REVIEW ARTICLE

Efficacy and Safety Profile of Antibiotic Prophylaxis

Usage in Clean and Clean-Contaminated Plastic
and Reconstructive Surgery
A Meta-Analysis of Randomized Controlled Trials
Yi Zhang, MD, Jiasheng Dong, MD, Yufei Qiao, MD, Jinguang He, MD, Tao Wang, MD,
and Sunxiang Ma, MD
Background: There is no consensus with regard to antibiotic prophylaxis
usage in clean and clean-contaminated plastic and reconstructive surgery. This
meta-analysis sought to assess the efficacy and safety of antibiotic prophylaxis
and to determine appropriate duration of prophylaxis.
Methods: An English language literature search was conducted using PubMed
and the Cochrane Collaboration for randomized controlled trials (RCTs) that
evaluate the use of antibiotic prophylaxis to prevent postoperative surgical site
infection (SSI) in patients undergoing clean and clean-contaminated plastic and
reconstructive surgery. Data from intention-to-treat analyses were used where
available. For the dichotomous data, results for each study were odds ratio (OR)
with 95% confidence interval (CI) and combined for meta-analysis using the
Mantel-Haenszel method or the DerSimonian and Laird method. Study quality
was critically appraised by 2 reviewers using established criteria. STATA version
12 was used for meta-analyses.
Results: Twelve RCTs involving 2395 patients were included, of which 8 trials were considered to be of high methodological quality. Effect of antibiotic
prophylaxis in plastic and reconstructive surgery was found favorable over
placebo in SSI prevention (13 studies; 2449 participants; OR, 0.53; 95% CI,
0.4Y0.7; P G 0.01) and the other wound complication (OWC) prevention
(9 studies; 1843 participants; OR, 0.36; 95% CI, 0.15Y0.84; P G 0.02). Subgroup analysis performed according to surgical wound type or the duration of
prophylaxis did not modify the results except for the OWC with short-term
antibiotic treatment. Compared with short-term antibiotic prophylaxis, longterm administration showed no evidence of a difference in risk of SSI
(7 studies; 1012 participants; OR, 0.99; 95% CI, 0.63Y1.55; P G 0.95), OWC
(5 studies; 824 participants; OR, 0.92; 95% CI, 0.46Y1.86; P G 0.82), and
adverse event relative to antibiotic administration (3 studies; 653 participants;
OR, 0.23; 95% CI, 0.01Y4.92; P G 0.35).
Conclusions: This meta-analysis of RCTs provides evidence supporting that
antibiotic prophylaxis reduced postoperative SSI in clean plastic surgeries
with high-risk factors and clean-contaminated plastic surgeries. Besides, a
short-course administration regimen seemed to be of adequate efficacy and
safety. High-quality prospective trials on larger scale are needed to further
confirm these findings.
Key Words: antibiotic prophylaxis, surgical site infection, plastic surgery,
meta-analysis
(Ann Plast Surg 2014;72: 121Y130)

Received June 2, 2013, and accepted for publication, after revision, August 26, 2013.
From the Shanghai Ninth Peoples Hospital affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China.
Conflicts of interest and sources of funding: none declared
Reprints: Jiasheng Dong, MD, Department of Plastic and Reconstructive Surgery,
Shanghai Ninth Peoples Hospital affiliated to Shanghai Jiao Tong University
School of Medicine, No. 639 Zhizhaoju Rd, Shanghai 200011, China. E-mail:
dongjiasheng_9y@163.com.
Copyright * 2013 by Lippincott Williams & Wilkins
ISSN: 0148-7043/14/7201-0121
DOI: 10.1097/01.SAP.0000440955.93769.8c

Annals of Plastic Surgery

& Volume 72, Number 1, January 2014

ccording to classification of the National Nosocomial Infections

Surveillance System recommended by the American Society of
Health-System Pharmacist, most of elective plastic surgeries can
generally be defined as clean or clean-contaminated.1Y2 Despite
the low risk of incidence, postoperative surgical site infection (SSI)
was still the most frequent complication in plastic and reconstructive
surgeries, which could lead to delayed wound healing, extended
hospital stay, and a considerable financial burden for patients. The
reported incidence of SSI after plastic surgeries varies in literature
from 0% to 32.6%.3Y6
Antibiotic prophylaxis is the administration of antimicrobial
agents before bacterial contamination to prevent undesirable infectious complications by lowering the bacterial burden. In the past few
decades, prophylactic antibiotics have been widely prescribed by
most plastic and reconstructive surgeons with varying administration
route, regimen, and duration, most of which were generally based on
personal preference or institutional tradition for the absence of a
specific guideline supported by scientific evidence, and its efficacy
on the prevention of postoperative complication remains unclear and
controversial.5,7Y9
This meta-analysis was conducted with available published valid
randomized controlled trial (RCT) evidence to address whether a difference in the risk of SSI exists between cases with and without antibiotic prophylaxis, and between short-term and long-term prophylaxis
among patients undergoing clean and clean-contaminated plastic and
reconstructive surgeries. Risk of other surgical wound complication
(including wound bleeding, wound rapture, bleeding hematomas,
wound necrosis, and delayed wound healing) and adverse events relative to antibiotics (including nausea, vomiting, diarrhea, rashes, and
pruritus) were evaluated in the analysis as the second and the third
outcomes.

METHODS
Literature Search
Literature on the effectiveness of prophylactic antibiotics in
patients undergoing clean and clean-contaminated plastic and reconstructive surgery were identified and selected. PubMed and
the Cochrane Central Register of Controlled Trials in The Cochrane
Library were searched for all publications up to January 2013 using
the following medical subject headings terms: (plastic surgery or
reconstructive surgery or reconstruction) AND (antibiotics or
antimicrobial) OR (infection or SSI). Reference lists of relevant studies were searched for other potentially appropriate publications. Literature reviews, single-case reports, letters, comments,
animal studies, and publications in languages other than English were
excluded.

Inclusion Criteria
The eligibility criteria for a study to be included in the analysis
are delineated in Table 1.
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Annals of Plastic Surgery

Zhang et al

Data Extraction
Data extracted from each trial referred to the name of the first
author, year of publication, location of the study, intention-to-treat
population, sex distribution, mean age, wound types, antibiotic regimen (type, dosage, and duration), duration of follow-up, and data regarding the effectiveness and safety of compared treatments. In trials
with more than 1 intervention arm, each comparison of 2 arms was
considered a single study.

Assessment of Methodological Quality

Two independent authors assessed the methodological quality
of each study included in the present meta-analysis using the Jadad
scale by methods of random allocation (up to 2 points), blinding (up to
2 points), and patient withdrawals (up to 1 point).10 Points were added
from each component, and the total can range from weak (0) to strong
(5). High quality was defined as a Jadad score more than 3.11

Statistical Methods
The statistical analysis was performed using STATA version 12
software (Stata Corp, College Station, Tex). The heterogeneity was
tested with the W2-based Cochran statistic and the inconsistency index
(I2).12 Statistically significant heterogeneity was considered present
with Pheterogeneity G 0.05 or I2 9 50%.13 In the presence of substantial
heterogeneity, a random-effects model (REM) was adopted as the
pooling method as opposed to a fixed-effects model (FEM).14 Odds
ratios (ORs) were calculated separately for each main outcome with
either the Mantel-Haenszel test in FEM or the DerSimonian and Laird
test in REM. Statistical significance was indicated by P value of less
than 0.05. Forest plots were produced, from which the OR with 95%
confidence interval (CI) and P value were reported. Funnel plots, Egger
regression test, and Begg rank correlation test were used to assess
publication bias.15,16

Subgroup Analysis and Sensitivity Analysis

Subgroup analysis for antibiotic prophylaxis efficacy was
performed (when at least 2 studies included the considered outcome) according to the surgical wound classification (clean vs
clean-contaminated), and the duration of antibiotic administration
(long-term vs short-term). Sensitivity analyses were performed by excluding any trials of the included studies and the P value of the
rest studies was estimated.

RESULTS
A f lowchart of the selection process is shown in Figure 1.
From the total 1097 articles identified in the initial search, 262 articles
were found to be potentially relevant, out of which full texts of 56 articles were reviewed. Twelve RCTs met the inclusion criteria. Among

TABLE 1. Eligibility Criteria for the Inclusion in the

Meta-analysis
1. RCT
2. Reported at least 1 clinical end point
3. Compared prophylactic antibiotic treatment with treatment of longer or
shorter duration, or placebo treatment
4. Short-term treatment was defined as antibiotics administered intravenously
within 2 d or orally within 3 d
5. Long-term antibiotic treatment was at least 2 d longer than the
corresponding short-term treatment
6. The surgical procedure was limited to clean and clean-contaminated

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& Volume 72, Number 1, January 2014

these trials, four 3-arm RCTs evaluated antibiotic group (long-term

and short-term) versus placebo group, five 2-arm RCTs evaluated
short-term antibiotic group versus placebo group, and three 2-arm
RCTs compared the effect between long-term prophylaxis and
short-term prophylaxis. No publication bias was observed for the
outcomes using funnel plots (Supplemental Digital Content 1Y2,
http://links.lww.com/SPA/A83).

Characteristics and Quality Assessment of RCTs

The included RCTs were published between 1994 and 2012,
and comprised a total of 3495 patients in the pooled data, of whom
1882 received antibiotic prophylaxis (1389 long-term; 493 shortterm). Among them, 1100 patients from the study of Baran et al17
were not included in the analysis because they had undergone a
contaminated surgical procedure rather than a clean or cleancontaminated operation, or the surgical wound type was unknown.
The methodological features and outcomes measured in the included
studies were presented in Tables 2 and 3; 8 of 12 of the RCTs were
considered to be of high methodological quality according to the
Jadad score (Table 4).

Antibiotic Versus Placebo

Surgical Site Infection
The incidence of postoperative SSI was reported as the primary outcome in all selected trials. The heterogeneity analysis did
not reach statistical significance neither for the overall analysis nor
for the subgroup analysis, so a FEM was used. Pooled analysis of the
9 included RCTs showed a 47% decrease in the risk of developing
SSI after prophylactic administration of antibiotics compared with
placebo groups (13 studies; 2449 participants; OR, 0.53; 95% CI,
0.4Y0.7; P G 0.01) (Fig. 2). Favorable effect was still observed in both
short-term and long-term antibiotic subgroup analysis (short-term,
9 studies; 1724 participants; OR, 0.50; 95% CI, 0.35Y0.7; P G 0.01;
long-term, 4 studies; 587 participants; OR, 0.59; 95%CI, 0.37Y0.94;
P G 0.03) (Fig. 2), and both clean and clean-contaminated operations
(clean operations, 4 studies; 404 participants; OR, 0.35; 95% CI,
0.21Y0.61; P G 0.01; clean-contaminated operations, 5 studies; 1282
participants; OR, 0.63; 95% CI, 0.42Y0.94; P G 0.02) (Fig. 3). In the
sensitivity analysis, exclusion of any comparison did not change the
overall efficacy of antibiotic prophylaxis and the efficacy of shortterm antibiotic prophylaxis. However, the effect with long-term
antibiotic regimen failed to reach statistical significance with the
exclusion of studies by Lilja et al.18

Other Wound Complication

Rates of surgical wound complication other than SSI or
wound infection, documented as wound bleeding, wound rapture,
bleeding hematomas, wound necrosis, and delayed wound healing,
were determined and combined. The heterogeneity analysis reached
statistical significance for both the overall analysis and the subgroup
analysis, so a REM was used. Analysis of the data from 6 included
RCTs showed a 64% decrease in the risk of developing other wound
complication (OWC) with antibiotic prophylaxis compared with
placebo groups (9 studies; 1843 participants; OR, 0.36; 95% CI,
0.15Y0.84; P G 0.01) (Fig. 4). Subgroup analysis revealed significant
decrease in patients with long-term prophylaxis (3 studies; 587 participants; OR, 0.22; 95% CI, 0.05Y0.91; P G 0.04), but no significant
effect with short-term prophylaxis (6 studies; 1256 participants; OR,
0.44; 95% CI, 0.15Y1.28; P G 0.13) (Fig. 4). In the sensitivity analysis, the effect of overall antibiotic prophylaxis presented marginal
statistical significance (P G 0.06) with the exclusion of study by
Ahmadi et al.19 And the effect with long-term antibiotic regimen
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Annals of Plastic Surgery

& Volume 72, Number 1, January 2014

Meta-analysis of Antibiotic Prophylaxis for PRS

failed to reach statistical significance with the exclusion of studies by

Ahmadi et al19 and Whittaker et al.20

0.46Y1.86; P G 0.82) (Fig. 5). Exclusion of any of the comparisons

did not change the result.

Long-term versus Short-term

Adverse Event
Adverse events potentially associated with the antibiotic administration were assessed by 3 RCTs, but events took place only in 2
studies. Heterogeneity existed among included studies and analysis
with REM was performed. The estimation did not significantly favor
either of the 2 intervention arms (3 studies; 653 participants; OR,
0.23; 95% CI, 0.01Y4.92; P G 0.35) (Fig. 5). The sensitivity analysis
excluding the study by Ricci and DAscanio21 showed statistically
significant decrease with the patients with short-term regimen.

Surgical Site Infection

The incidence rate of SSI was reported by 7 studies. The
heterogeneity analysis did not reach statistical significance, and
analysis with FEM was performed. Pooled analysis of the 7 included
RCTs did not favor either of the 2 treatment groups in SSI (7 studies;
1012 participants; OR, 0.99; 95% CI, 0.63Y1.55; P G 0.95) (Fig. 5).
Exclusion of any of the comparisons did not change the result.
Other Wound Complication
The incidence rate of OWC was reported in 5 studies. The
heterogeneity analysis did not reach statistical significance, and
analysis with FEM was performed. No advantage of either treatment
group was shown (5 studies; 824 participants; OR, 0.92; 95% CI,

DISCUSSION
Patients undergo plastic and reconstructive surgeries for both
therapeutic and cosmetic reasons. Although the risk of postoperative

FIGURE 1. Flowchart of the selection process.

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123

124

Country

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Italy

UK

Ricci 2012

Whittaker 2005

NA
46/28
417/213

22
39
100

NA
61.6
33

36.6
41
69

NA

NA

NA

NA

37

32

Mean
Age, y

Cle-Con
Cle-Con
Cle-Con

Cle and Cle-Con

Cle-Con
Cle-Con

Cle and Cle-Con

Clean

Cle-Con

Cle-Con

Clean

Clean

Wound
Type

Cefotaxime sodium for 24 h

IV clindamycin, 900 mg q 8 h, 3 doses
IV amoxicillin-clavulanate, 2.2 g once

Cephalosporin
(allergy: vancomycin)
for 24Y48 h
PO azithromycin, 1 g
(adults/children over 45 kg)/800 mg
(children 36Y45 kg)/600 mg
(children 26Y35 kg)/400 mg
(children 15Y25 kg) once
IV sulbactam-ampicillin, 2 g once
IV cefuroxime, 1.5 g once
PO azithromycin, 500 mg qd, 3 d

IV flucloxacillin,
1.0 g once

IV cephalosporin,
1 g once preoperatively
(IV levofloxacin, 500 mg
once for cephalosporin allergy)
IV cefazolin, 1.0 g once

IV cefazolin,
1 g once preoperatively
(IV levofloxacin,
500 mg once for
cephalosporin allergy)

ShortYTerm Antibiotics
(Type, Dosage, Duration)

Cefotaxime sodium for 5 d

IV clindamycin, 900 mg q 8 h, 15 doses
IV amoxicillin-clavulanate, 2.2 g once followed
by oral amoxicillin-clavulanate, 1 g bid, 7 d

None
None
None

None

None

IV cefazolin, 1 g once preoperatively

followed by postoperative IV cefazolin,
1 g q 8 h, 2 doses; and then oral cephalexin,
500 mg qd, 3 d (IV levofloxacin, 500 mg
once preoperatively followed by
postoperative oral levofloxacin,
500 mg qd, 3 d, for cephalosporin allergy)
IV cephalosporin, 1 g once preoperatively
(IV levofloxacin, 500 mg once for
cephalosporin allergy) followed by
postoperative levofloxacin, 500 mg qd, 3 d
IV cefazolin, 1.0 g once followed
by oral amoxicillin, 1 g q 12 h, 7 d
IV flucloxacillin, 1.0 g once followed
by oral flucloxacillin, 1 g qd, 7 d

LongYTerm Antibiotics
(Type, Dosage, Duration)

NA
1 wk
4 wk

11Y12 d
4 wk
2 wk

4 wk

NA

4 wk

2 wk

6 wk

NA

Duration of
Follow-Up

Annals of Plastic Surgery

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Cle-Con indicates clean-contaminated; F, female; ITT, intention-to-treat; L, long-term; M, male; NA, data not available; P: placebo; S: short-term.

NA
148/40
18/12

168/171

168/171

129/28

417/213

129/28

None
None
None

None

46

181

69

Baran 1999
Turkey
150 150
Lilja 2011
Finland
100 100
Kuijpers 2006
Netherlands
14
16
Short-term antibiotics vs long-term antibiotics
Bhathena 1998
India
None
28
Carroll 2003
United States None
35
Rajan 2005
Australia
None 100

168

47

56

197

69

None

Norway

59

55

252

69

NA

Sex
(M/F)

171

Amland 1995

Placebo vs short-term antibiotics

Serletti 1994
United States

Turkey

Asuman 2007

Placebo vs short-term antibiotics vs long-term antibiotics

Ahmadi 2005
United States
17
17
16

First Author
and Year

ITT Population

TABLE 2. Details of the RCTs Included in the Meta-Analysis

Zhang et al

& Volume 72, Number 1, January 2014

* 2013 Lippincott Williams & Wilkins

Outcomes

P
S

SSIs

* 2013 Lippincott Williams & Wilkins

14/17
NA

6/69

4/36

NA

4/34

OWCs

Wound infection; death; flap

necrosis; other infection;
fistula; adverse effect
Wound infection; adverse effect
None

None

0/100

4/35

2/28

L indicates long-term; NA, data not available; P, placebo; S: short-term.

Rajan 2005

Carroll 2003

None

3/100

4/39

2/22

None

None

None

NA

NA

NA

NA
NA
NA
NA

NA

None
None
None
None

None

NA

NA

None

None

None

NA

3/46

NA

NA

NA

NA

1/181

NA

9/36

Conclusion

0/39

NA

None

None
None

None

None

There is no beneficial effect rom administration of antibiotics for more

than 24 h postoperatively in patients undergoing major flap
reconstruction for head and neck cancel.
Short-course clindamycin is as effective as long-course in SSI
prevention in free flap reconstruction of head and neck.

The use of prophylactic antibiotics in reduction mamoplastic is not

efficacious in reducing the rate of wound infection or delayed healing.
There is a significant reduction in postoperative complication and in
additional use of antibiotics postoperatively in prophylaxis group.
Antibiotic prophylaxis is not necessary for plastic surgeries.
A single dose of intravenous cefuroxime before septoplasty is
recommended in patients having crusts or purulent secretion in the
nasal cavities or if the operation is expected to be prolonged.
Systemic antibiotics with an accurate bacterial spectrum should be
advised in full-thickness skin graft reconstruction after surgery for
nonmelanoma skin cancer of the nose.

2/100 29/100 A single dose of antibiotics administered preoperatively is sufficient

for prophylaxis of postoperative infections in septorhinoplasty.

0/35

NA

NA

NA
0/100

4/168

NA

NA

No favorable effect of antibiotic prophylaxis was found in SSI

prevention in reduction mammaplasty.
NA
NA A single preoperative dose of intravenous antibiotics is sufficient
to prevent postoperative infections in abdominoplasty.
23/197 22/181 Septal surgery with early removal of nasal packing does not require
routine antibiotic prophylaxis because of the low infection risk.
NA
NA No significant difference exists among the 3 groups with clean incised
hand injures.

NA

Adverse Events

& Volume 72, Number 1, January 2014

Short-term antibiotics vs long-term antibiotics

Bhathena 1998 Wound infection

Wound infection; wound

35/252 23/197 19/181 1/252 0/197
bleeding; adverse effect
Whittaker 2005 All wound problems;
8/55
7/56
2/46 11/55
8/56
wound infection
Placebo group vs short-term antibiotics
Serletti 1994
Wound infection; delayed
4/59
4/47
None 19/59 12/47
wound healing
Amland 1995
Wound infection; hematomas;
32/168 8/171 None
8/168 3/171
wound rupture; adverse effect
Baran 1999
Wound infection
3/150 2/150 None
NA
NA
Lilja 2011
Wound infection; wound
8/100 2/100 None
1/100 4/100
bleeding; wound hematomas;
allergic reaction
Kuijpers 2006 Wound infection;
0/14
0/16
None
NA
NA
graft survive rate

Ricci 2012

Placebo group vs short-term antibiotics vs long-term antibiotics

Ahmadi 2005
Wound infection; delayed
5/17
3/34
wound healing
Asuman 2007 Wound infection
9/69
3/69

First Author
and Year

TABLE 3. Outcomes and Conclusion of the RCTs Included in the Meta-analysis

Annals of Plastic Surgery

Meta-analysis of Antibiotic Prophylaxis for PRS

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TABLE 4. Jadad Score of the Included RCTs

First Author
and Year
Ahmadi 2005
Amland 1995
Asuman 2007
Baran 1999
Bhathena 1998
Carroll 2003
Ricci 2012
Lilja 2011
Kuijpers 2006
Rajan 2005
Serletti 1994
Whittaker 2005

Randomization

Randomization
Described

Double
Blind

Method of Blinding
Described

Description of
Withdrawal + Dropouts

JADAD
Score

1
1
1
1
1
1
1
1
1
1
1
1

1
1
1
0
0
1
1
1
0
1
0
1

0
1
0
0
0
1
1
1
0
1
0
1

0
1
0
0
0
1
0
1
0
0
0
1

1
1
1
1
0
0
0
1
0
1
1
1

3
5
3
2
1
4
3
5
1
4
2
5

FIGURE 2. Pooled OR for the overall SSI incidence with prophylactic antibiotics (long-term and short-term) compared to placebo.
The diamond denotes the fixed-effects pooled OR and 95% CI. The dashed line is drawn at the overall pooled estimate.
*Comparison of short-term arm and placebo in trials with more than 1 intervention arm; **comparison of long-term arm and
placebo in trials with more than 1 intervention arm.
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Annals of Plastic Surgery

& Volume 72, Number 1, January 2014

Meta-analysis of Antibiotic Prophylaxis for PRS

FIGURE 3. Pooled OR for SSI incidence after clean and clean-contaminated plastic and reconstructive surgeries with prophylactic
antibiotics compared to placebo. Size of the solid squares is inversely proportional to the variance of the study estimate. The
diamond denotes the fixed-effects pooled OR and 95% CI. Cle-Con indicates clean-contaminated.

infection is low, SSI will severely compromise therapeutic results,

facilitating OWCs, leading to significant discomfort and inconvenience for patients.22,23 On the other hand, inappropriate administration of prophylactic antibiotics will also cause iatrogenic
complications such as allergic reaction, thrombophlebitis, and the
risk of selecting resistant strains among hospital f lora.2 Therefore,
a better understanding of antibiotic prophylaxis will by all means
help plastic surgeons and benefit both aesthetic and functional
outcomes for patients.
In this meta-analysis, which identified as eligible for inclusion
only RCT performed in patients undergoing plastic surgeries, significant reduction of postoperative SSI as well as OWC rates were
shown with the prophylactic antibiotic treatment. In the subgroup
analysis, the most results still preferred the treatment group when
analyzed according to the duration of antibiotic administration (longterm vs short-term) and the surgical wound classification (clean vs
clean-contaminated).
The SSI incidence rate of plastic surgery varies according to
the operation performed and the presence of specific risk factors.3
Generally, clean-contaminated surgery is considered with higher risk
of infection and less debate on prophylactic antibiotic usage.18,24 In
the field of clean plastic surgery, antibiotic prophylaxis remains a
* 2013 Lippincott Williams & Wilkins

controversial subject and was not routinely recommended.9,25Y27 In

the present study, the total SSI rate of the clean plastic operations was
11.6%, much higher than was generally anticipated for clean surgery.2 The increased infection rate might be associated with the
spectrum of operations involved, most (85%) of which in our study
were characterized with large surgical incision and long procedure
duration such as breast reduction and abdominoplasty. Prolonged
procedure length (92 h), complicated anatomy of involved area, and
the surgical technique adopted had been identified as independent
risk factors magnifying SSI risk of clean operation, and should be
taken into consideration when antibiotic is administrated.3,28,29 Unfortunately, there were insufficient data available for these variables
to achieve a summated outcome in this analysis. Further high-quality
work of large scale with sufficient relative details documented is
expected.
Another subject of controversy is the optimal duration of antibiotic administration. Consistent with previous studies,30Y32
noninferiority of short-term prophylaxis was demonstrated compared
with long-term prophylaxis on postoperative SSI and OWCs in our
analysis. Ideally, short-term antibiotic prophylaxes are preferred to
longer-course regimen in reduction of hospitalization costs, drug
toxicity, and the emergence of resistant pathogens, especially in clean
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& Volume 72, Number 1, January 2014

FIGURE 4. Pooled OR for the overall incidence of wound complications except for SSI with prophylactic antibiotics (long-term
and short-term) compared to placebo. The diamond denotes the random-effects pooled OR and 95% CI. The dashed line is
drawn at the overall pooled estimate. *Comparison of short-term arm and placebo in trials with more than 1 intervention arm;
**comparison of long-term arm and placebo in trials with more than 1 intervention arm.

surgeries. Evidence of antibacterial activity with short-term regimen

had been reported by trials on clean operations of hernia, breast, and
varicose vein.33Y35 Gil-Ascencio et al36 advocated that a single-dose
intravenous first-generation cephalosporin was of adequate efficacy
to prevent SSI in clean-contaminated outpatient operations of short
duration. For inpatient surgeries, Thomas et al37 advocated that antibiotic prophylaxis could be achieved with long-acting antimicrobial
agents (like third-generation cephalosporins) even in a short-course
regimen. In terms of adverse events relative to antibiotics, no difference was found between long-term and short-term antibiotic regimens, which, however, should be interpreted with caution as they
might be due to the smaller number of studies (only 2) and lack of
power rather than a real lack of difference.
In conclusion, the results of this meta-analysis implied that antibiotic prophylaxis reduced postoperative SSI in clean plastic surgeries
with potential risk factors (prolonged procedure length, complicated
anatomy of involved area, and specific surgical technique adopted) and
clean-contaminated plastic surgeries. In addition, between long-term
and short-term prophylaxis, the analysis of the available data does not
show superiority of either regimen in prevention of SSI, OWC, or
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adverse events. Considering the hospitalization costs and adverse effects arising with antibiotic treatments, we recommend that a short-term
antibiotic regimen be of adequate efficacy and safety for clean plastic
surgeries and most clean-contaminated surgeries. The findings of this
study should not be interpreted without the consideration of potential
limitations. As previously documented, factors like patient-related risk,
operation type, surgical technique, surgical wound classification, antibiotic type, timing, and duration of antibiotic administration may
function as source of heterogeneity.38Y42 In this study, we only separately analyzed influence of surgical wound classification and duration
of antibiotics. Due to limitation of the number of studies and lack of
original data, we were not able to carry out subgroup analysis according
to the rest factors, and so the chance of possible performance bias might
be higher.43 Besides, although criteria for diagnosis of outcome events
were documented in most of the included RCTs, the definitions were
not standardized among studies because of the difference in operation
type and methodological quality, which might affect interpretation of the benefit of intervention. To overcome these limitations, we
recommend more high-quality RCTs of large scale to produce
conclusive results.
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Annals of Plastic Surgery

& Volume 72, Number 1, January 2014

Meta-analysis of Antibiotic Prophylaxis for PRS

FIGURE 5. Pooled OR for incidence of SSI, OWC, and AE relative to antibiotics with short-term prophylactic antibiotics
compared to long-term prophylactic antibiotics for plastic and reconstructive surgeries. The diamond denotes the fixed-effects
(SSI and OWC) or random-effects (AE) pooled OR and 95% CI. The dashed lines are drawn at the overall pooled estimate.
***Comparison of short-term and long-term arms in trials with more than 1 intervention arm; AE indicates adverse event.
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129

Annals of Plastic Surgery

Zhang et al

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