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A Statewide Assessment of Surgical Site Infection Following Colectomy: The Role of Oral Antibiotics

Englesbe, Michael J. MD*; Brooks, Linda RN*; Kubus, James MS*; Luchtefeld, Martin MD†; Lynch, James MD‡; Senagore, Anthony MD†; Eggenberger, John C. MD§; Velanovich, Vic MD¶; Campbell, Darrell A. Jr. MD*

doi: 10.1097/SLA.0b013e3181f244f8
Original Articles

Objective: To determine the utility of adding oral nonabsorbable antibiotics to the bowel prep prior to elective colon surgery.

Summary Background Data: Bowel preparation prior to colectomy remains controversial. We hypothesized that mechanical bowel preparation with oral antibiotics (compared with without) was associated with lower rates of surgical site infection (SSI).

Methods: Twenty-four Michigan hospitals participated in the Michigan Surgical Quality Collaborative–Colectomy Best Practices Project. Standard perioperative data, bowel preparation process measures, and Clostridium difficile colitis outcomes were prospectively collected. Among patients receiving mechanical bowel preparation, a logistic regression model generated a propensity score that allowed us to match cases differing only in whether or not they had received oral antibiotics.

Results: Overall, 2011 elective colectomies were performed over 16 months. Mechanical bowel prep without oral antibiotics was administered to 49.6% of patients, whereas 36.4% received a mechanical prep and oral antibiotics. Propensity analysis created 370 paired cases (differing only in receiving oral antibiotics). Patients receiving oral antibiotics were less likely to have any SSI (4.5% vs. 11.8%, P = 0.0001), to have an organ space infection (1.8% vs. 4.2%, P = 0.044) and to have a superficial SSI (2.6% vs. 7.6%, P = 0.001). Patients receiving bowel prep with oral antibiotics were also less likely to have a prolonged ileus (3.9% vs. 8.6%, P = 0.011) and had similar rates of C. difficile colitis (1.3% vs. 1.8%, P = 0.58).

Conclusions: Most patients in Michigan receive mechanical bowel preparation prior to elective colectomy. Oral antibiotics may reduce the incidence of SSI.

Using a statewide surgical quality collaborative, we evaluated the importance of oral antibiotics as part of bowel preparation prior to elective colon surgery. Using propensity matching, we noted significantly lower surgical site infection rates and low Clostridium difficile colitis rates in the group that received oral nonabsorbable antibiotics prior to surgery.

From the *Department of Surgery, the University of Michigan, Ann Arbor, MI; †Department of Surgery, The Spectrum Health System, Grand Rapids, MI; ‡Department of Surgery, The William Beaumont Hospital, Royal Oak, MI; §Department of Surgery, The St Joseph Mercy Health System, Novi, MI; and ¶Department of Surgery, The Henry Ford Health System, Detroit, MI.

Supported by NIH – NIDDK (K08 DK0827508) and the American Surgical Association Foundation. DAC was supported by a grant from Blue Cross and Blue Shield of Michigan (to M.J.E.).

This work represents a study done by a regional collaborative of surgeons in Michigan. Cooperation and expertise of a broad group of surgeons and researchers was needed to carry out this study. All authors below significantly contributed to the study. All authors participated in drafting or revision of the manuscript or analysis. All authors take responsibility for the content of the manuscript. Specific contributions are detailed below: Michael J. Englesbe: Design, drafting, statistical analysis, interpretation of analysis; Linda Brooks: Design, data collection, interpretation of analysis; James Kubus: Design, drafting, statistical analysis, interpretation of analysis; Samantha Hendron: drafting, interpretation of analysis; Martin Luchtefeld: Design, editing, interpretation of analysis; James Lynch: Design, editing, interpretation of analysis; Anthony Senagore: Design, editing, interpretation of analysis; John C. Eggenberger: Design, editing, interpretation of analysis; Vic Velanovich: Design, editing, interpretation of analysis; Darrell A. Campbell, Jr.: Design, drafting, statistical analysis, interpretation of analysis, supervision of the overall project.

Reprints: Michael J. Englesbe, MD, Department of Surgery, University of Michigan Medical School, 2926A Taubman Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109–5331. E-mail: englesbe@umich.edu.

© 2010 Lippincott Williams & Wilkins, Inc.