NIHR Signal Antibiotics are not necessary for preventing infections following simple hand surgery

Published on 24 May 2016

Antibiotics did not significantly reduce the number of infections in people with clean wounds who had simple hand surgery, this review found.

NICE guidance, published in 2008, recommends that antibiotics are not prescribed for uncomplicated surgery where the wound is clean. The findings of this review support this recommendation.

This work also fits with NICE 2015 guidance on antimicrobial stewardship, providing information to improve antibiotic prescribing decisions.

Many of the studies included in this review may have suffered from bias, so the results should be viewed with some caution.

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Why was this study needed?

Infection following surgery can lead to pain and poor surgical outcomes. Antibiotics may be used “just in case” to prevent such infection (prophylaxis) but there is inconsistency in prescribing practice. Lacerations account for approximately 10% of attendances at Accident and Emergency departments. Of these most are simple lacerations at low risk of infection. In a low risk population about 3.5% of people have been shown to develop an infection.

Bacteria are increasingly becoming resistant to the antibiotics that are currently available and in recent years there has been a drive towards prescribing antibiotics only when there is evidence to support that decision.

In the context of hand surgery, evidence is said to support use of antibiotics when there is an exposed (open) fracture, a crush injury, or a bite. In other situations there is limited evidence.

This review aimed to assess whether antibiotics were effective in preventing infection in people undergoing surgery on simple uncontaminated hand injuries.

What did this study do?

This review compared the findings of 13 trials looking at whether antibiotics, placebo or no antibiotics were more effective at preventing infection following simple hand surgery. The procedures studied ranged from simple suturing in the emergency department to tendon repair performed under general anaesthetic. Studies which involved patients with complex injuries or possible contamination were excluded (see Definitions tab).

The review included five randomised controlled trials, five non-randomised trials and three observational cohort studies. Two of the randomised controlled trials were at low risk of bias, but the risk of bias was high in the others due mainly to the lack of appropriate techniques for randomisation in the included studies. This means that the findings should be interpreted with some caution, because the results of the trials might have been affected by factors other than whether or not the person received antibiotics, such as the type of dressing or skin antisepsis used.

What did it find?

  • Combining the results of all of the studies indicated that antibiotics did not significantly reduce the number of infections, compared with either placebo or no antibiotics (risk ratio [RR] 0.89, 95% confidence interval [CI] 0.65 to 1.23).
  • When the authors just combined the results of the randomised controlled trials, there was still no significant difference in the infection rate (RR 0.66, 95% CI 0.36 to 1.21).

What does current guidance say on this issue?

In its 2008 guidance on surgical site infection, NICE recommends that antibiotic prophylaxis is only used prior to surgery where the wound is contaminated (for example with debris or infection), or that surgery that involves placement of an implant or prosthesis. It is not recommended for otherwise “clean” uncomplicated surgery.

What are the implications?

The findings of this review support NICE recommendations that antibiotics should not be given for surgery on wounds that are not contaminated, in this case simple hand injuries.

NICE’s 2015 guidance on antimicrobial stewardship recommends that commissioners ensure that antimicrobial stewardship operates across all care settings. This review highlights the need to understand the risks and benefits of antibiotic preventive treatment before prescribing.

Citation and Funding

Murphy GR, Gardiner MD, Glass GE, et al. Meta-analysis of antibiotics for simple hand injuries requiring surgery. Br J Surg. 2016;103(5):487-92.

No funding information was provided for this study.

Bibliography

Hollander JE, Singer AJ, Valentine SM, Shofer FS. ​Risk Factors for Infection in Patients with Traumatic Lacerations​. ​Acad Emerg Med. 2001;​​8(7):716–720.

NICE. Surgical site infections: prevention and treatment. CG74. London: National Institute for Health and Care Excellence; 2008.

NICE. Antimicrobial stewardship: systems and processes for effective antimicrobial medicine use. NG15. London: National Institute for Health and Care Excellence; 2015.

NHS Choices. The Antibiotic Awareness Campaign [internet]. NHS Choices; 2015.

PHE. Start Smart Then Focus Appendix 1 Resource Materials: Examples of audit tools, review stickers and drug charts. London: Public Health England; 2015.

Zehtabchi S, Yadav K, Brothers E, et al. Prophylactic antibiotics for simple hand lacerations: time for a clinical trial? Injury. 2012;43(9):1497-501.

Why was this study needed?

Infection following surgery can lead to pain and poor surgical outcomes. Antibiotics may be used “just in case” to prevent such infection (prophylaxis) but there is inconsistency in prescribing practice. Lacerations account for approximately 10% of attendances at Accident and Emergency departments. Of these most are simple lacerations at low risk of infection. In a low risk population about 3.5% of people have been shown to develop an infection.

Bacteria are increasingly becoming resistant to the antibiotics that are currently available and in recent years there has been a drive towards prescribing antibiotics only when there is evidence to support that decision.

In the context of hand surgery, evidence is said to support use of antibiotics when there is an exposed (open) fracture, a crush injury, or a bite. In other situations there is limited evidence.

This review aimed to assess whether antibiotics were effective in preventing infection in people undergoing surgery on simple uncontaminated hand injuries.

What did this study do?

This review compared the findings of 13 trials looking at whether antibiotics, placebo or no antibiotics were more effective at preventing infection following simple hand surgery. The procedures studied ranged from simple suturing in the emergency department to tendon repair performed under general anaesthetic. Studies which involved patients with complex injuries or possible contamination were excluded (see Definitions tab).

The review included five randomised controlled trials, five non-randomised trials and three observational cohort studies. Two of the randomised controlled trials were at low risk of bias, but the risk of bias was high in the others due mainly to the lack of appropriate techniques for randomisation in the included studies. This means that the findings should be interpreted with some caution, because the results of the trials might have been affected by factors other than whether or not the person received antibiotics, such as the type of dressing or skin antisepsis used.

What did it find?

  • Combining the results of all of the studies indicated that antibiotics did not significantly reduce the number of infections, compared with either placebo or no antibiotics (risk ratio [RR] 0.89, 95% confidence interval [CI] 0.65 to 1.23).
  • When the authors just combined the results of the randomised controlled trials, there was still no significant difference in the infection rate (RR 0.66, 95% CI 0.36 to 1.21).

What does current guidance say on this issue?

In its 2008 guidance on surgical site infection, NICE recommends that antibiotic prophylaxis is only used prior to surgery where the wound is contaminated (for example with debris or infection), or that surgery that involves placement of an implant or prosthesis. It is not recommended for otherwise “clean” uncomplicated surgery.

What are the implications?

The findings of this review support NICE recommendations that antibiotics should not be given for surgery on wounds that are not contaminated, in this case simple hand injuries.

NICE’s 2015 guidance on antimicrobial stewardship recommends that commissioners ensure that antimicrobial stewardship operates across all care settings. This review highlights the need to understand the risks and benefits of antibiotic preventive treatment before prescribing.

Citation and Funding

Murphy GR, Gardiner MD, Glass GE, et al. Meta-analysis of antibiotics for simple hand injuries requiring surgery. Br J Surg. 2016;103(5):487-92.

No funding information was provided for this study.

Bibliography

Hollander JE, Singer AJ, Valentine SM, Shofer FS. ​Risk Factors for Infection in Patients with Traumatic Lacerations​. ​Acad Emerg Med. 2001;​​8(7):716–720.

NICE. Surgical site infections: prevention and treatment. CG74. London: National Institute for Health and Care Excellence; 2008.

NICE. Antimicrobial stewardship: systems and processes for effective antimicrobial medicine use. NG15. London: National Institute for Health and Care Excellence; 2015.

NHS Choices. The Antibiotic Awareness Campaign [internet]. NHS Choices; 2015.

PHE. Start Smart Then Focus Appendix 1 Resource Materials: Examples of audit tools, review stickers and drug charts. London: Public Health England; 2015.

Zehtabchi S, Yadav K, Brothers E, et al. Prophylactic antibiotics for simple hand lacerations: time for a clinical trial? Injury. 2012;43(9):1497-501.

Meta-analysis of antibiotics for simple hand injuries requiring surgery

Published on 2 March 2016

Murphy, G. R.,Gardiner, M. D.,Glass, G. E.,Kreis, I. A.,Jain, A.,Hettiaratchy, S.

Br J Surg , 2016

BACKGROUND: Simple hand trauma is very common, accounting for 1.8 million emergency department visits annually in the USA alone. Antibiotics are used widely as postinjury prophylaxis, but their efficacy is unclear. This meta-analysis assessed the effect of antibiotic prophylaxis versus placebo or no treatment on wound infection rates in hand injuries managed surgically. METHODS: Embase, MEDLINE, PubMed, Cochrane Central, ClinicalTrials.gov and the World Health Organization International Clinical Trials Portal were searched for published and unpublished studies in any language from inception to September 2015. The primary outcome was the effect of antibiotic prophylaxis on wound infection rates. Open fractures, crush injuries and bite wounds were excluded. Study quality was assessed using the Cochrane risk-of-bias tool. Data were pooled using random-effects meta-analysis, and risk ratios (RRs) and 95 per cent c.i. obtained. RESULTS: Thirteen studies (2578 patients) were included, comprising five double-blind randomized clinical trials, five prospective trials and three cohort studies. There was no significant difference in infection rate between the antibiotic and placebo/no antibiotic groups (RR 0.89, 95 per cent c.i. 0.65 to 1.23; P = 0.49). Subgroup analysis of the five double-blind randomized clinical trials (864 patients) again found no difference in infection rates (RR 0.66, 0.36 to 1.21; P = 0.18). CONCLUSION: There was moderate-quality evidence that routine use of antibiotics does not reduce the infection rate in simple hand wounds that require surgery.

This meta-analysis used a variant of the wound classification scheme used by the US Centers for Disease Control. The review included ‘class III/contaminated’ wounds that are open, fresh, accidental wounds as a result of simple trauma. Wounds which were infected, contained extensive dead tissue, or contamination (such as sewage) are classed as ‘class IV/dirty’ and were excluded from the review.

Expert commentary

The authors should be congratulated on their timely review of this topic given the current emphasis on antibiotic stewardship. This paper is important because the methodology and conclusions are compelling enough to change clinical practice. When seeing a hand injury it’s traditional, and also rather tempting, to “give antibiotics just in case”. This attitude, perhaps driven by a well-meaning yet misguided wish to do what is best for the individual patient, or even by an unfounded fear of litigation, must be dispelled. Although this work was published in a prestigious journal, it will probably not be read by the majority of those dealing with these injuries (accident department staff, orthopaedic, plastic and hand surgeons). The challenge now is broad dissemination of this article to achieve the goal of reducing antibiotic resistance, avoiding the occasional risk of allergic reaction and saving taxpayers’ money.

Professor David Warwick, Consultant Hand Surgeon, University Hospital Southampton