Techniques in Coloproctology

https://doi.org/10.1007/s10151-018-1814-1

REVIEW

Topical antimicrobial prophylaxis in colorectal surgery

for the prevention of surgical wound infection: a systematic review
and meta-analysis
R. L. Nelson1 · A. Kravets2 · R. Khateeb2 · M. Raza2 · M. Siddiqui2 · I. Taha2 · A. Tummala2 · R. Epple2 · S. Huang2 ·
M. Wen2

Received: 2 April 2018 / Accepted: 26 June 2018

© Springer International Publishing AG, part of Springer Nature 2018

Abstract
Background Among the techniques investigated to reduce the risk of surgical wound infection or surgical space infection
(SSI) in patients having colorectal surgery are topical application of antimicrobials (antibiotics and antiseptics) to the open
wound or immediately after closure. The aim of the present study was to perform a systematic review of the literature on
those treatments, with the exception of antibiotic ointments applied to closed skin, which are adequately assessed elsewhere,
and a meta-analysis.
Methods Only randomized trials of patients having only colorectal surgery were included in this review. Studies were sought
in MEDLINE, EMBASE, the Cochrane Register of Controlled Trials, Clinical Trials.gov, and the World Health Organiza-
tion Internet clinical trials register portal. In addition, reference lists of included studies and other published reviews were
screened. Meta-analysis was performed for all included studies and subgroup analyses done for each individual interven-
tion. Risk of bias was assessed for each included study, paying particular attention to the preoperative antibiotic prophylaxis
used in each study. Sensitivity analyses were done to investigate heterogeneity of the analyses, excluding those studies with
a significant risk of bias issues. Absolute risk reduction (RR) was calculated. The overall quality of the evidence for each
individual intervention was assessed using the Grading of Recommendations Assessment, Development and Evaluation
(GRADE) approach, and was classified as high, moderate, low or very low.
Results A total of 30 studies are included in this review with 5511 patients, 665 of whom had SSI. The interventions included:
10 studies of gentamicin impregnated sponge or beads wound inlays, 4 studies of chlorhexidine impregnated suture, 11
studies of direct wound lavage or powder application or injection of antibiotics before closure, 4 studies of ionized silver
dressing applied to the closed skin, and 1 study of vitamin E oil applied to the open wound. All but one study used preopera-
tive antibiotic prophylaxis in addition to topical procedures, although, in some studies, the systemic antibiotic prophylaxis
was not the same between groups or varied significantly from the recommended guidelines. Use of gentamycin sponge did
not decrease SSI (RR 0.93, 95% CI 0.75–1.16; low-quality evidence) even after including only the studies of abdominal
wounds (RR 1.02, 95% CI 0.80–1.30; low-quality evidence). However, sensitivity analysis excluding studies at high risk
of bias decreased the heterogeneity and increased the effect of the prophylaxis for all wounds (RR 0.5, 95% CI 0.33–0.78;
low-quality evidence) and for abdominal wounds only (RR 0.38, 95% CI 0.20–0.72; moderate-quality evidence). Chlorhex-
idine impregnated suture showed no effect on SSI (RR 0.79, 95% CI 0.56–1.10; low-quality evidence) and an increased
efficacy after sensitivity analysis (RR 0.42, 95% CI 0.22–0.79; low-quality evidence). Antibiotic lavage showed a significant
decrease in SSI (RR 0.45, 95% CI 0.26–0.79; low-quality evidence) which increased after sensitivity analysis (RR 0.33, 95%
CI 0.15–0.72; moderate-quality evidence). Application of silver dressing to the closed wound resulted in a decrease of SSI
(RR 0.55, 95% CI 0.35–0.85; moderate-quality evidence). The one study of topical vitamin E oil applied to the open wound
showed a significant risk reduction (RR 0.22, 95% CI 0.05–0.98; low-quality evidence).
Conclusions Each of these interventions appears to be effective in decreasing SSI, but the number of studies for each is small
and the quality of evidence is very low to moderate. Within the various outcomes of GRADE assessment, even a moderate
classification suggests that further studies may well have very different results.. No randomized trials exist of combinations

Extended author information available on the last page of the article

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of two or more of the above interventions to see if there is a combined effect. Future studies should make sure that the anti-
biotic used preoperatively is uniform within a study and is consistent with the current guidelines. Deviation from this leads
to a significant heterogeneity and risk of bias.
Keywords Colorectal surgery · Surgical site infection · Topical antimicrobial prophylaxis
Introduction
It has been established that prophylactic antibiotics admin-
istered by mouth or intravenous injection before surgery
in patients having colorectal surgery can lower the risk of
surgical wound infection from the neighborhood of 40% to
about 10% [1, 2]. Methods to diminish that risk even further
are being investigated, including combined preoperative oral
and intravenous antibiotic administration with and without
mechanical bowel cleansing [3–5], application of antibiotic
ointments to the closed surgical wound [6], and hyperoxia
[7]. In addition, several antimicrobials have been applied to
the open wound during closure [8] or just after closure. This
systematic review will focus on the latter method of surgi-
cal space infection (SSI) prophylaxis without overlapping
with the previously published systematic review of antibiotic
ointments applied to a closed surgical wound in colorectal
surgery [6]. The interventions applied topically to surgical
wounds include application of antimicrobial agents of all
types, applied in the following manner:
Gentamicin impregnated collagen sponge inlay in the
open wound: the sponge is collagen and absorbable. 130 g
of gentamicin are present in each sponge and released after
skin closure. Gentamicin beads are also used often in per-
ineal wounds to fill dead space. The control group either had
no sponge or sponge with no gentamicin.
Chlorhexidine impregnated suture The suture is absorb-
able and usually polyglactin, polydioxanone, or similar, and
is applied to the peritoneum and fascia, with skin closed as
normal.
Antibiotic powder, lavage, or injection The antibiotic may
be applied as a powder to an open subcutaneous wound, as
a liquid wash before or after fascial closure or by injection
into subcutaneous fat.
Silver Ionized silver dressings are applied to the closed
abdominal wound.
Vitamin E oil is applied to the subcutaneous tissues
before skin closure.
Materials and methods
Studies included in this review were conducted on patients
of both sexes and all ages having operations only upon the
colon and rectum. Studies of patients having colorectal
13
Techniques in Coloproctology
surgery for suspected infections of the colon or rectum
including appendicitis, diverticulitis, and other suspected
perforations of the small or large bowel were excluded. Also
excluded were topical treatments for anorectal disease.
The comparator was no topical treatment, a sponge with-
out gentamicin, unimpregnated suture material, or lavage
with saline alone. The outcome assessed was surgical wound
infection of the abdominal or perineal wound, also known as
superficial and deep surgical space infection (SSI) [9], and
excluding organ space infection (OSI).
Only randomized-controlled trials were included without
restriction as to date or language.
MEDLINE and EMBASE were searched as well as the
Cochrane clinical trials register and the clinical trials reg-
istries Clinicaltrials.gov (https​://clini​caltr​ials.gov/) and the
World Health Organization Internet clinical trials registry
portal (http://www.who.int/ictrp​/searc​h/en/) (see below) to
8/24/2017. The Cochrane, Medline, and EMBASE search
strategies are reported in Appendix 1.
Study selection and review
Screening of each title, abstract and full text, data abstrac-
tion, data entry, and risk of bias assessments were all con-
ducted by at least three reviewers. All differences were
resolved by group discussion. The risk of bias of each study
was assessed against key criteria: random sequence genera-
tion, allocation concealment, blinding of participants, per-
sonnel and outcome assessors, incomplete outcome data,
and selective outcome reporting [10]. An additional risk
of bias was discovered upon review of the included studies
and assessed. It was related to the preoperative antibiotic
prophylaxis in each study. When studies were found where
preoperative prophylaxis deviated significantly from estab-
lished guidelines or varied significantly within a single study
population, it was felt that the effect of the topical antibiotic
would be clouded by that deviation or variation, introducing
significant bias. Those studies were excluded in sensitivity
analyses (see below).
Authors were contacted for missing data. When data after
randomization on SSI were unavailable, if it was outcome
data and could be assigned to a treatment group, they were
considered as treatment failures [11].
Clinical heterogeneity was assessed in the performance of
the surgery, or administration of the treatment, the veracity
of the diagnosis, and the accuracy and timing of the outcome
Techniques in Coloproctology
assessment. In addition, as mentioned above, heterogeneity
related to preoperative antibiotic prophylaxis was assessed.
Methodological heterogeneity was sought in the differential
risks of bias assessments between studies. Statistical hetero-
geneity was calculated in Revman [12]. It was defined as a
Chi-square (p < 0.10) and I-square (I2) (> 60%).
Subgroup analyses were done to investigate the individ-
ual interventions, or anatomic specificity of an intervention,
and to investigate sources of heterogeneity in meta-analyses.
Sensitivity analyses were done eliminating the studies found
to be of poor quality to assess the robustness of the results
of the meta-analysis as well as their effect on heterogeneity.
Data were analyzed using Revman 5.3. Results were
expressed as risk ratios and 95% confidence intervals for
the dichotomous outcomes, using the random-effects model
when a significant heterogeneity was seen.
The Grades of Recommendation, Assessment, Develop-
ment and Evaluation (GRADE) [13, 14] approach was used
to classify the quality of evidence for all included studies
and each intervention into one of four grades:
1. High Further research is very unlikely to change our
confidence in the estimate of effect
2. Moderate Further research is likely to have an impact on
our confidence in the estimate of effect and may change
the estimate;
3. Low Further research is very likely to have an important
impact on our confidence on the estimate of effect and is
likely to change the estimate;
4. Very low Any estimate of effect is very uncertain.
Each intervention began with a HIGH quality of evidence
and was downgraded either 0, 1, or 2 points for each of the
five factors listed below to MODERATE, LOW, or VERY
LOW depending on how seriously (one or two steps down)
the factor impacted the data.
1. Risk of bias as described above
2. Inconsistency (unexplained heterogeneity and thus
inconsistency of results); − 1 for Heterogeneity > 0.001;
− 2 for Heterogeneity < 0.001. [15];
3. Indirectness (indirect or atypical populations, interven-
tions, controls, and outcomes; for instance, a surrogate
outcome for SSI such as fever.)
4. Imprecision, as made evident by wide confidence inter-
vals, small study size, two or fewer studies, and/or fewer
than 100 SSI events (− 1) or fewer than 50 events (− 2)
in that comparison (except when events (SSI) became
rare in a sufficient population). Random error in that
case is too great [16].
5. Publication bias: Evidence either graphically in funnel
plots or from review of trials registries that many poten-
tially included studies have not been published.
Absolute risk reduction was calculated by the number of
controls with SSI per 1000 patients (rate × 1000) multiplied
by the risk ratio and confidence intervals for each interven-
tion, both in the full comparisons and the sensitivity analyses
(Table 2).
Results
Search
The preferred reporting items for systematic reviews and
meta-analyses: (PRISMA) flowchart for our search are
shown in Fig. 1. Ultimately, 30 eligible studies in 29 publi-
cations were found [17–45] (Table 1).
Trials were excluded from this review if they were found
to involve only oral or intravenous antibiotics or were stud-
ies in which colorectal surgery which patients were a sub-
group in a broader cohort with no evidence that they were
segregated at randomization. Isolating colorectal surgery in
such analyses is prone to confounding and type 1 error [46].
Third, antibiotic ointments applied to the closed abdomi-
nal wound in colorectal surgery were not included in this
review, since they have been very thoroughly reviewed and
recently reported elsewhere [7]. There is one exception here;
a three arm study of control, silver dressing, and mupirocin
applied to a closed abdominal wound [41]. This study was
not included in the Heal reports [7]. Besides a comparison of
silver to its control in this study, the mupirocin arm was also
compared separately to the same control group and included
for completeness in the antibiotic group.
In some studies, the lavage of the abdominal wound was
performed after fascial closure. In others, the peritoneal cav-
ity was lavaged before fascial closure, a wash which inevi-
tably would include the subcutaneous tissues. They were,
therefore, included. None of the ampicillin studies fall into
the latter group.
Results of interventions
The interventions described in the included studies and their
sensitivity analyses are listed in Table 2.
In addition to Table 2, the results of the meta-analyses
are shown in forest plots for all included studies (Figs. 2,
3) and the subgroups of each specific intervention (Figs. 4,
5, 6, 7 and 8). Forest plots of the sensitivity analyses are
not shown, except for the one paired with Fig. 2, displaying
those studies excluded in the sensitivity analyses (Fig. 3).
The results for other sensitivity analyses are only shown in
Tables 2 and 3.
Subgroup analyses were done within two specific interven-
tions. In the gentamicin impregnated collagen sponge studies,
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 Techniques in Coloproctology

the abdominal wound was also assessed separately, excluding

the studies that examined the perineal wound. Assessment of
SSI is more difficult in the perineum due to dead spaces in the
pelvis (Fig. 4). In the second, for topical antibiotics, ampicil-
lin, the most commonly tested topical antibiotic, was assessed
excluding other antibiotics (Fig. 6). Besides ampicillin, the fol-
lowing antibiotics were examined: cefotetan [32], gentamicin/
metronidazole [34], cefazolin [37], penicillin [38], clindamy-
cin/gentamicin [40], and mupirocin [41].
The sensitivity analyses were done excluding those seven
studies with issues described in the methods concerning pre-
operative antibiotic prophylaxis. These are marked as a high
risk of bias in column E of the risk-of-bias figures of the forest
plots in Figs. 2, 3, 4, 5, 6, 7 and 8 [17, 22, 28, 35, 37–39]. In
addition, three other studies were excluded from sensitivity
analyses, the first two due to excessive attrition after randomi-
zation and the inability to obtain group assignments of those
lost to follow-up [27, 34] (Column D in the Forest Plots’ Risk
of Bias) and the third, because it used hospital numbers as
an allocation assignment technique [21] (Column A), all of
these introduced serious risk of bias. Interestingly, in the last
study [21], the gentamicin sponge was wrapped around the
anastomosis. This was the only study in which that was done.
No sensitivity analysis was done for silver dressings as
none of these risks of bias applied and for vitamin E, since
there was only one study. The magnitude of the protective
effect was increased in each sensitivity analysis.
No deductions in GRADE were made due to Indirectness
or Publication bias. Publication bias was investigated in a
funnel plot (Fig. 9) [47]. The asymmetry was not conclusive
in that regard.
Table 3 displays the interventions and sensitivity analy-
ses, the heterogeneity for each comparison including the
sensitivity analyses, the GRADE score, the GRADE score
rationale, and the absolute risk reduction from each interven-
tion when compared to the control risk of SSI in each com-
parison group with confidence intervals for that reduction.
In addition to the magnitude of the protective effect being
increased for each analysis in the paired sensitivity analyses
(Table 2), the heterogeneity for each comparison for which
sensitivity analyses were done was diminished in all com-
parisons except for the antibiotic lavage/powder/injection
group, in some cases markedly. The quality of the evidence
in GRADE was not altered because of the decline in preci-
sion in each sensitivity analysis (Table 2), except for All
Topical, Antibiotic, and Ampicillin comparisons (Table 3).

Fig. 1  Preferred Reporting Items for Systematic Reviews and Meta-

Analyses (PRISMA) flowchart
Discussion

This is a grouping of very heterogeneous methods to dimin-

ish the risk of SSI of the abdominal wound after colorectal
surgery. It could have been the topic of six separate reports.

13
Techniques in Coloproctology

Table 1  Included studies Antimicrobial intervention Number of included References

studies

Gentamicin impregnated collagen sponge(s) or beads 10 studies [17–26]

Chlorhexidine impregnated fascial suture (Triclosan) 4 studies [27–30]
Antibiotics delivered by injection, lavage or powder or in one 11 studies [31–41]
case, wound dressing
Ionized silver dressing applied to the closed wound 4 studies [41–44]
Vitamin E oil applied to the open wound 1 study [45]

Table 2  Topical antimicrobial prophylaxis for colorectal surgery

Intervention test Reference #s Comparator # Studies # Partici- #Surgical wound Risk ratio and 95%
pants test/ infections test/ confidence interval
control control

1. All topical No treatment or placebo 30 2757/2754 268/397 0.57; 0.43–0.75

[17–45]
2. All topical; SA No treatment or placebo 20 1520/1517 102/236 0.46; 0.34–0.61
[17, 18, 21–27, 30, 33, 38–45]
3. Gentamycin sponge (total) [17–26] No treatment or placebo 10 919/928 129/140 0.93: [0.75, 1.16]
4. Gentamycin sponge (total); SA [18–20, 23–26] No treatment or placebo 7 408/414 29/58 0.51: [0.33, 0.78]
5. Gentamycin sponge abdominal wound only [17, No treatment or placebo 5 595/604 106/105 1.02: [0.80, 1.30]
20, 22, 23, 26]
6. Gentamycin sponge abdominal wound only; SA No treatment or placebo 3 197/206 12/33 0.38: [0.20, 0.72]
[20, 23, 26]
7. Triclosan [27–30] Plain suture 4 635/644 54/70 0.79: [0.56, 1.10]
8. Triclosan; SA [29, 30] Plain suture 2 297/297 13/31 0.42: [0.22, 0.79]
9. Antibiotic lavage/ powder/injection [31–41] No treatment or placebo 11 900/882 57/131 0.45: [0.26, 0.79]
10. Antibiotic lavage/ powder/injection; SA No treatment or placebo 6 512/506 32/91 0.33: [0.15, 0.72]
[31–33, 36, 40, 41]
11. Ampicillin powder [31, 33, 35, 36, 39] No treatment 5 476/470 17/69 0.28: [0.10, 0.78]
12. Ampicillin powder; SA [31, 33, 36] No treatment 3 345/338 11/49 0.26: [0.07, 0.91]
13. Silver [41–44] Placebo 4 249/246 26/47 0.55: [0.35, 0.85]
14. Vitamin E [45] No treatment 1 54/54 2/9 0.22: [0.05, 0.98]

SA sensitivity analyses, excluding studies from analyses due to serious risk of bias
Bold risk ratios are statistically significant

There are only a few published reports about each interven-
tion. However, the interventions are applied to patients in
more or less the same way, and it is assumed that each inter-
vention is effective by the same mechanism, the suppression
of bacterial growth in the subcutaneous space. Each inter-
vention in its sensitivity analysis showed a significant ability
to diminish SSI risk. There are no reports of combinations
of any two or more of the interventions reported above, i.e.,
whether there might be an additive effect of combined topi-
cal therapies.
The SSI rates were somewhat higher in all these compari-
sons than would be expected in the controls. Only one was
near the anticipated 10% or 100 per 1000 patients [27–30]
(Fig. 5). The rest were 40–90% higher. The detection of
SSI was pretty uniform among studies, from frank pus in
the wound to the Center for Disease Control and Preven-
tion (CDC) criteria. No surrogate outcomes were used in
the analyses of this review. As mentioned above, the preop-
erative antibiotic prophylaxis was variable and not always
appropriate, though, in the sensitivity analyses, preoperative
prophylaxis was much more uniform.
Interventions
Within the studies of gentamicin sponges or beads, there is
1 study that stood out as larger and of greater weight (42.2
and 56.4% in the abdominal wound only subgroup) in the
analyses than any of the others [17]. In its findings, it was
also an outlier, showing a significant benefit for the con-
trol group (RR = 1.47; CI 1.10–1.96) (Fig. 2). Preoperative

13

Fig. 2  All included studies
antibiotic prophylaxis varied within the study, apparently
depending on the site in a multi-site trial. This introduced
an additional variable into the study. In this and six other
studies, the preoperative antibiotic prophylaxis was variable
enough or deviated enough from accepted guidelines [2] to
exclude these studies in the sensitivity analyses. Studies with
a significant attrition and data loss [10] and inappropriate
allocation sequence generation [10] were also excluded.
The effect of these sensitivity analyses was to lower sta-
tistical heterogeneity, sometimes markedly, and increase
the magnitude of the therapeutic effect of the interventions
(Tables 2, 3). With the improved therapeutic effect, there
is also loss of power in these analyses. Statistical signifi-
cance must then be viewed with caution, as in the analyses of
chlorhexidine impregnated suture (Triclosan). With only two
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Techniques in Coloproctology
studies remaining in the sensitivity analysis (Fig. 4), there is
serious random error, and more and larger studies are needed
before guidelines are developed in this context (see below).
Chlorhexidine also raises the issue of what constitutes an
antiseptic and what is an antibiotic. Almost any definition
that was found leads to exceptions, e.g., antibiotics are taken
systemically and antiseptics applied topically, yet most of
the interventions in this review are topical antibiotics. There-
fore, in this review, all interventions were described together
as antimicrobial.
The studies of topical antibiotics encompass many differ-
ent antibiotics, but only ampicillin is seen in enough studies
to be segregated into a subgroup. In a systematic review
[48] of ampicillin, ampicillin in lieu of preoperative antibi-
otics was effective, but, when combined with preoperative
Techniques in Coloproctology
Fig. 3  Sensitivity analysis: all studies, minus those with risk of bias issues. Excluded studies have no means and confidence intervals shown in
this forest plot. Note the change in heterogeneity and summary statistic compared with Fig. 2
antibiotic prophylaxis, it had no added beneficial effect
(Table 3). Perhaps, more studies of an antibiotic better tai-
lored to colonic flora would be more effective.
Silver has been used to heal open wounds for over
50 years [49]. However, its use in prophylaxis for SSI is
very recent (Fig. 6). Therefore, the number of randomized
trials is still small [50]. A proposed advantage of silver over
antibiotic topical prophylaxis is the avoidance of develop-
ment of antibiotic resistance, though the magnitude of the
risk of antibiotic resistance in the context of topical prophy-
laxis is not known.
Vitamin E is new to this field, described as an immu-
nomodulatory antioxidant in dermatologic disorders [45].
Other systematic reviews and current clinical
guidelines
Numerous systematic reviews have been published related
to these interventions. For most, colorectal surgery, if men-
tioned at all, was a small portion of a larger group of studies
of all incisions. Several representative systematic reviews are
summarized in Table 4 [48, 50–60]. One of those that was
limited to colorectal surgery only assessed perineal wounds
in patients having abdominoperineal excision [60].
Conclusions
Guidelines published concerning the recommended proph-
ylaxis for SSI prevention across many surgical specialties
do not yet mention topical therapy for colorectal surgery
[61, 62]. At a meeting of the Cochrane Collaboration 10 or
15 years ago, it was stated that 85% of the published guide-
lines in the United States were not evidence based. Since
that time, it has become apparent that statistical significance
and the support of experts in the field were not sufficient to
advance an idea into clinical practice. As is shown above,
the quality of the accumulated evidence must be assessed as
well. Within the various outcomes of GRADE assessment,
even a moderate classification suggests that further studies
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Fig. 4  Gentamicin collagen sponge and beads: all studies and abdominal wound only
Fig. 5  Chlorhexidine impregnated fascial suture (triclosan)
may well have very different results. Preoperative antimicro-
bial prophylaxis for colorectal surgery has achieved a High
GRADE classification [2], stating that placebo controlled
trials are no longer needed. All the interventions described
in this review are available for use, but it is how they are
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Techniques in Coloproctology
presented to an individual patient that is the issue. They all
may help and there were no significant harms described in
any of these published trials. Further high-quality studies are
needed for each intervention before patients can be assured
that their outcomes will be improved by their use and that
this will be evident in the published guidelines.
Techniques in Coloproctology

Fig. 6  Antibiotic powder, lavage, or injection for the abdominal wound

Fig. 7  Ionized silver dressing on the closed abdominal wound

Fig. 8  Vitamin E oil to NO NOT “to”, in the abdominal wound

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 Techniques in Coloproctology

Table 3  Topical antimicrobial prophylaxis for colorectal surgery grade, heterogeneity, and absolute risk reduction due to the intervention
Intervention Inconsistency Total GRADE Rationale Absolute risk reduction: Risk reduction and 95%
heterogeneity strength of evidence control rate/1000 patients confidence interval
score

1 All topical 0.00001; 62% − 4; Very low Risk of bias (− 2) 146 with SSI in controls 62 fewer SSI in All topical
Inconsistency (− 2) [36–82]
2. All topical; SA 0.06; 35% − 2; Low Risk of bias 156 84 fewer; [61– 103]
Inconsistency
3. Gentamycin sponge 0.007; 60% − 2; Low Risk of bias 151 11; [− 24–38]
(total) Inconsistency
4. Gentamycin sponge 0.53; 0% − 2; Low Risk of bias 140 69; [31–94]
(total); SA Imprecision
5. Sponge (abdominal 0.001; 78% − 2; Low Risk of bias 174 − 3; [− 52–35]
wound only) Inconsistency
6. Sponge (abdominal 0.24; 30% − 1; Moderate Imprecision (-1) 160 99; [45–128]
wound only); SA
7. Triclosan 0.09; 53% − 2; Low Risk of bias (-2) 109 23; [− 11–48]
8. Triclosan; SA 0.64; 0% − 2; Low Imprecision (-2) 104 60; [22–81]
9. Antibiotic lavage/pow- 0.002; 63% − 2; Low Risk of bias 149 82; [31–110]
der/injection Inconsistency
10. Antibiotic lavage/ 0.005;70% − 1; Moderate Inconsistency 180 121; [50–153]
powder/injection; SA
11. Ampicillin powder 0.01; 69% − 4; Very low Risk of bias (− 2) 147 106; [32–132]
Imprecision
Inconsistency
12. Ampicillin powder; SA 0.03; 70% − 2; Low Imprecision 145 107; [13–135]
Inconsistency
13. Silver 0.18; 39% − 1; Moderate Imprecision 191 86; [29–124]
14. Vitamin E Only 1 study − 2; Low Imprecision (− 2) 169 130; [3–159]

SA sensitivity analyses, excluding studies from analysis with serious risk of bias
Bold risk reductions are statistically significant

Fig. 9  Funnel plot of all studies

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Techniques in Coloproctology

Table 4  Related systematic reviews

Author refer- CRS only: # Included Meta-anal- HeteroGe- Risk of bias GRADE Special Publication Quantified
ence test Year Studies ysis neity features included efficacy
also in this
review

Politano No NS No No No No Global 1 No
Silver [51] 2013
Charalam- No 15 Yes Yes Yes No 4 Yes
bous 2003 OR = 0.927 CI
Ampicillin 0.27–1.72
[48]
Li Silver No 9 Yes Yes Yes Yes 4 RR = 0.92 CI
[52] 2017 0.66–1.29
RR = 0.62; CI
0.28–1.41
for Colo-
rectal
Daoud No 15 Yes No Yes No Complex 3 Yes
Triclosan 2013 stats p = 0.00053
[53]
de Bruin No 9 No No No No 4 Yes
Gentamicin 2010 p < 0.01
sponge
[54]
Elsohl No 5 Yes Yes Yes Yes Funnel plot 3 Yes
Triclosan 2017 p = 0.15
[55]
Heal No 14 Yes Yes Yes Yes Cochrane None Yes
Antibiotic 2016, 2017 Review RR 0.61
on a closed CI 0.42–0.87
wound [56]
de Jonge No 21 Yes Yes Yes Yes TSC 4 Yes
Triclosan 2017 p = 0.001
[57]
Lv Yes 8 Yes Yes Yes: too No Geography 8 Yes
Gentamy- 2016 positive RR = 0.73
cinsponge CI 0.47–1.12
[58]
Mueller Subgroup 6 with anti- Yes Yes No No Most inclu- 5 Yes
Lavage [59] mixed microbials sions were p < 0.0001 but
analysis saline vs. not quite the
2015 nothing comparison
needed
Musters Yes APR 8: Mixed No No Yes No 3 Not exactly.
Gentamycin 2015 RCT & Perineal
sponge NRT wounds only
[60]
Sandini 61 Yes 6 Yes No Yes No Funnel plot 4 Yes
Triclosan 2016 OR = 0.81
CI 0.58–1.13

CRS colorectal surgery only, GRADE grading of recommendations assessment, development and evaluation, APR abdominoperineal resection;
NS not specified, RCT​randomized-controlled trial, NRT0 non-randomized trial

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 Techniques in Coloproctology

Compliance with ethical standards MEDLINE search strategy

Conflict of interest The authors declare that they have no conflict of Ovid MEDLINE (1950 to 08/24/2017)
interest.

Ethical approval This article does not contain any studies with human 1. exp Surgical Wound Infection/
participants performed by any of the authors. 2. exp Postoperative Complications/
3. exp Bacterial Infections/
Informed consent For this type of study formal consent is not required.
4. exp Infection/
5. exp Sepsis/
6. (postoperative complication* or infection* or sepsis).
Appendix 1: search strategy mp.
7. 1 or 2 or 3 or 4 or 5 or 6
Cochrane central (latest issue) 8. exp Antiinfective Agents/
9. exp Antibacterial Agents/
1. MeSH descriptor: [Surgical Wound Infection] explode 10. exp Antibiotic Prophylaxis/
all trees 11. exp Triclosan/
2. MeSH descriptor: [Postoperative Complications] 12. (antiinfective or antibiotic* or antimicrobial* or anti-
explode all trees bacterial* or triclosan* or prophylaxis or premedica-
3. MeSH descriptor: [Bacterial Infections] explode all tion or disinfect* or antiseptic*).mp.
trees 13. 8 or 9 or 10 or 11 or 12
4. MeSH descriptor: [Infection] explode all trees 14. exp Colorectal Surgery/
5. MeSH descriptor: [Sepsis] explode all trees 15. exp Colon/su [Surgery]
6. (postoperative complication* or infection* or 16. exp Rectum/su [Surgery]
sepsis):ti,ab,kw 17. exp Colectomy/
7. (#1 or #2 or #3 or #4 or #5 or #6) 18. ((colon* or rect* or colorect*) and (surgery or opera-
8. MeSH descriptor: [Antiinfective Agents] explode all tion or resection)).mp.
trees 19. (colectom* or colostom*).mp.
9. MeSH descriptor: [Antibacterial Agents] explode all 20. 14 or 15 or 16 or 17 or 18 or 19
trees 21. 7 and 13 and 20
10. MeSH descriptor: [Antibiotic Prophylaxis] explode all 22. randomized-controlled trial.pt.
trees 23. controlled clinical trial.pt.
11. MeSH descriptor: [Triclosan] explode all trees 24. randomized.ab.
12. (antiinfective or antibiotic* or antimicrobial* or anti- 25. placebo.ab.
bacterial* or triclosan* or prophylaxis or premedica- 26. clinical trial.sh.
tion or disinfect* or antiseptic*):ti,ab,kw 27. randomly.ab.
13. (#8 or #9 or #10 or #11 or #12) 28. trial.ti.
14. MeSH descriptor: [Colorectal Surgery] explode all 29. 22 or 23 or 24 or 25 or 26 or 27 or 28
trees 30. humans.sh.
15. MeSH descriptor: [Colon] explode all trees and with 31. 29 and 30
qualifier(s): [Surgery - SU] 32. 21 and 31
16. MeSH descriptor: [Rectum] explode all trees and with
qualifier(s): [Surgery - SU] EMBASE search strategy
17. MeSH descriptor: [Colectomy] explode all trees
18. ((colon* or rect* or colorect*) and (surgery or opera- Ovid EMBASE (1974–08/24/2017)
tion or resection)):ti,ab,kw
19. (colectom* or colostom*):ti,ab,kw 1. exp surgical infection/
20. (#14 or #15 or #16 or #17 or #18 or #19) 2. exp postoperative complication/pc [Prevention]
21. (#7 and #13 and #20) 3. exp bacterial infection/
4. exp sepsis/
5. (postoperative complication* or infection* or sepsis).
mp.
6. 1 or 2 or 3 or 4 or 5
7. exp antiinfective agent/

13
Techniques in Coloproctology

8. exp antibiotic prophylaxis/ 5. Intravenous versus Combined Oral and Intravenous Antimicrobial
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7. Heal CF, Banks JL, Lepper P, Kontopantelis E, van Driel ML
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R. L. Nelson1 · A. Kravets2 · R. Khateeb2 · M. Raza2 · M. Siddiqui2 · I. Taha2 · A. Tummala2 · R. Epple2 · S. Huang2 ·
M. Wen2
* R. L. Nelson
altohorn@uic.edu
1
Epidemiology/Biometry Division, University of Illinois
School of Public Health, 1603 West Taylor, Chicago, IL,
USA
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2
Honors College, University of Illinois at Chicago, Chicago,
IL, USA
13