Cochrane
Library
Cochrane Database of Systematic Reviews

   
Antibiotic prophylaxis for prevention of postoperative wound
infection in adults undergoing open elective inguinal or femoral
hernia repair (Review)

  Orelio CC, van Hessen C, Sanchez-Manuel FJ, Aufenacker TJ, Scholten RJPM  

  Orelio CC, van Hessen C, Sanchez-Manuel FJ, Aufenacker TJ, Scholten RJPM.  

Antibiotic prophylaxis for prevention of postoperative wound infection in adults undergoing open elective inguinal or femoral
hernia repair.
Cochrane Database of Systematic Reviews 2020, Issue 4. Art. No.: CD003769.
DOI: 10.1002/14651858.CD003769.pub5.

  www.cochranelibrary.com  

 
Antibiotic prophylaxis for prevention of postoperative wound infection in adults undergoing open elective
inguinal or femoral hernia repair (Review)
Copyright © 2020 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
 Cochrane Trusted evidence.
Informed decisions.
 
 
Library Better health. Cochrane Database of Systematic Reviews

[Intervention Review]

Antibiotic prophylaxis for prevention of postoperative wound infection

in adults undergoing open elective inguinal or femoral hernia repair

Claudia C Orelio1, Coen van Hessen2, Francisco Javier Sanchez-Manuel3, Theodorus J Aufenacker4, Rob JPM Scholten5

1Research Support, Diakonessenhuis Utrecht, Utrecht, Netherlands. 2Liesbreukcentrum Nederland, Diakonessenhuis Utrecht, Utrecht,
Netherlands. 3General and Digestive Surgery, Complejo Asistencial Universitario de Burgos. Universitary Burgos´s Hospital, Burgos,
Spain. 4Department of Surgery, Rijnstate Hospital, Arnhem, Netherlands. 5Cochrane Netherlands, Julius Center for Health Sciences and
Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands

Contact address: Claudia C Orelio, corelio@diakhuis.nl, claudia.orelio@gmail.com.

Editorial group: Cochrane Colorectal Group.

Publication status and date: Edited (no change to conclusions), published in Issue 10, 2020.

Citation: Orelio CC, van Hessen C, Sanchez-Manuel FJ, Aufenacker TJ, Scholten RJPM. Antibiotic prophylaxis for prevention of
postoperative wound infection in adults undergoing open elective inguinal or femoral hernia repair. Cochrane Database of Systematic
Reviews 2020, Issue 4. Art. No.: CD003769. DOI: 10.1002/14651858.CD003769.pub5.

Copyright © 2020 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

ABSTRACT

Background
Inguinal or femoral hernia is a tissue protrusion in the groin region and has a cumulative incidence of 27% in adult men and of 3% in
adult women. As most hernias become symptomatic over time, groin hernia repair is one of the most frequently performed surgical
procedures worldwide. This type of surgery is considered 'clean' surgery with wound infection rates expected to be lower than 5%. For
clean surgical procedures, antibiotic prophylaxis is not generally recommended. However after the introduction of mesh-based hernia
repair and the publication of studies that have high wound infection rates the debate as to whether antibiotic prophylaxis is required to
prevent postoperative wound infections started again.

Objectives
To determine the effectiveness of antibiotic prophylaxis in reducing postoperative (superficial and deep) wound infections in elective open
inguinal and femoral hernia repair.

Search methods
We searched several electronic databases: Cochrane Registry of Studies Online, MEDLINE Ovid, Embase Ovid, Scopus and Science Citation
Index (search performed on 12 November 2019). We also searched two trial registers and the reference list of included studies.

Selection criteria
We included randomised controlled trials comparing any type of antibiotic prophylaxis versus placebo or no treatment for preventing
postoperative wound infections in adults undergoing inguinal or femoral open hernia repair surgery (tissue repair and mesh repair).

Data collection and analysis

Two review authors independently selected studies, extracted data and assessed risk of bias. We separately analysed results for two
different surgical methods (herniorrhaphy and hernioplasty). Several studies revealed infection rates that were higher than the expected
5% for clean surgery and we therefore divided studies into two subgroups: high infection risk environments (≥ 5% infection rate); and low
infection risk environments (< 5% infection rate). We performed meta-analyses with random-effects models. We analysed three outcomes:
superficial surgical site infections (SSSI); deep surgical site infections (DSSI); and all postoperative wound infections (SSSI + DSSI).

Antibiotic prophylaxis for prevention of postoperative wound infection in adults undergoing open elective inguinal or femoral hernia 1
repair (Review)
Copyright © 2020 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
 Cochrane Trusted evidence.
Informed decisions.
 
 
Library Better health. Cochrane Database of Systematic Reviews

Main results
In this review update we identified and included 10 new studies. In total, we included 27 studies with 8308 participants in this review.

It is uncertain whether antibiotic prophylaxis as compared to placebo (or no treatment) prevents all types of postoperative wound
infections after herniorrhaphy surgery (risk ratio (RR) 0.86, 95% confidence interval (CI) 0.56 to 1.33; 5 studies, 1865 participants; very low
quality evidence). Subgroup analysis did not change these results. We could not perform meta-analyses for SSSI or DSSI as these outcomes
were not reported separately.

Twenty-two studies related to hernioplasty surgery (total of 6443 participants) and we analysed three outcomes: SSSI; DSSI; SSSI + DSSI.

Within the low infection risk environment subgroup, antibiotic prophylaxis as compared to placebo probably makes little or no difference
for the outcomes 'prevention of all wound infections' (RR 0.71, 95% CI 0.44 to 1.14; moderate-quality evidence) and 'prevention of SSSI' (RR
0.71, 95% CI 0.44 to 1.17, moderate-quality evidence). Within the high infection risk environment subgroup it is uncertain whether antibiotic
prophylaxis reduces all types of wound infections (RR 0.58, 95% CI 0.43 to 0.77, very low quality evidence) or SSSI (RR 0.56, 95% CI 0.41
to 0.77, very low quality evidence). When combining participants from both subgroups, antibiotic prophylaxis as compared to placebo
probably reduces the risk of all types of wound infections (RR 0.61, 95% CI 0.48 to 0.78) and SSSI (RR 0.60, 95% CI 0.46 to 0.78; moderate-
quality evidence).

Antibiotic prophylaxis as compared to placebo probably makes little or no difference in reducing the risk of postoperative DSSI (RR 0.65,
95% CI 0.26 to 1.65; moderate-quality evidence), both in a low infection risk environment (RR 0.67, 95% CI 0.11 to 4.13; moderate-quality
evidence) and in the high infection risk environment (RR 0.64, 95% CI 0.22 to 1.89; low-quality evidence).

Authors' conclusions
Evidence of very low quality shows that it is uncertain whether antibiotic prophylaxis reduces the risk of postoperative wound infections
after herniorrhaphy surgery. Evidence of moderate quality shows that antibiotic prophylaxis probably makes little or no difference in
preventing wound infections (i.e. all wound infections, SSSI or DSSI) after hernioplasty surgery in a low infection risk environment. In a
high-risk environment, evidence of very low quality shows it is uncertain whether antibiotic prophylaxis reduces all wound infections and
SSSI after hernioplasty surgery. Evidence of low quality shows that antibiotic prophylaxis in a high-risk environment may have little or no
difference in reducing the risk of DSSI.

PLAIN LANGUAGE SUMMARY

Can antibiotics as compared to placebo prevent postoperative wound infections after open groin hernia repair surgery?

Background

Groin hernia is a weakness in the abdominal wall in the groin area, through which soft tissue or organs can protrude. Groin hernias occur
often and therefore groin hernia repair is one of the most frequently performed surgical operations worldwide. It is considered a 'clean'
surgical technique with low postoperative wound infections rates and administration of antibiotics to patients undergoing open hernia
repair surgery is therefore not generally recommended. Up to the 1990s, suture-based hernia repair (herniorrhaphy) was the method of
choice. From then onwards hernia repair with a synthetic mesh (hernioplasty) gained increasing popularity and the debate as to whether
antibiotics are needed to prevent postoperative wound infections started again.

Investigation

We searched the literature (12 November 2019) for randomised controlled trials comparing antibiotics versus placebo to prevent wound
infections after open groin hernia repair surgery. We included both suture-based and mesh-type surgical methods. We divided infections
into superficial and deep wound infections. Several studies revealed infection rates that were higher than the expected 5% for clean
surgery. Therefore, we divided studies into a group with low infection rates (less than 5%) and one with high infection rates (more than 5%).

Study characteristics and key results

We identified five suture-based surgery studies and 22 mesh-type surgery studies. The suture-based studies were of very low
methodological quality. The mesh-type surgery studies were of low to moderate methodological quality.

This review shows that antibiotics do not prevent the occurrence of any type of wound infections after suture-based hernia repair. For
mesh-type hernia repair in a low infection risk environment, antibiotics probably make little to no difference in prevention of postoperative
superficial wound infections. However, in a high infection risk environment it is uncertain whether antibiotics reduce the risk of superficial
wound infection occurrence.

For deep wound infections, we show that antibiotics probably make little or no difference in reducing the risk in both a low and high
infection risk environment.

Quality of the evidence

Antibiotic prophylaxis for prevention of postoperative wound infection in adults undergoing open elective inguinal or femoral hernia 2
repair (Review)
Copyright © 2020 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
 Cochrane Trusted evidence.
Informed decisions.
 
 
Library Better health. Cochrane Database of Systematic Reviews

Evidence of very low quality shows that it is uncertain whether antibiotics reduce the risk of postoperative wound infections after suture-
based hernia repair. Evidence of moderate quality shows that that antibiotics probably make little or no difference in preventing superficial
or deep wound infections after mesh-type hernia repair in a low infection risk environment. Evidence of (very) low quality shows that it
is uncertain whether antibiotics reduce the risk of superficial wound infections, and antibiotics have little or no effect on deep wound
infections after mesh-type hernia repair in a high infection risk environment.

Antibiotic prophylaxis for prevention of postoperative wound infection in adults undergoing open elective inguinal or femoral hernia 3
repair (Review)
Copyright © 2020 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.