Running head: AN INTEGRATIVE REVIEW: PROPHYLACTIC ANTIBIOTIC USE

An Integrative Review: Prophylactic antibiotic use and surgical site infections

NUR4222 Nursing Research for RNs
Michael Phelps
May 3, 2015
I Pledge

AN INTEGRATIVE REVIEW: PROPHYLACTIC ANTIBIOTIC USE

Abstract
The evaluation of literature in regards to the administration of prophylactic antibiotics
with regards to the every patient or those at risk for developing a surgical site infection is the
goal of this integrative review. Surgical site infections are described as an infection that occurs
at or near a surgical incision within 30 days for a surgical procedure and within one year of an
implanted item. Prophylactic antibiotics have been used for more than 15 years for select
surgical procedures. And, with CDC and CMS development of the Surgical Care Improvement
Project, prophylactic antibiotic has prevalent presence for surgical procedures. Within this
integrative review, literature has been located with the aid of computer based search engines
like PubMed and EBSCO database. During my search 9 studies met the criteria for the topic but
only 5 were useful for this integrative review. Two limitations existed within this integrative
review: some articles were not available in full text or English, which decrease the number of
useful studies. And, statistical analysis test in the useful studies were not explained for readers.
The studies did not answer the question of usefulness of prophylactic antibiotics for minor
procedures; it did answer the PICOT question of administration to every patient or those with
surgical site infection risk factors. Further research should focus on the risk factors for surgical
site infections and use of prophylactic antibiotics.

AN INTEGRATIVE REVIEW: PROPHYLACTIC ANTIBIOTIC USE

An Integrative Review: Prophylactic antibiotic use and surgical site infections

This integrative review has one general purpose to search for and relate studies involving
prophylactic antibiotic use with minor surgical procedures. Surgical site infections are described
as an infection that occurs at or near a surgical incision within 30 days for a surgical procedure
and within one year of an implanted item (Heal, Buettner, & Drobetz, 2012). With surgical site
infections accounting for the third most common healthcare related infection resulting in
morbidity and deaths (Gharde, et al., 2014). Current prophylactic antibiotic guidelines
recommend prophylaxis for Cardiothoracic, Gastrointestinal, Orthopedic, Vascular, and GYN
procedures. Dermatological, General procedure not involving the gastrointestinal tract, and
urological procedures do not have a recommendation for prophylaxis. The PICOT question
proposed is as follows: Should prophylactic antibiotics be administered to every patient,
regardless, or just to those patients at risk for developing a surgical site infection?
Search Methods/ Designs
This integrative review is a complex collection of five studies involved in determining
the answer to one question without any assumptions for its research design. Research articles
were located with the use of two computer-based search engines PubMed and EBSCO. Related
terms included, antibiotics, prophylactic, prophylaxis, risk factors, and minor
procedures. The search resulted in 9 articles that met the criteria for the topic; however, only
five articles useful for the integrative review. While four of the articles were written within the
last six years, one article was written in 1998. This one article was deemed useful for its
research related to facial lacerations related to dog bites and contamination of the wound from
the dogs saliva. All related articles needed to be available in English. All related articles had to
relate to the PICOT question: should prophylactic antibiotics be administered to every patient,

AN INTEGRATIVE REVIEW: PROPHYLACTIC ANTIBIOTIC USE

regardless, or just to those patients at risk for developing a surgical site infection? Also, two out
of five of the articles had to have a qualitative in design and in relation to antibiotics, surgical site
infection risk factors, and the development of a surgical site infection. The other three articles are
quantitative in design and in relation to antibiotics, surgical site infection risk factors, and the
development of a surgical site infection. Articles not meeting the required criteria were exempt
from the integrative review.
Finding/Results
All five studies produced the same answer to the PICOT question regarding prophylactic
antibiotic administration for every patient or those with surgical site infection risk factors. All
five determined that prophylactic antibiotic usage has no significant role in reducing the
occurrence of surgical site infections. Also, the occurrence of a surgical site infection is
dependent on location, size of incision, comorbities of the patient, and the patients own microorganisms (Gharde, et al., 2014) (Heal, Buettner, & Drobetz, 2012) (Javaid, Feidberg, & Gipson,
1998) (Yuste, Romo, & Unamuno, 2015) (Zhou, Zhang, Wang, & Hu, 2009). The review has
been subdivided into three categories: Data collection, samples and subjects, and data analysis.
Data Collection
Even though all five studies produced a uniform outcome to prophylactic antibiotic
administration, they all had different methods to collecting data. Informed consent is only
mentioned in one of the five studies. The study conducted by Gharde and associates utilized data
collected from two groups (open cholecystectomies and laparoscopic cholecystectomies). The
study employed a comparative approach with regards to the two groups. All participants
received prophylactic antibiotics before surgery. Out of the two groups, the researchers

AN INTEGRATIVE REVIEW: PROPHYLACTIC ANTIBIOTIC USE

interviewed the participants on day seven post-surgery or whenever the participant exhibited
signs of infection (discharge, pain, and/or fever) (Gharde, et al., 2014).
The study conducted by Heal, Buettner, and Drobetz used a comparative approach after
interviewing patients from sixteen general practitioners in North Queensland, Australia. With
information like demographics, clinical data, and a body site map, the researchers formulate the
possible risk factors for infection related to patients. Even though the study does not mention an
informed consent, the researchers asked any patient presenting with a minor skin excision to
participate within the trail (Heal, Buettner, & Drobetz, 2012).
The study from Javaid, Feidberg, and Gipson is the only study that uses case notes from
April 1994 to April 1997. With the use of the case notes, the patients outcome and
complications related to the repair or reconstruction of the face (Javaid, Feidberg, & Gipson,
1998). Out of the all the studies, this study appeared to have the simplest data collection.
Even though the study conducted by Yuste, Romo, and Unamun does not contain a
specific plan for data collection. The researchers use already proven approaches to determining
the best effective route and antibiotic to use for postsurgical site infection prevention (Yuste,
Romo, & Unamuno, 2015). The data collected is provided from antibiotic literature that has
been already published from antibiotic manufactures. Since the data collection does not utilize
or quantify with a specific number, this study utilizes a ground theory for its qualitative view.
The same qualitative view applies towards the study conducted by Zhou, Zhang, and
Wang. The researchers utilize previous studies and recorded data pertaining to the previous
studies (Zhou, Zhang, Wang, & Hu, 2009). As a result, the use of the previous studies for data
collection supplies the researchers with a collaborative approach to defining the results for this
study.

AN INTEGRATIVE REVIEW: PROPHYLACTIC ANTIBIOTIC USE

Samples and Subjects

The Gharde, Heal, and Javaid studies are the only quantitative studies that utilize subjects
and a sampling method for the analysis of information. However, the Javaid study is the only
study that simplifies the answer with tables and grafts. The Heal study does not separate subjects
into different sexes, unlike the other two quantitative studies. Samples within these three studies
were convenient; subjects were either eligible or not eligible. The information on subjects for
the Javaid study were convenient and probable, subjects having already gone through surgery,
and case notes were the only information used for the study (Javaid, Feidberg, & Gipson, 1998).
The Gharde and Heal studies utilized information after a subject was located and a procedure had
been completed (Gharde, et al., 2014) (Heal, Buettner, & Drobetz, 2012). The Gharde study was
the only study to have 2 groups with a random number for males and females; however, each
group corresponded to two different types of cholecystectomy surgeries (Gharde, et al., 2014).
Two of the quantitative studies, Gharde and Heal, had a non-probability sampling method. The
researcher did not know what the possible outcome would be with this random number of
subjects.
In addition, the Yuste and Zhou studies employed a convenient sampling method with a
probability of the subjects outcome. The Yuste study utilized the already known outcomes and
information available for antibiotic administration effectiveness (Yuste, Romo, & Unamuno,
2015). On the other hand, the Zhou study used 20 previous studies and any recorded data
pertaining to antibiotic prophylaxis for elective laparoscopic cholecystectomies and created a
large scale analysis of those previous studies findings (Zhou, Zhang, Wang, & Hu, 2009). Even
though both studies, Yuste and Zhou, are qualitative in method and are using already published

AN INTEGRATIVE REVIEW: PROPHYLACTIC ANTIBIOTIC USE

information to a produce the same answer, these studies still provide a manage to devise the
answer from different sources.
Data analysis
Data analysis of the studies is more than likely the most difficult portion of the studies to
analysis. Therefore data analysis within this integrative review is a limitation for understanding
of the researchers needs to quantify the numerical answers within the Gharde, and Heal studies.
Within these two studies, the researchers used the Chi square test; however, none of the studies
explain what the Chi square test is and the significance behind the test (Gharde, et al., 2014)
(Heal, Buettner, & Drobetz, 2012). However, the Heal study did provide the purpose for MannWhitney-Wilcoxon test, generalized linear modeling, Poisson distribution, and logarithmic link
function were used for (Heal, Buettner, & Drobetz, 2012). The Zhou study utilized a Jadad
composite scale, quality assessment, odds ratio, and random effect model for its data analysis
(Zhou, Zhang, Wang, & Hu, 2009).
However, two studies, Javaid and Yuste, placed tables and grafts within the study that
corresponded to information gathered from the case notes and supplied information. These two
studies are the only two that simplify and provide easy to understand information regarding their
studies. Even though the Javaid and Yuste studies do not utilize some statistical analysis test,
they do use categories to produce and measure the data received and produced for the studies.
Discussion/ Implications
The PICOT question proposed whether or not prophylactic antibiotics be administered to
every patient, regardless, or just to those patients at risk for developing a surgical site infection?
Through this integrative review and research provided, five articles have provided a definitive
answer and also raised a possible future research topic. All five studies used a different method

AN INTEGRATIVE REVIEW: PROPHYLACTIC ANTIBIOTIC USE

or additional method in relation to each other in order to produce the same answer to the PICOT
question. Through data collection, different sampling sizes, varying subjects, even a study from
1998, varying statistical analyses, different research designs, and different types of produced
data, the researchers for each study produced the same findings. The Yuste study a qualitative
grounded theory to say that antibiotic prophylaxis is not necessary for uncontaminated clean skin
and that use is dependent on environmental and patient related factors (Yuste, Romo, &
Unamuno, 2015). Another study, Zhou, which analyzed 20 different studies, determined that
antibiotic prophylaxis has no role in reducing the incidences of surgical site infections in elective
laparoscopic cholecystectomies (Zhou, Zhang, Wang, & Hu, 2009). Within the total consensus,
the researchers have determined that antibiotic prophylaxis does not provide any type of
prevention or control in regards to surgical site infection occurrence, and that other factors
(wound location, wound type, comorbidities, and contamination) play a part in surgical site
infection occurrence (Gharde, et al., 2014) (Heal, Buettner, & Drobetz, 2012) (Javaid, Feidberg,
& Gipson, 1998) (Yuste, Romo, & Unamuno, 2015) (Zhou, Zhang, Wang, & Hu, 2009).
Implications of this information would be helpful with several issues. If healthcare
programs could predict or place patient within a surgical site infection probably, and only
administer antibiotics to those at risk for a surgical site infection, antibiotic usage could be
decreased. In essence, the occurrence of superbugs or drug resistant microbes could be curbed or
decreased within hospital setting. One study, Heal, suggests that their study will encourage the
judicial use of prophylactic antibiotics by defining high risk individuals for infection in regards
to skin lesion excisions (Heal, Buettner, & Drobetz, 2012). Another study, Yuste, suggests
prophylaxis for infection of orthopedic devices and other implants does not seem necessary, and
that corresponding specialist should be consulted in cases involving high-risk patients (Yuste,

AN INTEGRATIVE REVIEW: PROPHYLACTIC ANTIBIOTIC USE

Romo, & Unamuno, 2015). Another study, Zhou, suggests that antibiotic prophylaxis is
unnecessary and should not be routinely used in low-risk elective laparoscopic
cholecystectomies. In essence from all five studies, there is a future study or implication leading
to the decreased use of prophylactic antibiotics and/or the role of prophylactic antibiotics for
high-risk surgical site infection patients.
Limitations
Two limitations were observed during this integrative review. There are a limited number
for studies that were available within the database that were in full text. Some studies available
in full text were not available in English. Some full text studies were on sites that required
payment or membership. In addition, some full text studies in context were more like articles
and not research studies. The second limitation involved the statistical analyses of the
information within some of the studies used within this integrative review. The Gharde, and
Heal studies used the Chi square test; however, none of the studies explain what the Chi square
test is and the significance behind the test (Gharde, et al., 2014) (Heal, Buettner, & Drobetz,
2012). However, the Heal study did provide the purpose for Mann-Whitney-Wilcoxon test,
generalized linear modeling, Poisson distribution, and logarithmic link function were used for
(Heal, Buettner, & Drobetz, 2012). The Zhou study utilized a Jadad composite scale, quality
assessment, odds ratio, and random effect model for its data analysis (Zhou, Zhang, Wang, & Hu,
2009). However, process by which the researchers came up with their findings was not
understood and passed off as a generalized number.
Conclusion
This integrative reviews finding have provided an answer to the use of prophylactic
antibiotic use for those patients in regards to risk of surgical site infection. Findings indicate that

AN INTEGRATIVE REVIEW: PROPHYLACTIC ANTIBIOTIC USE

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antibiotic prophylaxis has not significant role in prevention or control of the occurrence of a
surgical site infection. The review continues to signify that there are several risk factors in the
occurrence of a surgical site infection: wound type, wound location, comorbidities of the patient,
and contamination of the site. This integrative review has not only answered a question, it has
also provided a support structure for the sensible use of prophylactic antibiotics. It has also,
provided a basis for the establishment of risk factors associated with surgical site infections and
the effect of antibiotic prophylaxis for high risk surgical site infection patients. However, until
the mandatory use of prophylactic antibiotics is deemed harmful to every surgical patient, the use
of it will be continuing.

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References
Gharde, P., Swarnkar, M., Waghmare, L., Bhagat, V., Gode, D., Wagh, D., . . . Sharma, A. (2014,
January). Role of antibiotics on surgical site infection in cases of open and laparoscopic
cholecystectomy : a comparative observational study. Journal of Surgical Technique &
Case Report. doi:10.4103/2006-8808.135132
Heal, C., Buettner, P., & Drobetz, H. (2012). Risk factors for surgical site infection after
dermatological surgery. International Journal of Dermatology, 796-803.
Javaid, M., Feidberg, L., & Gipson, M. (1998). Primary repair of dog bites to the face: 40 cases.
Journal of the Royal Society of Medicine, 414-416.
Yuste, M., Romo, A., & Unamuno, P. (2015). Antibiotic prophylaxis in dermatologic surgery.
Retrieved from Apps.elsevier.es: http://apps.elsevier.es/watermark/ctl_servlet?
_f=10&pident_articulo=90183736&pident_usuario=0&pcontactid=&pident_revista=403
&ty=46&accion=L&origen=actasdermo&web=www.actasdermo.org&lan=en&fichero=4
03v99n09a90183736pdf001.pdf
Zhou, H., Zhang, J., Wang, Q., & Hu, Z. (2009). Meta-analysis: Antibiotic prophylaxis in
elective laparoscopic cholecystectomy. doi:doi:10.1111/j.1365-2036.2009.03977.x

AN INTEGRATIVE REVIEW: PROPHYLACTIC ANTIBIOTIC USE

Authors
(Year)

Title of
Article

(Gharde,
et al.,
2014)

Role of
antibiotics
on surgical
site
infection in
cases of
open and
laparoscopi
c
cholecystec
tomy: a
comparativ
e
observation
al study.
Risk
PubMed
Factors for EBSCO
Surgical
Site
Infection
after
dermatologi
cal Surgery.

(Heal,
Buettner,
&
Drobetz,
2012)

Databas Keywords
e
used in
search
PubMed Antibiotics,
EBSCO Prophylactic,
Prophylaxis
Risk Factors
Minor
Procedures

Antibiotics,
Prophylactic,
Prophylaxis
Risk Factors
Minor
Procedures

12

Research
Design

Data Collection

Subjects

Sampling
Methods

Quantitative
Experimental

2 Groups
Interviews on 7th
day or whenever
signs of infection
appeared

Group A
(16-M
26-F)
Group B
(11-M
31-F)
Abdominal
symptoms
with
cholelithiasi
s

convenien
e
Nonprobabilit

Quantitative
Comparative
nonexperimental

Interviews with
general
practitioners and
patients
Demographics,
clinical data, and
body site map

972 patients

nonprobabilit

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13

(Javaid,
Feidberg,
&
Gipson,
1998)

Primary
Repair of
Dog Bites
to the Face:
40 cases.

PubMed
EBSCO

Antibiotics,
Prophylactic,
Prophylaxis
Risk Factors
Minor
Procedures

Quantitative
Quasiexpermental

Case notes from

April 1994 to
April 1997

17-M
23-F
Within 3
hour of
injury.
Within 1
hour of
injury.
More than 3
hours after
injury.

Convenien
and
probabilit

(Yuste,
Romo, &
Unamun
o, 2015)

Antibiotic
Prophylaxis
in
Dermatolog
ic Surgery.

PubMed
EBSCO

Antibiotics,
Prophylactic,
Prophylaxis
Risk Factors
Minor
Procedures

Qualitative
Grounded
theory

Antibiotic
administration
routes

3 groups
(Oral,
Topical, and
Intravenous)

Convenien
and
probabilit

(Zhou,
Zhang,
Wang, &
Hu, 2009)

Metaanalysis:
Antibiotic
prophylaxis
in elective
laparoscopi
c
cholecystec
tomy.

PubMed
EBSCO

Antibiotics,
Prophylactic,
Prophylaxis
Risk Factors
Minor
Procedures

Qualitative
Generic
research

Previous studies.
Recorded data

20 Relevant
studies

Convenien
and
probabilit

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