Evidence-based efficacy of antibiotic prophylaxis in patients undergoing elective laparoscopic cholecystectomy

Background: Elective laparoscopic cholecystectomy may result in surgical site infections (SSI), which may increase length of hospital stay and healthcare costs. Antibiotic prophylaxis in the form of a single dose of cephalosporin is still administered before the skin incision in elective laparoscopic cholecystectomy in many clinical settings. There has been a controversy over the use of routine antibiotic prophylaxis in patients undergoing elective laparoscopic cholecystectomy. We apply EBM methods to search systematically analyzed evidence to evaluate the safety and efficacy of routine antibiotic prophylaxis in patients undergoing elective laparoscopic cholecystectomy. Methods: The terms elective laparoscopic cholecystectomy, Antibiotic prophylaxis, surgical site infections and the synonyms were used to formulate a PICO and were engaged as keywords to search Cochrane Library, and PubMed to filter systematic review (SR) in priority. One relevant 2016 SR (and meta-analysis) was included out of 33 searching results in PubMed afterward for critical appraisal. Results: The SR included 21 RCTs (5207 patients). Antibiotic prophylaxis decreased the incidence of surgical site infections [risk ratio (RR) 0.61, 95% confidence interval [CI] 0.45 to 0.82, P = 0.001) and global infections (RR 0.55, 95% CI 0.38 to 0.79, P = 0.001) during hospitalization or after discharge, and postoperative length of hospital stay (weighted mean difference -0.16 (95% CI -0.28 to -0.04, P = 0.008). No adverse events were reported. Subgroup analyses revealed that two doses of antibiotic and 3-10 doses of antibiotic significantly reduced the incidence of surgical site infections compared with placebo or no antibiotics (two doses: RR 0.16, 95% CI 0.06-0.47; 3-10 doses: RR 0.46, 95% CI 0.27-0.80), while a single dose of antibiotic administration did not. Conclusion: Antibiotic prophylaxis is safe and effective in decreasing the incidence of surgical site infections and global infections during hospitalization or after discharge, and postoperative length of hospital stay in low-risk patients undergoing elective laparoscopic cholecystectomy. Two or more doses of antibiotic prophylaxis should be recommended for such patients (Level 1).