Sora Ely, MD1, Rebecca C Gologorsky, MD1, Michelle R Huyser, MD1, Genna Beattie, MD1, C K Chang, MD2. 1UCSF East Bay Surgery, 2Kaiser Permanente Oakland Medical Center
Introduction: Debate continues regarding utility and safety of routine antibiotic prophylaxis for elective laparoscopic cholecystectomy. Several small, randomized controlled trials have failed to demonstrate benefit, while a handful of larger meta-analyses have reported statistically significant reductions in surgical site infections. However, most of these studies come from clinical settings outside the United States. We used a national database to examine factors associated with postoperative infection in outpatient laparoscopic cholecystectomy.
Methods: We retrospectively reviewed outpatient laparoscopic cholecystectomy cases from the 2015-2016 American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. Chi-square test and ANOVA were used to identify pre- and intra-operative NSQIP variables associated with postoperative surgical infection, defined as any surgical site, deep wound, or organ space infection.
Results: Postoperative surgical infection occurred in 347 of 41,665 cases (0.8%). Notably, incidence of Clostridium difficile infection in this population was also low (0.2%), but not insignificant by comparison. Furthermore, the majority (91.9%) of C.difficile infections occurred in the absence of a surgical infection.
Factors associated with higher infection rates included: age >89 years, hypertension, congestive heart failure, acute renal failure, dialysis, and chronic steroid use (p<0.05). Strongest predictors of postoperative infection included higher wound classification (p<0.001) and longer operative time (>80 minutes, p<0.001). Infection rates were low in wound classes 1-3, with a marked increase only in class 4 (0.7%, 0.7%, 1.2%, 3.2% respectively).
Using these two clinical variables, we developed a simple scoring system to predict infection risk. Figure 1 shows postoperative infection rates stratified by this score: operating room minutes ≤80 (0) or >80 (1) plus wound class 1-3 (0) or 4 (1).
Conclusions: Risk of postoperative surgical infection after outpatient laparoscopic cholecystectomy is low, and the incidence of C. difficile infection is non-trivial. Although antibiotics may be associated with lower rates of postoperative infection, their marginal clinical benefit in the setting of low absolute risk is tempered by the risk of C. difficile infection, antibiotic resistance, and other adverse effects of antibiotic use.
We recommend against routine antibiotic prophylaxis in low-risk patients undergoing elective, outpatient laparoscopic cholecystectomy. Antibiotics should be considered in cases for which the wound class is 4 and/or the operative time exceeds 80 minutes. Surgeons may wish to utilize this scoring system intra-operatively to inform their decision to administer antibiotics during the case once operative time can be reasonably estimated. A randomized controlled trial is needed to validate this recommendation.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 94892
Program Number: P264
Presentation Session: Poster Session (Non CME)
Presentation Type: Poster