Clinical bottom line

Adults having abdominal and pelvic surgery experienced significantly fewer postoperative lung infections, urinary tract infections and surgical site infections when cared for on an enhanced recovery after surgery (ERAS) or fast track surgery (FTS) protocol, compared with standard care.

Clinical scenario

Healthcare-associated infections (HAIs) are a significant problem after surgery and you are frustrated in your efforts to reduce these. A number of perioperative strategies are known to reduce risk of HAIs but current protocols do not ensure these are consistently applied. You have heard that enhanced recovery after surgery (ERAS) protocols are associated with reducing HAIs and decide to review the evidence.

Question

In adults undergoing surgery, does an ERAS protocol reduce hospital acquired infection (HAI) in comparison with standard care?

Search strategy

PubMed-Clinical Queries (Therapy/Narrow): enhanced recovery after surgery AND infection

Citation

Grant MC, Yang D, Wu CL et al., Impact of Enhanced Recovery After Surgery and Fast Track Surgery Pathways on Healthcare-associated Infections: Results From a Systematic Review and Meta-analysis. Ann Surg, 2017. 265(1): p. 68-79 10.1097/sla.0000000000001703

Study summary

A systematic review evaluating whether ERAS and FTS protocols reduce HAIs. Inclusion criteria were:

Type of study: Randomised controlled trials

Participants: Adults (age>18) undergoing general anaesthesia for abdominal and pelvic surgery

Intervention: Perioperative care using either ERAS or FTS protocols, compared with standard care

Outcomes:

Primary outcomes: postoperative incidence of lung infection (LI), urinary tract infection (UTI), and surgical site infection (SSI). Secondary outcomes: length of stay (LOS), serum protein markers of inflammation, neurogenic stress, humoral immunity, and cellular immunity.

Study validity

Search strategy: Electronic databases searched to locate eligible English-language studies were PubMed, EMBASE, CINAHL, Web of Science, and Cochrane Library from inception to June 2015.

Review process: Two authors independently searched for and screened potentially relevant studies, extracted data using a standardised form and assessed risk of bias within included studies. Disagreements resolved by group consensus.

Quality assessment: Risk of bias was assessed using the Cochrane Collaboration tool (assesses sequence generation, allocation concealment, blinding of participants/outcome assessment, incomplete outcome data, selective outcome reporting, and other potential sources of bias).

Overall validity: A high-quality review involving a large number of randomised controlled trials but with moderate risk of bias.

Study results

After removal of 365 duplicates, 855 abstracts were screened for eligibility. Full text of 47 studies were assessed, from which 36 RCTs (41 comparisons) involving 4,142 participants were included in this review. Twenty-five comparisons involved open surgical procedures, 15 comparisons involved laparoscopic procedures and one study involved both. Studies commonly involved colorectal surgery (26 comparisons). Other studies involved gastrectomy (7), abdominal aneurysm repair (2), hepatectomy (2), general intestinal (2), oesophagectomy (1), and prostatectomy (1).

Most studies followed patients up to 28 days postoperatively (29 comparisons; 71 per cent). Studies compared multimodal ERAS or FTS protocol administration with standard care (refer comments). ERAS or FTS was associated with a statistically significant reduction in postoperative LI, UTI and SSI, compared with standard care (refer table). Subgroup analysis of studies involving colorectal surgery also showed statistically significant reductions in LI, UTI and SSI compared with standard care. Subgroup analysis of studies involving open incisions showed statistically significant reductions in LI, UTI but not SSI, compared with standard care. Hospital LOS was also significantly reduced with use of ERAS/FTS protocols.

Comments:

Sensitivity analysis involving exclusion of studies at high risk of bias did not substantially change the findings. Funnel plot analysis of primary outcome data showed no evidence of publication bias (no missed studies).

ERAS and FTS protocols commonly involved preoperative counselling, avoiding bowel preparation, preoperative carbohydrate, avoiding nasogastric tubes, preventing hypothermia, goal directed fluids, avoiding peritoneal drainage, regional analgesia, early urinary catheter removal, early oral feeding and early mobilisation, in comparison with standard care.

One explanation is that ERAS and FTS protocols promote comprehensive, multidisciplinary best practice care that is more effective than isolated infection-reducing strategies. The significant reductions in inflammatory markers observed in FTS or ERAS patients suggests that reduced systemic inflammation may also be a contributing factor.

Implementing these findings requires a multidisciplinary quality improvement effort including (from personal experience) ensuring sufficient nursing resource to support safe, early mobilisation.

Reviewer: Cynthia Wensley RN, MHSc. Honorary Professional Teaching Fellow, University of Auckland and PhD Candidate, Deakin University, Melbourne.
[email protected]

Table: Summary of results