral antibiotics were used. The article by Washington et al5 also had a trial arm with oral neomycin alone (no anaerobic activity) that had the same infection rate as placebo. Within 5 years, 2 more studies showed similar results.6,7 It soon became standard to use both oral antibiotics with mechanical bowel prep and parenteral antibiotics, but some asked whether both were necessary or whether one was more effective than the other. An influential but flawed study from Great Britain comparing oral-only with parenteralonly antibiotics appeared to show a lack of efficacy with oral antibiotics, but in an effort to avoid any systemic effects of the oral antibiotic, the investigators stopped the oral antibiotic 2 days preoperatively, rendering it ineffective.8 Sometime during the 1980s, most American and Canadian surgeons adopted oral antibiotics with a mechanical bowel prep combined with parenteral prophylaxis whereas many European surgeons abandoned oral antibiotics. This was followed by a number of studies comparing mechanical bowel prep with no prep, with both groups treated with parenteral antibiotics alone,9–11 and these trials showed no benefit from the mechanical prep. This continued for some time, and as more articles were published suggesting the lack of value for mechanical bowel prep, this was dropped by some surgeons in North America along with the oral antibiotics that had been given after the mechanical prep and before the operation. Certainly, patients do not like bowel preps, and the gradual spread of the concepts of enhanced recovery after surgery also promoted the abandonment of mechanical bowel preps. With this as background, Lewis12 conducted a prospective trial in 2002 comparing parenteral antibiotics alone with the combination of parenteral antibiotics and preoperative oral antibiotics, with both groups receiving a mechanical bowel prep. In this article, he demonstrated a lower incidence of bacteria in the surgical incision at the end of the operation and a dramatically lower rate of SSI (relative risk 0.29; P < 0.01) in the patients who received both oral and parenteral antibiotics. Lewis went on to perform a meta-analysis of existing articles comparing parenteral prophylaxis alone with combined oral and parenteral prophylaxis, demonstrating a 50% reduction with the combined approach. In 2009, 2 Cochrane meta-analyses were published in the same year, one comparing mechanical bowel prep with no prep,13 with most patients getting parenteral antibiotics alone, whereas the other14 compared patients who received only parenteral antibiotic prophylaxis with those who received both oral and parenteral prophylaxis, with both groups receiving a mechanical bowel prep. The analysis by Guenaga et al13 showed no advantage for mechanical bowel prep, with slightly lower, but not statistically significant, SSI rates in the group without a prep. The analysis by Nelson et al14 showed a highly significant lower rate of SSI in patients who had received both oral and parenteral antibiotic prophylaxis than in those who received parenteral antibiotics alone (relative risk = 0.55) or oral antibiotics alone (relative risk = 0.34).14 This was followed by several observational studies from the Michigan Surgical Quality Collaborative15,16 and a large VASQIP (Veterans Affairs Surgical Quality Improvement Program) study,17 both of which demonstrated a 50% or more reduction in SSI with the combined use of oral and parenteral antibiotics compared with parenteral antibiotics alone. These articles also confirmed the lack of benefit of mechanical bowel preparation when not combined with
From the Department of Surgery, University of Washington, Seattle, WA. Disclosure: The author declares no conflicts of interest. Reprints: E. Patchen Dellinger, MD, Department of Surgery, University of Washington, Box 356410, Room BB 441, 1959 NE Pacific St, Seattle, WA 98195. E-mail: [email protected]. C 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright ISSN: 0003-4932/15/26106-1041 DOI: 10.1097/SLA.0000000000001124
Annals of Surgery r Volume 261, Number 6, June 2015
www.annalsofsurgery.com | 1041
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Annals of Surgery r Volume 261, Number 6, June 2015
Dellinger
oral antibiotics.15,17 In addition, they showed no increase in Clostridium difficile infections with the use of oral antibiotics and a statistically significant reduction in postoperative ileus with the use of oral antibiotics. This was confirmed in a follow-up study.18,19 About the same time, investigators in Texas proposed the introduction of an “evidence-based” bundle of perioperative care for colorectal surgical care that eliminated mechanical bowel prep and oral antibiotics, and in a prospective randomized trial, they achieved an increase in their SSI rate from 24% to 45% (P = 0.003).20 In the 1960s and 1970s, it was assumed that cleaning the colon of its contents was necessary for a safe operation, but experience in trauma colectomies21 and later prospective trials22 showed that this was not necessarily the case. Similarly, many assumed that for oral antibiotics to be effective in preventing infection, the bulk of feces would have to be cleared from the colon, but we have learned over the years that our assumptions, when tested with well-designed studies, sometimes turn out to be wrong. A fascinating bit of information buried in the VASQIP study is that 7% of the patients were recorded as receiving oral antibiotics without evidence of a bowel prep, and their SSI rate (8%) was essentially the same as that of patients who received both a bowel prep and oral antibiotics (9%), whereas patients without oral antibiotics had the same rate regardless of bowel prep (20%) or no prep (18%).17 The one weakness of this observation is that bowel prep was identified by the prescription of a laxative in the VA system, so we don’t actually know if those without a prescription really did not get a prep. Both the Guenaga et al22 and Nelson et al23 Cochrane analyses have been updated since the 2009 publications and continue to show the same results. Thus, the data so far indicate that a bowel prep without oral antibiotics does not benefit the patient but oral antibiotics combined with a bowel prep cut the SSI risk by about 50% compared with no oral antibiotics either with or without a bowel prep. However, a careful reading of the most recent Guenaga et al22 analysis reveals that although the great majority of the trials cited omitted oral antibiotics in both the prep and no prep arms, 3 of the published articles24–26 did administer oral antibiotics to both arms in the trial, although in the Jung et al25 article, they were given to only 46% of the patients. The results for SSI when you separate the articles with and without oral antibiotics can be seen in Table 1.22 These data contain the hint that oral antibiotics, even without a mechanical bowel prep, may reduce the SSI rate (6.0% vs 10.3%). The article by Morris and colleagues1 in this issue brings new, highly reliable data on this question, derived from real-world practice in NSQIP hospitals where standardized data recording allows us to see how these issues play out in the real world. They provide data on 8415 colorectal operations from 121 hospitals in the years 2011 and 2012. They provide data on both open (37%) and laparoscopic (63%) operations reflective of modern surgical practice. What is intriguing about their data is the fact that 45% of their patients had a mechanical bowel prep without oral antibiotics, a practice that has conclusively been shown to have no benefit whatsoever for the patient. As have all other publications in this area, they demonstrate a clinically and statistically significant 50% reduction in SSI rates with the use of oral antibiotics (6.5%) compared with no oral antibiotics (13%). But
TABLE 1. SSI Results With and Without Oral Antibiotics All patients No oral antibiotics Oral antibiotics
Mechanical Prep
No Mechanical Prep
223/2305 = 9.7% 145/1336 = 10.9% 78/969 = 8.0%
196/2290 = 8.6% 140/1353 = 10.3% 56/937 = 6.0%
1042 | www.annalsofsurgery.com
another hint is found in their article. They combined patients who did or did not have a mechanical bowel prep but did get oral antibiotics into one group, but in the text of their article, they report that 8% of the patients who received oral antibiotics did not have a documented mechanical bowel prep and that there was a lower, but not statistically significant, SSI rate in those patients without a documented prep (6.3% vs 9.4%; P = 0.09). These data combined with those from Cannon et al17 and the data excerpted earlier from Guenaga et al22 suggest to me that it is high time to conduct a 4-arm trial that would randomize patients into mechanical bowel prep versus no prep and to preoperative oral antibiotics versus no oral antibiotics while all patients get effective parenteral prophylaxis. In the meantime, until the results of this trial are available, if I need my colon operated on, I will suffer through the bowel prep and take preoperative oral antibiotics.
REFERENCES 1. Morris M, Graham LA, Chu DI, et al. Oral antibiotic bowel prep significantly reduces surgical site infection rates and readmission rates in elective colorectal surgery. Ann Surg. 2015;261:1034–1040. 2. Polk HC, Jr, Lopez-Mayor JF. Postoperative wound infection: a prospective study of determinant factors and prevention. Surgery. 1969;66:97–103. 3. Nichols RL, Gorbach SL, Condon RE. Alteration of intestinal microflora following preoperative mechanical preparation of the colon. Dis Colon Rectum. 1971;14:123–127. 4. Clarke JS, Condon RE, Bartlett JG, et al. Preoperative oral antibiotics reduce septic complications of colon operations: results of prospective, randomized, double-blind clinical study. Ann Surg. 1977;186:251–259. 5. Washington JA, II, Dearing WH, Judd ES, et al. Effect of preoperative antibiotic regimen on development of infection after intestinal surgery: prospective, randomized, double-blind study. Ann Surg. 1974;180:567–572. 6. Matheson DM, Arabi Y, Baxter-Smith D, et al. Randomized multicentre trial of oral bowel preparation and antimicrobials for elective colorectal operations. Br J Surg. 1978;65:597–600. 7. Wapnick S, Guinto R, Reizis I, et al. Reduction of postoperative infection in elective colon surgery with preoperative administration of kanamycin and erythromycin. Surgery. 1979;85:317–321. 8. Keighley MR, Arabi Y, Alexander-Williams J, et al. Comparison between systemic and oral antimicrobial prophylaxis in colorectal surgery. Lancet. 1979;1:894–897. 9. Burke P, Mealy K, Gillen P, et al. Requirement for bowel preparation in colorectal surgery. Br J Surg. 1994;81:907–910. 10. Santos JC, Jr, Batista J, Sirimarco MT, et al. Prospective randomized trial of mechanical bowel preparation in patients undergoing elective colorectal surgery. Br J Surg. 1994;81:1673–1676. 11. Miettinen RP, Laitinen ST, Makela JT, et al. Bowel preparation with oral polyethylene glycol electrolyte solution vs. no preparation in elective open colorectal surgery: prospective, randomized study. Dis Colon Rectum. 2000;43:669–675; discussion 675–677. 12. Lewis RT. Oral versus systemic antibiotic prophylaxis in elective colon surgery: a randomized study and meta-analysis send a message from the 1990s. Can J Surg. 2002;45:173–180. 13. Guenaga KK, Matos D, Wille-Jorgensen P. Mechanical bowel preparation for elective colorectal surgery. Cochrane Database Syst Rev. 2009:CD001544. 14. Nelson RL, Glenny AM, Song F. Antimicrobial prophylaxis for colorectal surgery. Cochrane Database Syst Rev. 2009:CD001181. 15. Englesbe MJ, Brooks L, Kubus J, et al. A statewide assessment of surgical site infection following colectomy: the role of oral antibiotics. Ann Surg. 2010;252:514–519; discussion 519–520. 16. Waits SA, Fritze D, Banerjee M, et al. Developing an argument for bundled interventions to reduce surgical site infection in colorectal surgery. Surgery. 2014;155:602–606. 17. Cannon JA, Altom LK, Deierhoi RJ, et al. Preoperative oral antibiotics reduce surgical site infection following elective colorectal resections. Dis Colon Rectum. 2012;55:1160–1166. 18. Kim EK, Sheetz KH, Bonn J, et al. A statewide colectomy experience: the role of full bowel preparation in preventing surgical site infection. Ann Surg. 2014;259:310–314. 19. Krapohl GL, Phillips LR, Campbell DA, Jr, et al. Bowel preparation for colectomy and risk of Clostridium difficile infection. Dis Colon Rectum. 2011;54:810–817.
C 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Annals of Surgery r Volume 261, Number 6, June 2015
20. Anthony T, Murray BW, Sum-Ping JT, et al. Evaluating an evidence-based bundle for preventing surgical site infection: a randomized trial. Arch Surg. 2011;146:263–269. 21. Conrad JK, Ferry KM, Foreman ML, et al. Changing management trends in penetrating colon trauma. Dis Colon Rectum. 2000;43:466–471. 22. Guenaga KF, Matos D, Wille-Jorgensen P. Mechanical bowel preparation for elective colorectal surgery [update of: Cochrane Database Syst Rev. 2009:CD001544]. Cochrane Database Syst Rev. 2011:CD001544. 23. Nelson RL, Gladman E, Barbateskovic M. Antimicrobial prophylaxis for colorectal surgery. Cochrane Database Syst Rev. 2014:CD001181.
C 2015 Wolters Kluwer Health, Inc. All rights reserved.
The Confusion Over Bowel Prep and Oral Antibiotics
24. Alcantara Moral M, Serra Aracil X, Bombardo Junca J, et al. A prospective, randomised, controlled study on the need to mechanically prepare the colon in scheduled colorectal surgery. Cir Esp. 2009;85: 20–25. 25. Jung B, Pahlman L, Nystrom PO, et al. Multicentre randomized clinical trial of mechanical bowel preparation in elective colonic resection. Br J Surg. 2007;94:689–695. 26. Zmora O, Mahajna A, Bar-Zakai B, et al. Colon and rectal surgery without mechanical bowel preparation: a randomized prospective trial. Ann Surg. 2003;237:363–367.
www.annalsofsurgery.com | 1043
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
