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ORIGINAL ARTICLE
Year : 2019  |  Volume : 32  |  Issue : 3  |  Page : 1137-1141

The role of antibiotic prophylaxis in the prevention of surgical-site infection after hernioplasty in Menoufia University Hospital


Department of General Surgery, Faculty of Medicine, Menoufia University, Shebeen El-Kom, Egypt

Date of Submission05-Jan-2016
Date of Acceptance07-Mar-2016
Date of Web Publication17-Oct-2019

Correspondence Address:
Mahmoud M. A. Al-Rahawy
Shebeen El-Kom, Menoufia
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_10_16

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  Abstract 

Objective
The aim of this paper was to evaluate the effectiveness of prophylactic antibiotics in the prevention of postoperative wound infection after Lichtenstein open mesh inguinal hernia repair.
Background
Inguinal hernia is one of the most common conditions encountered in clinical practice. Mesh repair is becoming the most popular technique for the repair of inguinal hernia. A surgical-site infection is defined as an infection that occurs at or near a surgical incision within 30 days of the procedure or within three months if an implant is left in place. The decision of perioperative antibiotic prophylaxis is made according to a number of risk factors, in particular, in aseptic interventions. The use of antibiotic prophylaxis for clean surgical procedures such as inguinal hernia surgery is controversial.
Patients and methods
Between November 2014 and November 2015, this prospective randomized-controlled study included 40 patients who presented with inguinal hernia. Patients were randomized into two groups. Group A was administered an antibiotic at the induction of anesthesia. Group B was administered sterile normal saline. After Lichtenstein inguinal hernioplasty, patients were followed up at 7–10 and 28–35 days to assess surgical-site infection.
Results
Of a total of 40 patients (37 men and three women), 20 in each group, one (2.5%) patient developed wound infection in group A and two (5%) patients developed wound infection in group B.
Conclusion
There is no benefit of an intravenous single-dose antibiotic prophylaxis in the prevention of wound infection following Lichtenstein inguinal hernioplasty in patients with no other co-morbid conditions.

Keywords: antibiotic prophylaxis, inguinal hernia, Lichtenstein repair, wound infection


How to cite this article:
Kahla SM, Gaber A, Al-Rahawy MM. The role of antibiotic prophylaxis in the prevention of surgical-site infection after hernioplasty in Menoufia University Hospital. Menoufia Med J 2019;32:1137-41

How to cite this URL:
Kahla SM, Gaber A, Al-Rahawy MM. The role of antibiotic prophylaxis in the prevention of surgical-site infection after hernioplasty in Menoufia University Hospital. Menoufia Med J [serial online] 2019 [cited 2019 Nov 14];32:1137-41. Available from: http://www.mmj.eg.net/text.asp?2019/32/3/1137/268798




  Introduction Top


Hernia is a protrusion of a viscus or part of a viscus through an abnormal opening in the walls of its containing cavity. Inguinal hernia is one of the most common conditions (75% of all external abdominal wall hernia) encountered in clinical practice [1].

The Lichtenstein technique is a tension-free repair of a weakened inguinal floor using an apolypropylene mesh [2].

Perioperative antibiotic prophylaxis is defined as a single administration of antibiotics shortly before a surgical intervention. A so-called prolonged prophylaxis including the postoperative period (e.g., 1–3 days postoperatively) should be avoided as it does not reduce the number of wound infections and is associated with an increased risk of antimicrobial resistance and side effects [3].

Of the various methods for adult inguinal hernia repair, mesh repair is rapidly becoming the most popular technique [4].

Surgical-site infection (SSI) is a major potential complication of any surgical procedure. The relative reduction in risk appears to be consistently around 60% across many different forms of surgery, ranging from clean to heavily contaminated procedures [5].

For surgical procedures, intravenous prophylactic antibiotics should be administered within 60 min before the skin is incised and as close to the time of incision as practically possible. For operative durations up to 3 h, the one-time administration of an antibiotic is sufficient. In prolonged surgery (>3 h) or massive blood loss (>1500 ml), a repeated intraoperative administration is necessary [6].

There are only a few publications analyzing mesh infections; thus, it is difficult to determine the frequency of SSI following hernia repair from a tertiary care hospital of a low-income country [7].

Aim

This study aimed to answer the question of whether or not the use of prophylactic antibiotics is effective in the prevention of postoperative wound infection after Lichtenstein open mesh inguinal hernia repair.


  Patients and Methods Top


After approval of the Menoufia Ethics Committee, between November 2014 and November 2015, this prospective randomized study was carried out in Menoufia University Hospitals. Randomization was performed according to the randomization technique in Microsoft Corporation, in Redmond, Washington, USA.

In total, 40 patients with inguinal hernia were included in this study. Patients were divided into two groups:

  1. Group A: received cefazolin 1 g intravenously at the time of induction of anesthesia
  2. Group B: normal saline was used as a placebo in the control group.


Cefazoline is a β-lactam antibiotic and covers the expected pathogens for the operative site.

Informed written consent was obtained from every patient before his or her enrollment in the trial. Patients who had strangulated hernia, immunosuppressive disease, or allergy to the antibiotic administered were excluded from the study.

Each patient was subjected to a full assessment of history, thorough clinical examination, laboratory investigations, and radiological investigation in the form of chest radiography and pelvi-abdominal ultrasound.

Patients were fasted preoperatively for 8 h. Abdominal and groin hair was shaved from the costal margin to middle of the thigh.

All patients received spinal anesthesia. Prophylactic antibiotic 1 g of cefazoline was administered during anesthesia to the group receiving antibiotic prophylaxis.

A standard Lichtenstein hernia repair was performed. Two surgeons who specialized in hernia surgery performed the operations. A monofilament polypropylene flat mesh was sutured in place with monofilament polypropylene suture (prolene), followed by skin closure.

No postoperative antibiotics were used. Dressings will be removed at 48 h after surgery.

Wounds were examined daily during the hospital stay and at the subsequent follow-up visits at 7–9 and 28–42 days. During the first follow-up visit, a detailed assessment of history on the presence or absence of pain over the incision site, redness, local bulging, and any discharge from the wound was performed and a local examination was performed to look for erythema, local bulging, heat, tenderness, and any discharge from the wound that required culture. Suture was also removed and the patient was advised to attend follow-up at 28–42 days. During the second follow-up visit, enquiries were made on the presence of persistent pain, presence of persistent of infection, sinus formation, testicular atrophy, and recurrence of hernia.

All data were collected and statistically analyzed.


  Results Top


The study was carried on 40 patients who had inguinal hernia. The patients' age ranged from 18 to 65 years, with a mean age of 39.5 years in group A and 38.5 years in group B. There were 37 men and three women in the study group [Table 1].
Table 1: Demographic characteristics of the studied groups

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Among the 37 male patients, there were 25 smokers and only one ex-smoker. None of the female patients smoked.

This study did not find statistically significant differences between the antibiotic prophylaxis and placebo in the wound infection rate as there was one (5%) patient with SSI in the antibiotic prophylaxis group versus two (10%) cases in the placebo group, with a P value of 0.54, which is not significant [Table 2].
Table 2: Wound infection among the studied groups

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The duration of illness was less than 1 year in nine (45%) patients in group A and 12 (60%) patients in group B, with no statistically significant difference between both groups [Table 3].
Table 3: Duration of illness among the studied groups

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A total of 10 patients had direct inguinal hernia (25% of all patients), 29 patients had indirect hernia (72.5%), and one patient had combined inguinal hernia (2.5%), with a P value of 42 [Table 4].
Table 4: Type of hernia among the studied groups

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Operative time was about 30–60 min in group A, with a mean of 42.75 ± 7.34. In group B, the operative time was 30–52 min, with a mean of 42.08 ± 6.52, with no statistically significant difference between both groups [Table 5].
Table 5: Operative time among the studied groups

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The duration of hospital stay ranged between 24 and 48 h, with a mean ± SD of 26.4 ± 7.38 for group A and a mean ± SD of 27.52 ± 6.24 for group B (P = 0.17), which is not significant [Table 6].
Table 6: Hospital stay among the studied groups

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During the postoperative period, one patient (2.5% of total patients) had urinary retention in our study and two (5% of total patients) patients had mild seroma, which improved rapidly. There were two (5%) cases of drug allergy in this study [Table 7].
Table 7: Complications among the studied groups

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  Discussion Top


Inguinal hernia is the most common problem in all external hernias and surgery for inguinal hernia is one of the most common procedures performed in a general surgical service, accounting for approximately one-third of all interventions [8]. Although many patients are asymptomatic, most of them have local symptoms and, if left untreated, hernia itself leads to potential complications such as irreducibility, incarceration, strangulation, peritonitis, and sepsis [9]. As inguinal hernia repair represents one of the most frequently performed surgical procedures, any improvement in their treatment could have a major medical and economic impact, especially a reduction in the number of wound infections [10]. Mesh repair is considered the gold standard in inguinal hernia repair worldwide [11].

Introduction of antibiotic therapy in the mid-20th century fostered hope that surgical infection would be eliminated [12]. The benefit of antibiotic prophylaxis in 'clean' surgical procedures, such as inguinal hernia surgery, has been considered questionable. The low rate of wound infection and the straightforward treatment, if they occur at all, are the main arguments against routine antibiotic coverage during inguinal hernia surgery [13].

In this study of 40 inguinal hernia repairs in 40 patients, the age ranges were 18–65 years. Only one (2.5%) patient was older than 60 years of age. The patients had a broad range of occupations and life-styles; 20% were office workers (eight patients) and 80% were manual laborers (32 patients).

In this study, there was no statistically significant difference between both groups in the mean age and sex distribution, but the mean age in the antibiotic prophylaxis group (mean ± SD: 38.30 ± 10.72) was lower than in the placebo group (mean ± SD: 39.60 ± 12.93). The mean age was lower than that in the study of Aufenacker et al. [14]; in their study, a total of 1040 patients were included [481 (95.6) males, 58.28 ± 12.9 years old for the antibiotic group, and 490 (97.0) males, 58.22 ± 13.2 years old for the placebo group].

In this study, there was no statistically significant difference between the antibiotic prophylaxis and placebo groups in the wound infection rate; one (5%) patient received antibiotic prophylaxis versus two (10%) in the placebo group, with a P value of 0.54, which is not significant. Similarly, Bidur et al. [2] reported that from a total of 60 patients (59 men and one woman), 30 in each group were enrolled. During the first follow-up, one (3.3%) patient developed wound infection from group B, whereas none (0%) of the patients developed wound infection from group A, with a P value of 0.365, which is not significant [2]. Similarly, Aufenacker et al. reported that among 1040 patients, the number of wound infections was eight (1.6%) in the antibiotic prophylaxis group and nine (1.8%) in the placebo group, with a P value of 0.82, which is not significant [14].

Similarly, Ijaz et al. [15] reported that from a total of 100 patients who were equally divided into two groups of 50 patients each, out of one hundred patients, wound infections were found in a total of seven (7%). All the patients were equally divided into two groups of 50 each, the results showed that two (4%) patients of the antibiotic prophylaxis group had wound infection compared to five patients (10%) in the placebo group. Statistical analysis showed no significant difference in the number of wound infections in both groups (P = 0.240) [15].

Ullah et al. [16] reported that a total of 166 cases of inguinal hernia mesh repair were recorded during the study period. In the antibiotic group, SSI was observed in six (7.2%) patients, whereas 77 (92.8%) had a healthy scar. In the placebo group, SSI was observed in 15 (18.1%) patients and 68 (81.9%) had healthy scars. The difference between the two groups was significant (P = 0.036) and it was concluded that antibiotic prophylaxis is the preferred option for mesh plasty [16].

In the southeast of England, there is a strong recommendation by surgeons for the use of antibiotic prophylaxis in this procedure [5].

In this study, in the antibiotic group, there were six patients with direct inguinal hernia, 13 with indirect inguinal hernias, and one patient with combined inguinal hernias. In the placebo group, there was four patients with direct inguinal hernia and 16 patients with direct inguinal hernia.

Similarly, in the study carried out by Tzovarus et al. [17], indirect hernia was present in 221 (58%) patients and direct hernia was present in 158 (42%) patients.

This study showed that the duration of surgery ranged from 30 to 60 min in the antibiotic group, with a mean ± SD duration of 42.75 ± 7.34 min, and in the placebo group, the duration of surgery ranged from 30 to 52 min, with a mean ± SD duration of 42.08 ± 6.52 min. The majority of the patients, 68%, were operated on between 40 and 50 min. This is comparable to the study carried out by Perez et al. [10], who reported a mean duration of surgery of 53 min.

This study showed that there is no statistically significant difference between both groups in the hospital stay, with a mean ± SD of 26.4 ± 7.38 for group A and a mean ± SD of 27.52 ± 6.24 for group B, and a P value of 0.17, which is not significant. The average preoperative hospital stay was 1 day in both groups and the average duration of surgery was less than 60 min.

In this study, during the postoperative period, one (2.5%) patient developed urinary retention. This represents a low rate of urinary retention after 40 patients received spinal anesthesia compared with the results of Bidur et al. [2] that showed that out of 18 patients who were operated under spinal anesthesia, two (11%) patients developed urinary retention in the immediate postoperative period in the ward and Foley catheterization was performed under aseptic conditions.

None of the patients in this study developed local wound complications such as bruising and hematoma or systemic complications such as chest infection and deep vein thrombosis during hospital stay.

There were total of 40 patients in this study; 30 attended regular follow-up. None of the patients had persistence of pain, persistent infection, sinus formation, testicular atrophy, or recurrence of hernia. However, two patients developed mild seroma that improved rapidly. There were two cases of drug allergy in this study, which could serve as a warning that excessive unnecessary use of antibiotics may only cause side effects, with no benefits.


  Conclusion Top


Lichtenstein inguinal primary hernia repair is a clean operation; thus, there is no benefit of intravenous single-dose antibiotic prophylaxis in the prevention of wound infections in low-risk patients with no other co-morbid conditions.

Conversely, the use of antibiotic prophylaxis in inguinal hernia repair could increase the risks of toxic and allergic side effects, the possible development of bacterial resistance or super-infection, and increase costs.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Russel RC, Williams NS, Bulstrode CJ. Bailey & love short practice of surgery. London: Hodder Arnold; 2004. pp. 1272–1293.  Back to cited text no. 1
    
2.
Bidur Kc, Regmi R, Agrawal C, Pathania O. Role of single dose antibiotic prophylaxis in prevention of wound infection following lichtenstein inguinal hernioplasty: a randomized clinical trial. Nepal Journal of Medical Sciences, 2013; 2:108–113.  Back to cited text no. 2
    
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Hagel S, Scheuerlein H. Perioperative antibiotic prophylaxis and antimicrobial therapy of intra-abdominal infections. Viszeralmedizin 2014; 30:310–316.  Back to cited text no. 3
    
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Bay-Nielsen M, Kehlet M, Strand L, Malmstrøm J, Andersen FH, Wara P, et al. Quality assessment of 26304 herniorrhaphies in Denmark: a prospective nationwide study. Lancet 2001; 358:1124–1128.  Back to cited text no. 4
    
5.
Aiken AM, Haddow JB, Symons NR, et al. Use of antibiotic prophylaxis in elective inguinal hernia repair in adults in London and south-east England: a cross-sectional survey. Hernia 2013; 17:657–664.  Back to cited text no. 5
    
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Hirokawa F, Hayashi M, Miyamoto Y, et al. Evaluation of postoperative antibiotic prophylaxis after liver resection. Am J Surg 2013; 206:8–15.  Back to cited text no. 6
    
7.
Pardhan A, Mazahir S, Avi AR et al. Surgical site infection following hernia repair. JPMA 2013; 63:760–762.  Back to cited text no. 7
    
8.
Devereux DF, O'Connell SM, Liesch JB, et al. Induction of leukocyte activation by meshes surgically implanted in the peritoneal cavity. Am J Surg 1991; 162:243–246.  Back to cited text no. 8
    
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Sanabria A, Domínguez LC, Valdivieso E, Gómez G. Prophylactic antibiotics for mesh inguinal hernioplasty. A meta-analysis. Ann Surg 2007; 245:392–396.  Back to cited text no. 9
    
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Perez AR, Roxas MF, Hilvano SS. A randomized, double-blind, placebo-controlled trial to determine effectiveness of antibiotic prophylaxis for tension-free mesh herniorrhaphy. J Am Coll Surg 2005; 200:393–398.  Back to cited text no. 10
    
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Cainzos M, Lozano F, Balibrea JL. Postoperative infection multicentric prospective and controlled study. Cir Esp 1990; 48:481–490.  Back to cited text no. 11
    
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Surahio AR, Khan AA, Farooq MU, Fatima. Single versus 3-dose antibiotic prophylaxis in clean and clean contaminated operations. J Ayub Med Coll Abbottabad 2010; 22:4.  Back to cited text no. 12
    
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Sanchez-Manuel FJ, Seco-Gil JL. Antibiotic prophylaxis for hernia repair. Cochrane Database Syst Rev 2003; 2:37–69.  Back to cited text no. 13
    
14.
Aufenacker TJ, van Geldere D, van Mesdag T, Bossers AN, Dekker B, Scheijde E, et al. The role of antibiotic prophylaxis in prevention of wound infection after Lichtenstein open mesh repair of primary inguinal hernia. Ann Surg 2004; 240:955–961.  Back to cited text no. 14
    
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Ijaz A, Amer MS. Post-operative wound infection prevention: the role of antibiotic prophylaxis in Lichtenstein. Professional Med J 2010; 17:174–179.  Back to cited text no. 15
    
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Ullah B, Khan SA, Ahmed S, Pasha T. Efficacy of preoperative single dose antibiotic in Patients undergoing mesh repair for inguinal hernia. J Ayub Med Coll Abbottabad 2013; 25:103–105.  Back to cited text no. 16
    
17.
Tzovaras G, Delikoukos S, Christodoulides G, Spyridakis M, Mantzos F, Tepetes K, et al. The role of antibiotic prophylaxis in elective tension free mesh inguinal hernia repair: result of a single center prospective randomized trial. Int J Clin Pract 2007; 61:236–239.  Back to cited text no. 17
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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