CURRENT STATUS
Comparing Mechanical Bowel Preparation With Both
Oral and Systemic Antibiotics Versus Mechanical
Bowel Preparation and Systemic Antibiotics Alone
for the Prevention of Surgical Site Infection After
Elective Colorectal Surgery: A Meta-Analysis of
Randomized Controlled Clinical Trials
Min Chen, M.D.1 • Xue Song, M.D.1 • Liang-zhou Chen, M.D.1 • Zhi-dong Lin, M.D.1
Xue-li Zhang, M.D.2
1 Department of General Surgery, Xiamen Traditional Chinese Medicine Hospital, Xiamen, China
BACKGROUND:  The discussion on the role of mechanical
bowel preparation and oral antibiotics in elective
colorectal surgery is still ongoing.
OBJECTIVE:  This meta-analysis aimed to determine
whether oral systemic antibiotics with mechanical
bowel preparation are superior to systemic antibiotics
and mechanical bowel preparation for prophylaxis of
bacterial infection during elective colorectal operation.
DATA SOURCES:  Embase, PubMed, and the Cochrane
Library were searched using the terms oral, antibiotics/
antimicrobial, colorectal/rectal/colon/rectum, and surgery/
operation.
STUDY SELECTION:  All of the available randomized
controlled trials that compared the efficacy of combined
oral and systemic antibiotics and mechanical bowel
preparation with systemic antibiotics alone and
mechanical bowel preparation in colorectal surgery
and defined surgical site infection based on Centers for
Disease Control and Prevention criteria were included.
INTERVENTION:  All of the statistical analyses were
performed using Review Manager 5.2 software. A fixed
model was used if there was no evidence of heterogeneity;
otherwise, a random-effects model was used.
Financial Disclosure: None reported.
Correspondence: Min Chen, M.D., Department of General Surgery,
Xiamen Traditional Chinese Medicine Hospital, Xiamen 361009, China.
E-mail: amadon@126.com
Dis Colon Rectum 2016; 59: 70–78
DOI: 10.1097/DCR.0000000000000524
© The ASCRS 2015
70
Copyright © The American Society of Colon & Rectal Surgeons, Inc. Unauthorized reproduction of this article is prohibited.
MAIN OUTCOME MEASURES:  We focused on incidence of
surgical site infection among the groups.
RESULTS:  Seven randomized controlled trials that
consisted of 1769 cases were eligible for analysis.
We found that both total surgical site infection and
incisional surgical site infection were significantly
reduced in patients who received oral systemic
antibiotics and mechanical bowel preparation compared
with patients who received systemic antibiotics alone
and mechanical bowel preparation (total: 7.2% vs 16.0%,
p < 0.00001; incisional: 4.6% vs 12.1%, p < 0.00001).
However, no significant difference was detected in the
rate of organ/space surgical site infection (4.0% vs 4.8%;
p = 0.56) after elective colorectal surgery.
LIMITATIONS:  The meta-analysis was limited by the risk
of bias because a majority of the studies did not use the
blinding method.
CONCLUSIONS:  Oral systemic antibiotics and mechanical
bowel preparation significantly lowered the incidence
of surgical site infection after elective colorectal surgery
compared with systemic antibiotics alone and mechanical
bowel preparation.
KEY WORDS:   Colorectal surgery; Mechanical bowel
preparation; Meta-analysis; Oral antibiotics; Surgical site
infection.
S
urgical site infection (SSI) is a common complica-
tion that results from a surgical procedure. It is de-
fined as an infection occurring within 30 days of an
operation or within a year of surgery if an implant is left
Diseases of the Colon & Rectum Volume 59: 1 (2016)
 Diseases of the Colon & Rectum Volume 59: 1 (2016) 71

Identification
Records identified through Additional records identified
database searching through other sources
(n = 820) (n = 1)

Records after duplicates removed

(n = 805)
Screening

Records screened Records excluded

(n = 805) (n = 783)

Full-text articles assessed Full-text articles excluded,

for eligibility with reasons
Eligibility

(n = 22) (n = 4)

Studies included in
qualitative synthesis
(n = 18)
Included

Studies included in
quantitative synthesis
(meta-analysis)
(n = 7)

FIGURE 1.  Flow diagram of the trial selection process for inclusion.

in place and the infection appears related to the implant.1
It is now one of the most common and expensive health
care–associated infections.2 Patients with SSI tend to have
2.0 to 11.0 times higher risk for mortality and 1.9 times
higher risk for incisional hernia compared with patients
without SSI.3–5 In patients who underwent surgery and
died with nosocomial SSI, 77% of deaths were related to
infection.1
To some extent, SSI occurrence is associated with
particular organs that are subjected to surgery. Under-
standably, higher SSI rates (26%–40%6, 7) were reported
in patients with colorectal surgery compared with other
types of surgeries.8
A mass of microflora resides in the lower end of the
GI tract. Many members of GI microbiota are opportu-
nistic pathogens, such as gram-negative bacilli (eg, Esch-
erichia coli), gram-positive organisms (eg, enterococci),
and sometimes anaerobes (eg, Bacillus fragilis).1 Because
the GI tract is opened in colorectal surgery, the surgi-
cal site could easily be contaminated with opportunis-
tic bacterial pathogens. The National Surgical Infection
Prevention Project recommends preventive antibiotic
treatment. The administration route can be oral, which
is given 18 to 24 hours before the operation, or systemic,
which is intravenously infused within 1 hour before the
operation.9 The advantage of administering oral antibi-
otics is to inhibit opportunistic pathogens in the colonic
lumen before opening the colon with a potential pitfall
to disturb the GI microbiota. The benefit of systemic an-
tibiotics is to achieve adequate tissue levels of antibiot-
ics, but antibiotics are less accessible to the opportunistic
pathogen in the GI tract.
Although there is a consensus that preventive anti-
biotics should be given before colorectal surgery, there is
no consensus whether antibiotics should be administered
through the systemic route alone or a combined oral and
systemic route. Conflicting results were reported in evalu-
ating the incidence of SSI related to single and combined
antibiotics routes. Some reports noted that SSI was sig-
nificantly reduced with the combined route10,11 but not by
other reports.12,13
Noticeably, frequency of use of the combined ad-
ministration route in colorectal surgery has declined, as
shown by questionnaire surveys of surgeons. In the Unit-

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 72

TABLE 1.   Characteristics of studies included in the meta-analysis

Matching factors between the 2 groups
Types of Blood PN
Study Year Country operation ASA score Blood loss transfusion Operation time Group Regimen Age, y (M/W) BMI
32
Ishida et al 2001 Japan p = 0.72 NR p = 0.65 NR p = 0.53 o+s K(o)+E(o)bid×2d 62 (37–87) 72 (47/25) NR
Cefotiam(v)
s Cefotiam(v) 65 (21–89) 71 (42/29) NR
Lewis31 2002 Canada Similar NR NR NR NR o+s N(o)+M(o)bid×1d Amikacin(v)+M(v) 68.8 ± 13.5 104 25.2
s Amikacin(v)+M(v) 71.4 ± 12.9 104 24.9
Espin-Basany et al12 2005 Spain Similar NR NR NR NR o+s N(o)+M(o)tid×1d Cefoxitin(v) 66.6 100 (63/37) 26.8
s Cefoxitin(v) 69 100 (62/38) 27.1
Kobayashi et al33 2007 Japan p > 0.99 Similar p = 0.32 p = 0.76 p = 0.33 o+s K(o)+E(o)tid×1d Cefmetazole(v) 67.9 (31–92) 242 (154/88) NR
s Cefmetazole(v) 69.1 (46–95) 242 (137/105) NR
Takesue et al34 2009 Japan NR NR NR NR NR o+s K(o)+E(o)tid×1d cephalosporin(v) NR 171 (NR) NR
s Cephalosporin(v) NR 174 (NR) NR
Oshima et al10 2013 Japan NR p = 0.413 p = 0.702 p = 0.473 Similar o+s K(o)+M(o)tid×1d Cephalosporin(v) 41.8 ± 14.8 97 (55/42) ≥25 n = 10
18.1−25 n = 69
<18 n = 18
s Cephalosporin(v) 40.6 ± 14.8 98 (57/41) ≥25 n = 8
18.1−25 n = 70
<18 n = 20
Sadahiro et al11 2014 Japan Similar p = 0.75 p = 0.77 p = 0.31 p = 0.89 o+s K(o)+M(o)tid×1d Flomoxef(v) 67 ± 9 99 (56/43) NR

s Flomoxef(v) 66 ± 12 95 (51/44) NR

PN = number of patients; M/W = men/women; NR = not reported; o = oral; s = systemic; v = intravenous; K = kanamycin; M = metronidazole; E = erythromycin; N = neomycin
Chen et al: Preventing SSI After Elective Colorectal Surgery

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 Diseases of the Colon & Rectum Volume 59: 1 (2016) 73

TABLE 2. Summary of risk of biases: review of author judgments on each risk of bias item for each included study
Sequence Allocation Blinding of outcome Incomplete Selective outcome
Study Year generation concealment assessors outcome data reporting Other bias
Ishida et al
32
2001 Yes Yes No Yes Yes Yes
Lewis31 2002 Yes Yes Yes Yes Yes Yes
Espin-Basany et al12 2005 No No Yes Yes Yes Yes
Kobayashi et al33 2007 Yes Yes No Yes Yes Yes
Takesue et al34 2009 No No No Yes Yes Yes
Oshima et al10 2013 No No No Yes Yes Yes
Sadahiro et al11 2014 Yes Yes Yes Yes Yes Yes

ed States, the combined route was prescribed in 88.0%
of colorectal surgeries in 1990,14 86.5% of colorectal sur-
geries in 1997,15 75.0% of colorectal surgeries in 2003,16
and 36.0% of colorectal surgeries in 2010.17 In Japan, the
combined route was prescribed in ≥70% of colorectal
surgeries in 1993 and only 20% of colorectal surgeries in
2003.18 In Korea, the frequency of prescribing the com-
bined route was 52.1% of colorectal surgeries in 2013.19
The main reason for declining the use of oral antibiot-
ics is that most surgeons doubt the effectiveness of oral
antibiotics.16
Mechanical bowel preparation (MBP) is performed
before elective colorectal surgery to reduce massive
bowel contents, which is a source of colorectal leak-
age and infectious pathogens, thereby minimizing the
chance for SSI. However, the routine use of MBP for
elective colorectal surgery is being abandoned gradually,
because several studies have concluded that omitting
MBP before an operation was safe and had fewer post-
operative morbidities.20,21 In addition, 2 meta-analyses
have demonstrated that patients who underwent elec-
tive colorectal surgery did not benefit from MBP before
an operation.22,23 The practice of abandoning MBP was
further promoted because MBP causes discomfort to
patients, including nausea, vomiting, and electrolyte
abnormalities.24
Recently, 2 studies have reported that combining MBP
and oral antibiotics results in a significantly lower inci-
dence of incisional SSI, anastomotic leakage, and hospital
readmission compared with no preoperative bowel prepa-
ration in colorectal surgery. However, there was no effect
when MBP or oral antibiotics were used alone.25,26 The
conclusion that they provided was in line with the writ-
ings of surgical infection expert Dr Fry, who reported in
2012 that MBP alone does not reduce SSI, but the addition
of both oral and systemic preoperative antibiotics is supe-
rior compared with systemic antibiotics alone.27 Thus, we
performed a meta-analysis of randomized controlled tri-
als (RCTs) to evaluate the effect of oral systemic antibiot-
ics and MBP compared with systemic antibiotics alone and
MBP on SSI in colorectal surgery.
MATERIALS AND METHODS
Literature Search
A comprehensive search of literatures was performed
from 1971 to October 2014 in the Embase, PubMed, and
Cochrane Library databases. No restriction was applied
to region, publication type, or language. The following
Medical Subject Headings terms and their combina-
tions were searched [title/abstract]: oral, antibiotics/an-
timicrobial, colorectal/rectal/colon/rectum, and surgery/
operation. The Related Articles function was also used
to broaden the search. The computer search was supple-
mented with the manual examination of reference lists
of all retrieved studies, review articles, and conference

o+s s Risk Ratio Risk Ratio

Study or Subgroup Events Total Events Total Weight M-H. Fixed. 95% CI Year M-H. Fixed. 95% CI
Ishida et al32 8 72 17 71 12.1% 0.46 (0.21–1.01) 2001
Lewis31 5 104 17 104 12.0% 0.29 (0.11–0.77) 2002
Espin-Basany et al12 11 100 10 100 7.1% 1.10 (0.49–2.47) 2005
Kobayashi et al33 17 242 26 242 18.4% 0.65 (0.36–1.17) 2007
Takesue et al34 7 171 27 174 19.0% 0.26 (0.12–0.59) 2009
Oshima et al10 6 97 22 98 15.5% 0.28 (0.12–0.65) 2013
Sadahiro et al11 10 99 22 95 15.9% 0.44 (0.22–0.87) 2014

Total (95% CI) 885 884 100.0% 0.45 (0.34–0.60)

Total events 64 141
Heterogeneity: χz = 9.95, df = 6 (p = 0.13); Iz = 40%
0.01 0.1 1 10 100
Test for overall effect: Z = 5.55 (p < 0.00001) Favors o+s Favors s

FIGURE 2.  Forest plot for total surgical site infection (SSI) after surgery. A Mantel–Haenszel fixed-effects model was used for meta-analysis.
Risk ratios are shown with 95% CIs. o = oral antibiotics; s = systemic antibiotics; df = degrees of freedom.

Copyright © The American Society of Colon & Rectal Surgeons, Inc. Unauthorized reproduction of this article is prohibited.
 74 Chen et al: Preventing SSI After Elective Colorectal Surgery

o+s s Risk Ratio Risk Ratio

Study or Subgroup Events Total Events Total Weight M-H. Fixed. 95% CI Year M-H. Fixed. 95% CI
Ishida et al32 8 72 12 71 14.0% 0.41 (0.15–1.11) 2001
Lewis31 5 104 17 104 19.7% 0.29 (0.11–0.77) 2002
Espin-Basany et al12 7 100 6 100 6.9% 1.17 (0.41–3.35) 2005
Kobayashi et al33 6 242 14 242 16.2% 0.43 (0.17–1.10) 2007
Oshima et al10 4 97 20 98 23.0% 0.20 (0.07–0.57) 2013
Sadahiro et al11 6 99 17 95 20.1% 0.34 (0.14–0.82) 2014

Total (95% CI) 714 710 100.0% 0.38 (0.26–0.56)

Total events 33 86
Heterogeneity: χz = 6.20, df = 5 (p = 0.29); Iz = 19%
0.01 0.1 1 10 100
Test for overall effect: Z = 4.90 (p < 0.00001) o+s s

FIGURE 3.  Forest plot for incisional surgical site infection (SSI) after surgery. A Mantel–Haenszel fixed-effects model was used for meta-
analysis. Risk ratios are shown with 95% CIs. o = oral antibiotics; s = systemic antibiotics; df = degrees of freedom.

abstracts. When multiple reports that described the
same populations were identified, the most recent or
complete report was used.
Study Eligibility and Selection
All of the available RCTs that compared the efficacy of com-
bined oral and systemic antibiotics and MBP with systemic
antibiotics alone and MBP in colorectal surgery were includ-
ed. Because definitions of SSI varied among studies, we only
included RTCs that defined SSI based on Centers for Disease
Control and Prevention criteria.28 RCTs that used obsolete
antibiotic regimes were excluded. Letters to the editor, edito-
rials, review articles, meta-analyses, case reports, and animal
experimental studies were excluded. Data that only con-
tained abstracts or nonfull-text articles were also excluded.
Primary Outcome
Incidence of SSI was selected as the primary outcome. SSI
was classified as incisional and organ/space SSI. Incisional
SSI was further subdivided into superficial and deep inci-
sional SSI. Organ/space SSIs refer to infections that involve
any part of the anatomy (eg, organ or space) other than
incised body wall layers.
Data Review and Extraction
Two investigators (X.S. and L.-z.C.) independently ex-
tracted the defined information from each eligible study
using a standardized form. Information about the char-
acteristics of the study population and relevant outcomes
were recorded. Different opinions regarding data abstrac-
tion were resolved through discussion. When necessary,
a third investigator (Z.d.-L.) was consulted to reach a
consensus.
Quality Assessment
Study quality was assessed using guidelines of the Cochrane
Collaboration,29 which consists of 6 factors, including se-
quence generation, allocation concealment, blinding, incom-
plete outcome data, selective outcome reporting, and other
biases. Blinding was deemed as having a low risk of bias if
outcome assessors were blinded to the treatment information.
All of the statistical analyses were performed us-
ing Review Manager 5.2 software (Cochrane Collabo-
ration, Oxford, United Kingdom). A fixed model was
used if there was no evidence of heterogeneity; other-
wise, a random-effects model was used. Statistical het-
erogeneity between studies was assessed using the χ2 test
with significance set at p < 0.10, and heterogeneity was
quantified using the I2 statistic. Relative risk was cal-
culated for each trial from the number of evaluable pa-
tients, and all of the results were reported with 95% CI.
P value for the overall effect was calculated using the
z test, with significance set at p < 0.05. Sensitivity analysis
and estimation of publication bias were also performed.

o+s s Risk Ratio Risk Ratio

Study or Subgroup Events Total Events Total Weight M-H. Fixed. 95% CI Year M-H. Fixed. 95% CI
Ishida et al32 8 72 6 71 20.7% 0.66 (0.19–2.23) 2001
Espin-Basany et al12 4 100 4 100 13.7% 1.00 (0.26–3.89) 2005
Kobayashi et al33 11 242 12 242 41.2% 0.92 (0.41–2.04) 2007
Oshima et al10 2 97 2 98 6.8% 1.01 (0.15–7.03) 2013
Sadahiro et al11 4 99 5 95 17.5% 0.77 (0.21–2.77) 2014

Total (95% CI) 610 606 100.0% 0.85 (0.51–1.44)

Total events 25 29
Heterogeneity: χz = 0.31, df = 4 (p = 0.99); Iz = 0%
0.01 0.1 1 10 100
Test for overall effect: Z = 0.59 (p = 0.56) Favors o+s Favors s

FIGURE 4.  Forest plot for organ/space surgical site infection (SSI) after surgery. A Mantel–Haenszel fixed-effects model was used for meta-
analysis. Risk ratios are shown with 95% CIs. o = oral antibiotics; s = systemic antibiotics; df = degrees of freedom.

Copyright © The American Society of Colon & Rectal Surgeons, Inc. Unauthorized reproduction of this article is prohibited.
 Diseases of the Colon & Rectum Volume 59: 1 (2016) 75

o+s s Risk Ratio Risk Ratio

Study or Subgroup Events Total Events Total Weight M-H. Fixed. 95% CI M-H. Fixed. 95% CI
Sadahiro et al11 10 99 22 95 76.7% 0.44 (0.22–0.87)
Takesue et al34 4 99 7 104 23.3% 1.60 (0.18–1.99)

Total (95% CI) 198 199 100.0% 0.47 (0.26–0.86)

Total events 14 29
Heterogeneity: χz = 0.20, df = 1 (p = 0.65); Iz = 0%
Test for overall effect: Z = 2.44 (p = 0.01) 0.01 0.1 1 10 100
Favors o+s Favors s

FIGURE 5.  Forest plot for total surgical site infection (SSI) after CRC surgery. A Mantel–Haenszel fixed-effects model was used for meta-
analysis. Risk ratios are shown with 95% CIs. o = oral antibiotics; s = systemic antibiotics; df = degrees of freedom.

RESULTS
Trial Characteristics
A total of 821 studies were initially retrieved. The trial se-
lection process for inclusion is shown in Figure 1.30 Finally,
7 RCTs published as full-length articles met the predefined
inclusion criteria and were eligible for the final analysis.
These trials included 885 patients who received combined
oral and systematic antibiotics and MBP (combination
group) and 884 patients who received systematic antibiot-
ics alone and MBP (systemic antibiotics group). The char-
acteristics of these 7 studies are shown in Table 1. The risks
of biases of these 7 studies are shown in Table 2.
Summary of Antibiotic Regimes
A standard oral antibiotic regimen of neomycin plus met-
ronidazole was used in 2 studies.12,31 Kanamycin was given
in combination with either neomycin or metronidazole
in 5 studies,10,11,32–34 which are active against both aerobes
and anaerobes. A minimum of 3 doses of oral antibiotics
was given after MBP in all except 1 study.31 Broad-spec-
trum antibiotics that cover pathogenic bacteria were all
intravenously administered within 1 hour before surgery
at adequate doses. Intravenous antibiotics were repeated
every 3 hours during surgery in 3 studies,10,11,33 and in-
travenous antibiotics were continued for a minimum of
24 hours postoperatively in 5 studies.10,12,32–34
Meta-Analysis Results
Total SSI
Total SSI rates were reported in all of the included studies.
Total SSI rates for the combination and systemic antibiot-
ics groups were 7.2% (64/885) and 16.0% (141/884). Total
SSI rate was significantly lower in the combination group
than in the systemic antibiotics group (relative risk, 0.45
(95% CI: 0.34–0.60); p < 0.00001; Fig. 2)
Incisional SSI
Incisional SSI rates were reported in 6 of 7 studies
(N = 1424 patients). Incisional SSI rates for the combina-
tion and systemic antibiotics groups were 4.6% (33/714)
and 12.1% (86/710). Incisional SSI rate was significantly
lower in the combination group than in the systemic an-
tibiotics group (relative risk, 0.38 (95% CI: 0.26–0.56);
p < 0.00001; Fig. 3).
Organ/Space SSI
Postoperative organ/space SSI rates were analyzed in 5 of 7
studies (N = 1216 patients). Organ/space SSI rates for the
combination and systematic antibiotics groups were 4.0%
(25/610) and 4.8% (29/606), and there was no significant
difference between the 2 groups (relative risk, 0.85 (95%
CI, 0.51–1.44); p = 0.56; Fig.4).
SSI in Colorectal Cancer and Ulcerative Colitis
SSI rates for colorectal carcinoma (CRC) and ulcerative
colitis (UC) were included in 3 of 7 studies (N = 734 pa-
tients). For CRC, SSI rates for the combined and system-
atic antibiotics groups were 7.1% (14/198) and 14.6%
(29/199). For UC, SSI rates for the combined and sys-
tematic antibiotics groups were 5.3% (9/169) and 25.0%
(42/168). Improved effectiveness was detected with the
addition of oral antibiotics in both CRC and UC surgery
(Figs. 5 and 6).

o+s s Risk Ratio Risk Ratio

Study or Subgroup Events Total Events Total Weight M-H. Fixed. 95% CI M-H. Fixed. 95% CI
Oshima et al10 6 97 22 98 51.9% 0.28 (0.12–0.65)
Takesue et al34 3 72 20 70 48.1% 0.15 (0.05–0.47)

Total (95% CI) 169 168 100.0% 0.21 (0.11–0.42)

Total events 9 42
Heterogeneity: χz = 0.75, df = 1 (p = 0.39); Iz = 0%
Test for overall effect: Z = 4.41 (p < 0.0001) 0.01 0.1 1 10 100
Favors o+s Favors s

FIGURE 6.  Forest plot for total surgical site infection (SSI) after ulcerative colitis surgery. A Mantel–Haenszel fixed-effects model was used for
meta-analysis. Risk ratios are shown with 95% CIs. o = oral antibiotics; s = systemic antibiotics; df = degrees of freedom.

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 76
TABLE 3. Comparison of sensitivity analysis of SSIs in the 4 studies that used true randomization and allocation concealment (a mix of
blinded and unblinded studies)
Outcomes of
interest No. of studies o+s No. s No.
Total SSI 4 517 512
Incisional SSI 4 517 512
Organ/space 3 413 408
SSI
SSI = surgical site infection; o = oral; s = systemic; df = degrees of freedom.
Sensitivity Analysis and Publication Bias
Sensitivity analysis was performed to determine the sig-
nificance of the results (Tables 3 and 4). Publication bias
was not assessed because of the small number of trials.
DISCUSSION
This study aimed to determine the efficacy of oral systemic
antibiotics and MBP compared with systemic antibiotics
alone and MBP on SSI rate in colorectal surgery through
increasing sizes of cohorts of combined comparable stud-
ies. Our meta-analysis revealed that oral systemic antibiot-
ics and MBP significantly reduced incisional SSI compared
with systemic antibiotics alone and MBP. This effect holds
true regardless of CRC or UC surgery. However, no signifi-
cant difference was detected in the rate of organ/space SSI.
These results highlight the importance to locally inhibiting
bacterial pathogens and cleaning the lumen before surgery.
The reason for the superior efficacy achieved by com-
bined oral and MBP is obvious, because MBP would reduce
massive bowel contents, which is a source of colorectal leak-
age and infectious pathogens, and oral administration of
antibiotics would increase the local concentration of anti-
biotics in the GI tract, as well as increase the early and easy
access of antibiotics to the bacteria. Thus, all of these factors
would contribute to a more effective inhibition of bacteria.
Patients with IBD have some factors that are suspect-
ed to increase the risk of SSI, such as malnutrition, usage
of steroid or immunosuppressive agents, preoperative ab-
dominal abscesses, peritonitis, and intestinal obstruction.
These factors contribute to the fact that there are relatively
higher SSI rates in Crohn’s disease and UC surgery than
in other colorectal surgeries.35 Takesue et al34 reported
that oral systemic antibiotics and MBP can significantly
TABLE 4.   Comparison of the sensitivity analysis of SSI in the 2 studies that used true randomization and allocation concealment (blinded
studies)
Outcomes of interest No. of studies o+s No. s No.
Total SSI 2 203 199
Incisional SSI 2 203 199
Organ/space SSI 1
SSI = surgical site infection; o = oral; s = systemic; df = degrees of freedom.
Copyright © The American Society of Colon & Rectal Surgeons, Inc. Unauthorized reproduction of this article is prohibited.
Chen et al: Preventing SSI After Elective Colorectal Surgery
Study heterogeneity
OR (95% CI) p df I2, % p
0.48 (0.34–0.69) <0.0001 3 0 0.54
0.36 (0.23–0.58) <0.0001 3 0 0.94
0.82 (0.45–1.47) 0.50 2 0 0.90
decrease the SSI rate in patients with UC but fail to cause
the same effect in patients with CRC compared with sys-
temic antibiotics and MBP. Our results in this meta-anal-
ysis revealed that the effect of oral antibiotics and MBP in
militating SSI was independent from CRC or UC surgery.
Furthermore, no RCTs have explored the effect of oral an-
tibiotics and MBP in patients with Crohn’s disease.
We wanted to ensure the uniformity and comparability
among included studies for this analysis. A consistent and
standardized definition is required for diagnosing SSI. Fail-
ure to use objective and uniform SSI criteria could make the
reported SSI rates incomparable.36,37 We initially recruited 18
RCTs but later found tremendous variations in defining SSIs
among the 18 studies. For example, in a study performed
by the Kaiser group,38 wound infections were compared.
However, only skin infections were included, and superficial
subcutaneous tissues were excluded in the data analysis. In
another study by Nohr et al,39 all of the major wounds and
intra-abdominal abscesses only involved deep infections. SSI
diagnostic criteria defined by the National Nosocomial In-
fections Surveillance of the Centers for Disease Control and
Prevention are widely accepted and are regarded as the stan-
dard in different settings. For this reason, only 7 of 18 RCTs
that defined SSI with the Centers for Disease Control and
Prevention criteria were eventually eligible for this study.
We also evaluated the quality of each study. Four of
7 studies used true randomization and allocation conceal-
ment.11,31–33 Two of these 4 studies were blinded.11,31 We sep-
arately performed a sensitivity analysis of those 4 (a mix of
blinded and unblended studies) and 2 studies (only blinded
studies) and found no significant discrepancies between
these 2 analyses.
This study contained some limitations that originated
from the included studies. First, a majority of the ­studies
Study heterogeneity
OR
(95% CI) p df I2 (%) p
0.37 (0.21–0.66) 0.0006 1 0 0.51
0.32 (0.17–0.61) 0.0005 1 0 0.83
 Diseases of the Colon & Rectum Volume 59: 1 (2016)
did not use the blinding method. Inadequate blinding
tends to increase the risk of bias. Second, the type and
course of oral and systemic antibiotics varied among tri-
als, which may underestimate efficacy.
CONCLUSION
This meta-analysis revealed that oral systemic antibiotics
and MBP are superior to systemic antibiotics alone and
MBP in minimizing SSI for elective colorectal operation.
Such effectiveness holds true regardless of CRC or UC
surgery.
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