Comparison Between Continued Post-Operative Prophylactic Antibiotics and Single Preoperative Dosing in Elective Hernia Open Mesh Repair Patients

Hafiz Yahya  Iftikhar; Farhan  Zaheer; Syeda  Mahjabeen; Amber  Ali; Tayram  Khalid

doi:10.54112/bcsrj.v6i5.2012

Authors

Hafiz Yahya Iftikhar Surgical Unit 5, Dr Ruth K M Pfau CHK, Karachi, Pakistan
Farhan Zaheer Department Surgical 5, Institute Dow University of Health Sciences, Karachi, Pakistan
Syeda Mahjabeen Surgical Unit 5, Dr Ruth K M Pfau CHK, Karachi, Pakistan
Amber Ali Surgical Unit 5, Dr Ruth K M Pfau CHK, Karachi, Pakistan
Tayram Khalid Surgical Unit 5, Dr Ruth K M Pfau CHK, Karachi, Pakistan

DOI:

https://doi.org/10.54112/bcsrj.v6i5.2012

Keywords:

Hernia repair, Mesh, Surgical site infection, Antibiotic prophylaxis, Pakistan, Antimicrobial stewardship

Abstract

Surgical site infection (SSI) remains a key concern in elective mesh hernia repair, particularly in low- and middle-income countries where infection control practices may be inconsistent. International guidelines recommend a single preoperative prophylactic antibiotic dose; however, extended postoperative regimens remain common in Pakistan due to perceived higher risk. Objective: To compare wound outcomes between single-dose preoperative prophylaxis and continued postoperative antibiotic use in elective open mesh hernia repair. Methods: A randomized comparative study was conducted at Civil Hospital, Karachi, from March 2024 to August 2024. One hundred adult patients undergoing elective open Lichtenstein mesh repair were randomized: Group A received a single preoperative dose of IV Augmentin (1.2 g). In contrast, Group B received the same preoperative dose plus three days of postoperative antibiotics. Wound healing was assessed up to Day 30 using the Southampton Wound Scoring System (SWSS). Primary outcomes included SSI rates and wound healing status. Multivariable logistic regression adjusted for diabetes, BMI, smoking, and operative duration. Results: Of 100 patients (mean age 25–60 years, 82% male), comorbidities were balanced between groups. Mean SWSS scores were comparable at all time points, with Day-30 means of 2.96 ± 1.3 (single-dose) vs 3.07 ± 1.2 (continued antibiotics; p = 0.801). By Day 30, 89% of single-dose patients and 87% of continued-prophylaxis patients achieved complete healing (p = 0.42). Local wound signs occurred in 14% vs 16%, systemic signs in <5% overall, and no patient required mesh removal. Logistic regression confirmed no significant effect of regimen on non-healing (aOR 0.92, 95% CI 0.38–2.21, p = 0.85). Diabetes was the only independent predictor of impaired healing (aOR 2.14, 95% CI 1.01–4.55, p = 0.047). Conclusion: In this tertiary government hospital setting, a single preoperative prophylactic dose was as effective as extended postoperative antibiotic use in preventing SSI after elective open mesh hernia repair. These findings support guideline-concordant single-dose prophylaxis as a safe, cost-effective, and stewardship-aligned approach, provided surgical asepsis and patient risk-factor optimization are maintained.

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References

Kingsnorth A, LeBlanc K. Hernias: inguinal and incisional. Lancet. 2003 Nov 8;362(9395):1561–71. https://doi.org/10.1016/S0140-6736(03)14746-0

Lichtenstein IL, Shulman AG, Amid PK, Montllor MM. The tension-free hernioplasty. Am J Surg. 1989 Feb;157(2):188–93. https://doi.org/10.1016/0002-9610(89)90526-6

Engelsman AF, van Dam GM, van der Mei HC, Busscher HJ, Ploeg RJ. Infection of prosthetic mesh: biofilm formation and prevention. Biofouling. 2010;26(4):355–63. https://doi.org/10.1080/08927014.2010.484972

Bay-Nielsen M, Kehlet H, Strand L, Malmstrøm J, Andersen FH, Wara P, et al. Quality assessment of 26,304 herniorrhaphies in Denmark. Lancet. 2001 Sep 29;358(9288):1124–8. https://doi.org/10.1016/S0140-6736(01)06356-6

Kingsnorth A. Hernia surgery: from guidelines to clinical practice. Ann R Coll Surg Engl. 2009;91(3):273–9. https://doi.org/10.1308/003588409X428540

Aufenacker TJ, van Geldere D, van Mesdag T, Bossers AN, Dekker B, Scheijde E, et al. The role of antibiotic prophylaxis in prevention of wound infection after Lichtenstein open mesh repair of primary inguinal hernia: a multicenter double-blind randomized controlled trial. Ann Surg. 2004 Dec;240(6):955–60. https://doi.org/10.1097/01.sla.0000148411.36712.0d

Shankar VG, Srinivasan K, Sistla SC, Jagdish S. Prophylactic antibiotics in open mesh repair of inguinal hernia: randomized controlled trial. Int J Surg. 2010;8(6):444–7. https://doi.org/10.1016/j.ijsu.2010.06.017

Mazaki T, Mado K, Masuda H, Shiono M, Tochikura N, Kaburagi M. A randomized trial of antibiotic prophylaxis for prevention of surgical site infection after open mesh-plug hernia repair. Am J Surg. 2014 Apr;207(4):476–84. https://doi.org/10.1016/j.amjsurg.2013.01.047

Mazaki T, Nishizawa T, et al. Antibiotic prophylaxis for mesh hernia repair: systematic review. Surg Infect (Larchmt). 2013;14(2):128–33. https://doi.org/10.1089/sur.2012.145

Sanabria A, Domínguez LC, Valdivieso E, Gómez G. Prophylactic antibiotics for mesh inguinal hernioplasty. Ann Surg. 2007 Sep;245(3):392–6. https://doi.org/10.1097/01.sla.0000255642.12374.1b

Al-Riyees L, Lee S, Keshavarz P, et al. Antibiotic prophylaxis against surgical site infection after open hernia surgery: systematic review and meta-analysis. Eur Surg Res. 2021;62(3):121–33. https://doi.org/10.1159/000517404

World Health Organization. Global guidelines for the prevention of surgical site infection. Geneva: WHO; 2016. (WHO publication)

Berríos-Torres SI, Umscheid CA, Bratzler DW, Leas B, Stone EC, Kelz RR, et al. Centers for Disease Control and Prevention guideline for the prevention of surgical site infection, 2017. JAMA Surg. 2017 Aug 1;152(8):784–91. https://doi.org/10.1001/jamasurg.2017.0904

Ullah B, Bakhtiar B, Khan SA, Ahmed S, Pasha T. Efficacy of preoperative single-dose antibiotic versus placebo in inguinal hernia mesh repair. J Ayub Med Coll Abbottabad. 2013;25(1-2):103–5.

Akhtar K, Khan Z, Bhatti AM, Mahmood K. Impact of using prophylactic antibiotics on the prevention of wound infection in inguinal herniorrhaphy. Pak Armed Forces Med J. 2015;65(4):453–7.

Masood A, Arshad AR, Ashraf M. Comparison between the outcome of a single dose of prophylactic antibiotic versus postoperative antibiotic in inguinal hernia surgery. Pak J Med Sci. 2022 May-Jun;38(5):1210–15. https://doi.org/10.12669/pjms.38.5.5332

Laxminarayan R, Matsoso P, Pant S, Brower C, Røttingen JA, Klugman K, et al. Access to effective antimicrobials: a worldwide challenge. Lancet. 2016 Jan 9;387 (10014):168–75. https://doi.org/10.1016/S0140-6736(15)00474-2

Khan S, Mehmood A, Khan A, Asad H. Role of Intravenous Cefuroxime Antibiotic Prophylaxis in the Prevention of Surgical Site Infection in Open Mesh Inguinal Hernia Repair. Pak Armed Forces Med J. 2023;73(6):1835–37. https://doi.org/10.51253/pafmj.v73i6.11424

Erdas E, Medas F, Pisano G, Nicolosi A, Calò PG. Antibiotic prophylaxis for open mesh repair of groin hernia: systematic review and meta-analysis. Hernia. 2016 Dec;20(6):765–76. https://doi.org/10.1007/s10029-016-1536-0

Korol E, Johnston K, Waser N, Sifakis F, Jafri HS, Lo M, et al. A systematic review of risk factors associated with surgical site infections among surgical patients. PLoS One. 2013;8(12):e83743. https://doi.org/10.1371/journal.pone.0083743

Boonchan T, Cooper NJ, Lees TA, et al. Network meta-analysis of antibiotic prophylaxis for prevention of surgical site infection after groin hernia repair. Br J Surg. 2017;104(2):e106–e114. https://doi.org/10.1002/bjs.10428

Tian XJ, Wang XM, Lei YH, et al. The role of prophylactic antibiotics in elective inguinal tension-free hernia repair: a systematic review and meta-analysis. Int Wound J. 2023;20(4):1191–1204. https://doi.org/10.1111/iwj.13978

Sánchez-Manuel FJ, Lozano-García J, Seco-Gil JL. Antibiotic prophylaxis for hernia repair. Cochrane Database Syst Rev. 2012;2:CD003769. https://doi.org/10.1002/14651858.CD003769.pub4

Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013 Feb 1;70(3):195–283. https://doi.org/10.2146/ajhp120568

Celdrán A, Frieyro O, de la Pinta JC, Souto JL, Esteban J, Rubio JM, et al. The role of antibiotic prophylaxis on wound infection after mesh hernia repair under local anaesthesia on an ambulatory basis. Hernia. 2004 Feb;8(1):20–2. https://doi.org/10.1007/s10029-003-0164-7

Perez AR, Roxas MF, Hilvano SS. A randomized, double-masked, placebo-controlled trial to determine the effectiveness of antibiotic prophylaxis for tension-free mesh herniorrhaphy. J Am Coll Surg. 2005 Mar;200(3):393–7. https://doi.org/10.1016/j.jamcollsurg.2004.11.019

Yerdel MA, Genc A, Cok G, et al. Does a single preoperative dose of antibiotic prevent wound infection after mesh repair of inguinal hernia? Ann Surg. 2001 Jan;233(1):26–33. https://doi.org/10.1097/00000658-200101000-00005

Jain SK, Hameed T, Jain D, Singh M, Nizam A. The role of antibiotic prophylaxis in Lichtenstein repair of primary inguinal hernia: a prospective double-masked randomized placebo-controlled trial. Niger J Surg. 2021 Jan-Jun;27(1):5–8. https://doi.org/10.4103/njs.NJS_52_19

Kulacoglu H. Hernia, mesh and topical antibiotics, especially gentamicin—review and evolving practice. Front Surg. 2015 Apr 10;2:53. https://doi.org/10.3389/fsurg.2015.00053

Laxminarayan R, Chaudhury RR. Antibiotic resistance in South Asia: drivers and opportunities for action. Lancet Glob Health. 2016 Jun;4(6):e353–4. https://doi.org/10.1016/S2214-109X(16)30087-8