Objective: Current practice guidelines recommend cefazolin, cefoxitin, cefotetan, or ampicillin-sulbactam as first-line antibiotic prophylaxis in hysterectomy. We undertook this systematic review and meta-analysis of randomized controlled trials (RCTs) to determine whether cefazolin, with limited antianaerobic spectrum, is as effective in preventing surgical site-infection (SSI) as the other first-choice antimicrobials that have more extensive antianaerobic activity.
Methods: We searched PubMed, Scopus, Web of Science, Cochrane Central, and EMBASE for relevant randomized controlled trials (RCT) in any language up to January 23, 2018. We only included trials that measured SSI (our primary outcome) defined as superficial, deep, or organ space. We excluded trials of β-lactams no longer in clinical use.
Results: In terms of SSI incidence, cefazolin use was not inferior to its comparator in 12 of 13 individual RCTs included in the analysis. The meta-analysis summary estimate showed a significantly higher SSI risk with cefazolin versus cefoxitin or cefotetan (risk ratio, 1.7; 95% CI, 1.04-2.77; P = .03). However, most studies included nonstandardized dosing and duration of antimicrobial prophylaxis, had indeterminate or high risk of bias, did not include patients with gynecological malignancies, and/or were older RCTs not reflective of current clinical practices.
Conclusion: Due to inherent limitations associated with old RCTs with limited relevance to contemporary surgery, an RCT of cefazolin versus regimens with significant antianaerobic spectrum is needed to establish the optimal choice for SSI prevention in hysterectomy.