Abstract

Surgical site infection (SSI) is a major cause of morbidity worldwide following elective colorectal resection, affecting up to 20% of patients 1, 2, 3. Reduction in SSI rates requires a multi‐faceted approach 4 and can be achieved with the use of SSI reduction bundles 5. Such bundles include prophylactic intravenous antibiotics 6 which represent an undisputed standard of care 4. They do not include the use of mechanical bowel preparation (MBP) alone which is not recommended in elective colonic resection to reduce SSI 7, 8, 9, although may offer an advantage in elective rectal resection 10. A long‐standing area of controversy is the use of mechanical bowel preparation and oral antibiotics (MOAB) prior to elective colorectal resection 11, 12. Marked differences exist between clinicians worldwide 13. Recent guidelines from the American Society of Colon and Rectal Surgeons strongly recommend the use of MOAB in elective colorectal resection to reduce SSI 14, 15. Other international bodies have recognized the increasing body of evidence and altered their recommendations in a more conservative manner but stopped short of endorsing this practice because of the lack of Level 1 evidence 16. This paper summarizes the arguments for and against the use of MOAB in elective colorectal resection, highlighting the areas of controversy and evidence gaps, and provides pragmatic suggestions for colorectal practice (Fig. ​(Fig.11). Open in a separate window Figure 1 Arguments for and against the use of mechanical bowel preparation and oral antibiotics in elective colorectal resection. MOAB, mechanical bowel preparation and oral antibiotics; MIS, minimally invasive surgery; ERAS, enhanced recovery after surgery; BMI, body mass index; SSI, surgical site infection; ABx, antibiotics; CDI, Clostridium difficile infection; QI, quality improvement.

Highlights

  • Surgical site infection (SSI) is a major cause of morbidity following elective colorectal resection worldwide

  • This paper summarises the arguments for and against the use of mechanical bowel preparation and oral antibiotics (MOAB) in elective colorectal resection, highlighting the controversies surrounding this issue (Figure 1)

  • It is possible that any observed effect on reduced SSI rates may be due to the use of OAB alone rather than MOAB

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Summary

Arguments supporting the use of MOAB

The combination of MOAB in elective colorectal resection is associated with lower rates of SSI. Numerous reports from the North American Surgical Quality Improvement programmes (NSQIP) show improved clinical outcomes after varying versions of preoperative MOAB [17,18,19,20,21,22,23,24,25,26,27,28,29,30,31] These observational studies include many thousands of patients undergoing elective surgery and show that the combination of MOAB in comparison to MBP alone is associated with a reduction in SSI of about 50%. There is no evidence of harm in terms of increase in CDI rates by using MOAB

Arguments against the use of MOAB
Findings
Conclusion
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