TY - JOUR
T1 - Prevention of severe infectious complications after colorectal surgery using oral non-absorbable antimicrobial prophylaxis
T2 - Results of a multicenter randomized placebo-controlled clinical trial
AU - Mulder, Tessa
AU - Kluytmans-Van Den Bergh, Marjolein
AU - Vlaminckx, Bart
AU - Roos, Daphne
AU - De Smet, Anne Marie
AU - De Vos Tot Nederveen Cappel, Robert
AU - Verheijen, Paul
AU - Brandt, Alexandra
AU - Smits, Anke
AU - Van Der Vorm, Eric
AU - Bathoorn, Erik
AU - Van Etten, Boudewijn
AU - Veenemans, Jacobien
AU - Weersink, Annemarie
AU - Vos, Margreet
AU - Van 'T Veer, Nils
AU - Nikolakopoulos, Stavros
AU - Bonten, Marc
AU - Kluytmans, Jan
N1 - © The Author(s) 2020.
PY - 2020/6/15
Y1 - 2020/6/15
N2 - Background: Surgical site infections (SSIs) are common complications after colorectal surgery. Oral non-absorbable antibiotic prophylaxis (OAP) can be administered preoperatively to reduce the risk of SSIs. Its efficacy without simultaneous mechanical cleaning is unknown. Methods: The Precaution trial was a double-blind, placebo-controlled randomized clinical trial conducted in six Dutch hospitals. Adult patients who underwent elective colorectal surgery were randomized to receive either a three-day course of preoperative OAP with tobramycin and colistin or placebo. The primary composite endpoint was the incidence of deep SSI or mortality within 30 days after surgery. Secondary endpoints included both infectious and non-infectious complications at 30 days and six months after surgery. Results: The study was prematurely ended due to the loss of clinical equipoise. At that time, 39 patients had been randomized to active OAP and 39 to placebo, which reflected 8.1% of the initially pursued sample size. Nine (11.5%) patients developed the primary outcome, of whom four had been randomized to OAP (4/39; 10.3%) and five to placebo (5/39; 12.8%). This corresponds to a risk ratio in the intention-to-treat analysis of 0.80 (95% confidence interval (CI) 0.23-2.78). In the per-protocol analysis, the relative risk was 0.64 (95% CI 0.12-3.46). Conclusions: Observational data emerging during the study provided new evidence for the effectiveness of OAP that changed both the clinical and medical ethical landscape for infection prevention in colorectal surgery. We therefore consider it unethical to continue randomizing patients to placebo. We recommend the implementation of OAP in clinical practice and continuing monitoring of infection rates and antibiotic susceptibilities. Trial registration: The PreCaution trial is registered in the Netherlands Trial Register under NL5932 (previously: NTR6113) as well as in the EudraCT register under 2015-005736-17.
AB - Background: Surgical site infections (SSIs) are common complications after colorectal surgery. Oral non-absorbable antibiotic prophylaxis (OAP) can be administered preoperatively to reduce the risk of SSIs. Its efficacy without simultaneous mechanical cleaning is unknown. Methods: The Precaution trial was a double-blind, placebo-controlled randomized clinical trial conducted in six Dutch hospitals. Adult patients who underwent elective colorectal surgery were randomized to receive either a three-day course of preoperative OAP with tobramycin and colistin or placebo. The primary composite endpoint was the incidence of deep SSI or mortality within 30 days after surgery. Secondary endpoints included both infectious and non-infectious complications at 30 days and six months after surgery. Results: The study was prematurely ended due to the loss of clinical equipoise. At that time, 39 patients had been randomized to active OAP and 39 to placebo, which reflected 8.1% of the initially pursued sample size. Nine (11.5%) patients developed the primary outcome, of whom four had been randomized to OAP (4/39; 10.3%) and five to placebo (5/39; 12.8%). This corresponds to a risk ratio in the intention-to-treat analysis of 0.80 (95% confidence interval (CI) 0.23-2.78). In the per-protocol analysis, the relative risk was 0.64 (95% CI 0.12-3.46). Conclusions: Observational data emerging during the study provided new evidence for the effectiveness of OAP that changed both the clinical and medical ethical landscape for infection prevention in colorectal surgery. We therefore consider it unethical to continue randomizing patients to placebo. We recommend the implementation of OAP in clinical practice and continuing monitoring of infection rates and antibiotic susceptibilities. Trial registration: The PreCaution trial is registered in the Netherlands Trial Register under NL5932 (previously: NTR6113) as well as in the EudraCT register under 2015-005736-17.
KW - Colorectal surgery
KW - Infection control
KW - Preoperative oral antibiotic prophylaxis
KW - Surgical site infection
UR - http://www.scopus.com/inward/record.url?scp=85086621852&partnerID=8YFLogxK
U2 - 10.1186/s13756-020-00745-2
DO - 10.1186/s13756-020-00745-2
M3 - Article
C2 - 32547735
SN - 2047-2994
VL - 9
SP - 1
EP - 11
JO - Antimicrobial Resistance and Infection Control
JF - Antimicrobial Resistance and Infection Control
IS - 1
M1 - 84
ER -