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Cochrane Database of Systematic Reviews

Antibiotic prophylaxis for the prevention of methicillin‐resistant Staphylococcus aureus (MRSA) related complications in surgical patients

Information

DOI:
https://doi.org/10.1002/14651858.CD010268.pub2Copy DOI
Database:
  1. Cochrane Database of Systematic Reviews
Version published:
  1. 19 August 2013see what's new
Type:
  1. Intervention
Stage:
  1. Review
Cochrane Editorial Group:
  1. Cochrane Wounds Group

Copyright:
  1. Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Authors

  • Kurinchi Selvan Gurusamy

    Correspondence to: Department of Surgery, Royal Free Campus, UCL Medical School, London, UK

    [email protected]

  • Rahul Koti

    Department of Surgery, Royal Free Campus, UCL Medical School, London, UK

  • Peter Wilson

    Department of Microbiology & Virology, University College London Hospitals, London, UK

  • Brian R Davidson

    Department of Surgery, Royal Free Campus, UCL Medical School, London, UK

Contributions of authors

KS Gurusamy: wrote the review, assessed the trials for inclusion and extracted data on included trials.
R Koti: independently assessed the trials for inclusion and extracted data on included trials.
P Wilson and BR Davidson: commented critically on the review and approved the review.

Contributions of editorial base

Nicky Cullum: edited the protocol; advised on methodology, interpretation and review content. Approved the review for submission.
Susan O'Meara: Editor: advised on methodology, interpretation and content.
Sally Bell‐Syer: co‐ordinated the editorial process. Advised on methodology, interpretation and content. Edited and copy edited the review.
Ruth Foxlee: designed the search strategy and edited the Search methods section.

Sources of support

Internal sources

  • No sources of support supplied

External sources

  • National Institute for Health Research, UK.

    National Institute for Health Research, the health research wing of the UK Government Department of Health funds K Gurusamy to complete this review.

  • NIHR/Department of Health (England), (Cochrane Wounds Group), UK.

Declarations of interest

KS Gurusamy and BR Davidson are funded by a joint funding scheme between Department of Health and Wellcome Trust on a completely unrelated project.
R Koti: none known.
APR Wilson is a consultant microbiologist in the NHS advising on antibiotic use and advises some private hospitals on infection control. He is a member of a clinical trial drug safety monitoring board for a monoclonal antibody. He has been an expert witness in infection‐related cases. He has a number of non‐commercial grants for research in the area of transmission of infection. APR Wilson was part‐funded by the UCLH/UCL Comprehensive Biomedical Centre with funding from the Department of Health's NIHR Biomedical Research Centres.

This project was funded by the National Institute for Health Research (NIHR).

Disclaimer

Department of Health disclaimer: The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the NIHR, NHS (National Health Service), or the Department of Health.

Acknowledgements

The authors would like to acknowledge the contribution of the peer referees, Wounds Group Editors (Julie Bruce) and referees (Caroline Main; Richard Kirubakaran; Jo Sutton) and copy editors Elizabeth Royle and Heather Maxwell.

Version history

Published

Title

Stage

Authors

Version

2013 Aug 19

Antibiotic prophylaxis for the prevention of methicillin‐resistant Staphylococcus aureus (MRSA) related complications in surgical patients

Review

Kurinchi Selvan Gurusamy, Rahul Koti, Peter Wilson, Brian R Davidson

https://doi.org/10.1002/14651858.CD010268.pub2

2012 Dec 12

Antibiotic prophylaxis for the prevention of Methicillin resistant Staphylococcus aureus (MRSA) infections and related complications in surgical patients

Protocol

Kurinchi Selvan Gurusamy, Peter Wilson, Brian R Davidson

https://doi.org/10.1002/14651858.CD010268

Differences between protocol and review

Peto's odds ratios were used for outcomes with a proportion of less than 1% events.
MRSA overall infections was included as a secondary outcome, since the antibiotics act on MRSA at any site rather than on the surgical wounds alone.

Keywords

MeSH

Study flow diagram.
Figures and Tables -
Figure 1

Study flow diagram.

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies
Figures and Tables -
Figure 2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies

Risk of bias summary: review authors' judgements about each risk of bias item for each included study
Figures and Tables -
Figure 3

Risk of bias summary: review authors' judgements about each risk of bias item for each included study

Comparison 1 Comparison of different regimens of prophylactic antibiotics, Outcome 1 Mortality.
Figures and Tables -
Analysis 1.1

Comparison 1 Comparison of different regimens of prophylactic antibiotics, Outcome 1 Mortality.

Comparison 1 Comparison of different regimens of prophylactic antibiotics, Outcome 2 Overall surgical site infection.
Figures and Tables -
Analysis 1.2

Comparison 1 Comparison of different regimens of prophylactic antibiotics, Outcome 2 Overall surgical site infection.

Comparison 1 Comparison of different regimens of prophylactic antibiotics, Outcome 3 MRSA surgical site infection.
Figures and Tables -
Analysis 1.3

Comparison 1 Comparison of different regimens of prophylactic antibiotics, Outcome 3 MRSA surgical site infection.

Comparison 1 Comparison of different regimens of prophylactic antibiotics, Outcome 4 Overall MRSA infections.
Figures and Tables -
Analysis 1.4

Comparison 1 Comparison of different regimens of prophylactic antibiotics, Outcome 4 Overall MRSA infections.

Comparison 2 Sensitivity analysis, Outcome 1 Mortality (kanamycin, erythromycin and cefotiam versus cefotiam).
Figures and Tables -
Analysis 2.1

Comparison 2 Sensitivity analysis, Outcome 1 Mortality (kanamycin, erythromycin and cefotiam versus cefotiam).

Comparison 2 Sensitivity analysis, Outcome 2 Mortality (vancomycin versus cefuroxime).
Figures and Tables -
Analysis 2.2

Comparison 2 Sensitivity analysis, Outcome 2 Mortality (vancomycin versus cefuroxime).

Comparison 2 Sensitivity analysis, Outcome 3 Surgical site infection (kanamycin, erythromycin and cefotiam versus cefotiam).
Figures and Tables -
Analysis 2.3

Comparison 2 Sensitivity analysis, Outcome 3 Surgical site infection (kanamycin, erythromycin and cefotiam versus cefotiam).

Comparison 2 Sensitivity analysis, Outcome 4 Surgical site infection (vancomycin versus teicoplanin).
Figures and Tables -
Analysis 2.4

Comparison 2 Sensitivity analysis, Outcome 4 Surgical site infection (vancomycin versus teicoplanin).

Comparison 2 Sensitivity analysis, Outcome 5 Surgical site infection (vancomycin and cefazolin versus daptomycin and cefazolin).
Figures and Tables -
Analysis 2.5

Comparison 2 Sensitivity analysis, Outcome 5 Surgical site infection (vancomycin and cefazolin versus daptomycin and cefazolin).

Comparison 2 Sensitivity analysis, Outcome 6 Surgical site infection (vancomycin and cefazolin versus cefazolin).
Figures and Tables -
Analysis 2.6

Comparison 2 Sensitivity analysis, Outcome 6 Surgical site infection (vancomycin and cefazolin versus cefazolin).

Comparison 2 Sensitivity analysis, Outcome 7 Surgical site infection (daptomycin and cefazolin versus cefazolin).
Figures and Tables -
Analysis 2.7

Comparison 2 Sensitivity analysis, Outcome 7 Surgical site infection (daptomycin and cefazolin versus cefazolin).

Comparison 2 Sensitivity analysis, Outcome 8 Surgical site infection (vancomycin versus cefuroxime).
Figures and Tables -
Analysis 2.8

Comparison 2 Sensitivity analysis, Outcome 8 Surgical site infection (vancomycin versus cefuroxime).

Comparison 2 Sensitivity analysis, Outcome 9 MRSA surgical site infection (kanamycin, erythromycin and cefotiam versus cefotiam).
Figures and Tables -
Analysis 2.9

Comparison 2 Sensitivity analysis, Outcome 9 MRSA surgical site infection (kanamycin, erythromycin and cefotiam versus cefotiam).

Comparison 2 Sensitivity analysis, Outcome 10 MRSA surgical site infection (vancomycin versus teicoplanin).
Figures and Tables -
Analysis 2.10

Comparison 2 Sensitivity analysis, Outcome 10 MRSA surgical site infection (vancomycin versus teicoplanin).

Comparison 2 Sensitivity analysis, Outcome 11 MRSA surgical site infection (vancomycin and cefazolin versus daptomycin and cefazolin).
Figures and Tables -
Analysis 2.11

Comparison 2 Sensitivity analysis, Outcome 11 MRSA surgical site infection (vancomycin and cefazolin versus daptomycin and cefazolin).

Comparison 2 Sensitivity analysis, Outcome 12 MRSA surgical site infection (vancomycin and cefazolin versus cefazolin).
Figures and Tables -
Analysis 2.12

Comparison 2 Sensitivity analysis, Outcome 12 MRSA surgical site infection (vancomycin and cefazolin versus cefazolin).

Comparison 2 Sensitivity analysis, Outcome 13 MRSA surgical site infection (daptomycin and cefazolin versus cefazolin).
Figures and Tables -
Analysis 2.13

Comparison 2 Sensitivity analysis, Outcome 13 MRSA surgical site infection (daptomycin and cefazolin versus cefazolin).

Comparison 2 Sensitivity analysis, Outcome 14 MRSA surgical site infection (vancomycin versus cefuroxime).
Figures and Tables -
Analysis 2.14

Comparison 2 Sensitivity analysis, Outcome 14 MRSA surgical site infection (vancomycin versus cefuroxime).

Comparison 2 Sensitivity analysis, Outcome 15 Overall MRSA infections (kanamycin, erythromycin and cefotiam versus cefotiam).
Figures and Tables -
Analysis 2.15

Comparison 2 Sensitivity analysis, Outcome 15 Overall MRSA infections (kanamycin, erythromycin and cefotiam versus cefotiam).

Summary of findings for the main comparison. Antibiotic prophylaxis for the prevention of methicillin‐resistant Staphylococcus aureus (MRSA) infections and related complications in surgical patients: mortality

Mortality

Patient or population: surgical patients
Settings: secondary
Intervention: comparison of different regimens of prophylactic antibiotic regimens

Comparisons

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Assumed risk

Corresponding risk

Control

Comparison of different regimens of prophylactic antibiotic regimens

One dose of cefotiam or cefmetazol versus four doses of cefotiam or cefmetazol (elective surgery for colon cancer)

See comment

See comment

Not estimable

275
(1 study)

⊕⊝⊝⊝
very low1,2

Kanamycin, erythromycin and cefotiam versus cefotiam (surgery for colorectal diseases)

See comment

See comment

Not estimable

143
(1 study)

⊕⊝⊝⊝
very low1,2

Co‐amoxiclav or cefotaxime versus placebo (percutaneous endoscopic gastrostomy)

146 per 1000

79 per 1000
(25 to 251)

RR 0.54
(0.17 to 1.72)

99
(1 study)

⊕⊝⊝⊝
very low1,2

Vancomycin versus cefuroxime (coronary artery bypass graft without valvular disease)

2 per 1000

5 per 1000
(0 to 50)

RR 2.02
(0.18 to 22.18)

884
(1 study)

⊕⊝⊝⊝
very low1,2

*The basis for the assumed risk is the control group risk in the study. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; RR: Risk ratio.

GRADE Working Group grades of evidence:
High quality: further research is very unlikely to change our confidence in the estimate of effect
Moderate quality: further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate
Low quality: further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate
Very low quality: we are very uncertain about the estimate

1 The risk of bias in the trial was high
2 The confidence intervals overlapped 1 and/or 0.75 and 1.25. There were fewer than 300 events in total in the intervention and control groups

Figures and Tables -
Summary of findings for the main comparison. Antibiotic prophylaxis for the prevention of methicillin‐resistant Staphylococcus aureus (MRSA) infections and related complications in surgical patients: mortality
Summary of findings 2. Antibiotic prophylaxis for the prevention of methicillin‐resistant Staphylococcus aureus (MRSA) infections and related complications in surgical patients: surgical site infection

Surgical site infection

Patient or population: surgical patients
Settings: secondary
Intervention: comparison of different regimens of prophylactic antibiotic regimens

Comparisons

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Assumed risk

Corresponding risk

Control

Comparison of different regimens of prophylactic antibiotic regimens

Cefamendole versus cefamendole and gentamycin (median sternotomy)

Moderate

RR 5.08
(0.24 to 105.24)

522
(1 study)

⊕⊝⊝⊝
very low1,2

5 per 1000

25 per 1000
(1 to 526)

Cefazolin versus cefamendole (median sternotomy)

8 per 1000

27 per 1000
(6 to 131)

RR 3.55
(0.75 to 16.95)

514
(1 study)

⊕⊝⊝⊝
very low1,2

Cefazolin versus cefazolin and gentamycin (median sternotomy)

32 per 1000

28 per 1000
(10 to 75)

RR 0.87
(0.32 to 2.36)

508
(1 study)

⊕⊝⊝⊝
very low1,2

Co‐amoxiclav or cefotaxime versus placebo (percutaneous endoscopic gastrostomy)

375 per 1000

98 per 1000
(41 to 244)

RR 0.26
(0.11 to 0.65)

99
(1 study)

⊕⊕⊝⊝
low1

Daptomycin and cefazolin versus cefazolin (vascular surgery)

129 per 1000

39 per 1000
(9 to 177)

RR 0.3
(0.07 to 1.37)

113
(1 study)

⊕⊝⊝⊝
very low1,2

Kanamycin, erythromycin and cefotiam versus cefotiam (surgery for colorectal diseases)

239 per 1000

110 per 1000
(50 to 242)

RR 0.46
(0.21 to 1.01)

143
(1 study)

⊕⊝⊝⊝
very low1,2

Levofloxacin versus ofloxacin (breast cancer)

61 per 1000

40 per 1000
(11 to 146)

RR 0.66
(0.18 to 2.39)

181
(1 study)

⊕⊝⊝⊝
very low1,2

One day of piperacillin, cefazolin, cefmetazole, or cefotiam versus three days of piperacillin, cefazolin, cefmetazole, or cefotiam (elective colorectal surgery)

54 per 1000

57 per 1000
(28 to 116)

RR 1.06
(0.52 to 2.15)

521
(1 study)

⊕⊝⊝⊝
very low1,2

One dose of cefotiam or cefmetazol versus four doses of cefotiam or cefmetazol (elective surgery for colon cancer)

65 per 1000

51 per 1000
(19 to 134)

RR 0.79
(0.3 to 2.07)

275
(1 study)

⊕⊝⊝⊝
very low1,2

Pefloxacin versus cefazolin and oxacillin (tibial fracture requiring external fixation)

90 per 1000

67 per 1000
(39 to 115)

RR 0.74
(0.43 to 1.28)

616
(1 study)

⊕⊝⊝⊝
very low1,2

Vancomycin and cefazolin versus cefazolin (open fractures)

87 per 1000

87 per 1000
(23 to 327)

RR 1
(0.27 to 3.76)

92
(1 study)

⊕⊝⊝⊝
very low1,2

Vancomycin and cefazolin versus cefazolin (vascular surgery) ‐ suggest add for all comparisons

129 per 1000

125 per 1000
(49 to 323)

RR 0.97
(0.38 to 2.5)

118
(1 study)

⊕⊝⊝⊝
very low1,2

Vancomycin and cefazolin versus daptomycin and cefazolin (vascular surgery)

39 per 1000

125 per 1000
(27 to 575)

RR 3.19
(0.69 to 14.65)

107
(1 study)

⊕⊝⊝⊝
very low1,2

Vancomycin versus teicoplanin (paediatric cardiac surgery)

No infection in either group

Not estimable

22
(1 study)

⊕⊝⊝⊝
very low1,2

Vancomycin versus cefuroxime (coronary artery bypass graft without valvular disease)

32 per 1000

34 per 1000
(17 to 70)

RR 1.08
(0.53 to 2.21)

884
(1 study)

⊕⊝⊝⊝
very low1,2

*The basis for the assumed risk is the control group risk in the study. When there were no events in either group, we have indicated so. When there were events in the intervention group but not in the control group, we have used a moderate proportion of 0.5% in the control group. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; RR: Risk ratio.

GRADE Working Group grades of evidence:
High quality: further research is very unlikely to change our confidence in the estimate of effect
Moderate quality: further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate
Low quality: further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate
Very low quality: we are very uncertain about the estimate

1 The risk of bias in the trial was high
2 The confidence intervals overlapped 1 and/or 0.75 and 1.25. There were fewer than 300 events in total in the intervention and control groups

Figures and Tables -
Summary of findings 2. Antibiotic prophylaxis for the prevention of methicillin‐resistant Staphylococcus aureus (MRSA) infections and related complications in surgical patients: surgical site infection
Summary of findings 3. Antibiotic prophylaxis for the prevention of methicillin‐resistant Staphylococcus aureus (MRSA) infections and related complications in surgical patients: MRSA surgical site infection

MRSA surgical site infection

Patient or population: surgical patients
Settings: secondary
Intervention: comparison of different regimens of prophylactic antibiotic regimens

Comparisons

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Assumed risk

Corresponding risk

Control

Comparison of different regimens of prophylactic antibiotic regimens

Cefamendole versus cefamendole and gentamycin (median sternotomy)

No infection in either group

Not estimable

522
(1 study)

⊕⊝⊝⊝
very low1,2

Cefazolin and gentamycin versus cefamendole and gentamycin (median sternotomy)

No infection in either group

Not estimable

516
(1 study)

⊕⊝⊝⊝
very low1,2

Cefazolin versus cefamendole (median sternotomy)

Moderate

RR 3.05
(0.12 to 74.45)

514
(1 study)

⊕⊝⊝⊝
very low1,2

5 per 1000

15 per 1000
(1 to 372)

Cefazolin versus cefazolin and gentamycin (median sternotomy)

Moderate

RR 2.98
(0.12 to 72.72)

508
(1 study)

⊕⊝⊝⊝
very low1,2

5 per 1000

15 per 1000
(1 to 364)

Co‐amoxiclav or cefotaxime versus placebo (percutaneous endoscopic gastrostomy)

188 per 1000

9 per 1000
(0 to 156)

RR 0.05
(0 to 0.83)

99
(1 study)

⊕⊕⊝⊝
low1

Daptomycin and cefazolin versus cefazolin (vascular surgery)

32 per 1000

8 per 1000
(0 to 159)

RR 0.24
(0.01 to 4.94)

113
(1 study)

⊕⊝⊝⊝
very low1,2

Ertapenem versus cefotetan (elective colorectal surgery)

15 per 1000

9 per 1000
(2 to 37)

RR 0.59
(0.14 to 2.46)

672
(1 study)

⊕⊝⊝⊝
very low1,2

Kanamycin, erythromycin and cefotiam versus cefotiam (surgery for colorectal diseases)

28 per 1000

55 per 1000
(10 to 294)

RR 1.97
(0.37 to 10.43)

143
(1 study)

⊕⊝⊝⊝
very low1,2

Levofloxacin versus ofloxacin (breast cancer)

No infection in either group

Not estimable

181
(1 study)

⊕⊝⊝⊝
very low1,2

One day of piperacillin, cefazolin, cefmetazole, or cefotiam versus three days of piperacillin, cefazolin, cefmetazole, or cefotiam (elective colorectal surgery)

No infection in either group

Not estimable

521
(1 study)

⊕⊝⊝⊝
very low1,2

One dose of cefotiam or cefmetazol versus four doses of cefotiam or cefmetazol (elective surgery for colon cancer)

22 per 1000

22 per 1000
(5 to 107)

RR 1.02
(0.21 to 4.98)

275
(1 study)

⊕⊝⊝⊝
very low1,2

Pefloxacin versus cefazolin and oxacillin (tibial fracture requiring external fixation)

3 per 1000

13 per 1000
(1 to 113)

RR 3.8
(0.43 to 33.78)

616
(1 study)

⊕⊝⊝⊝
very low1,2

Vancomycin and cefazolin versus cefazolin (open fractures)

Moderate

RR 3
(0.13 to 71.78)

92
(1 study)

⊕⊝⊝⊝
very low1,2

5 per 1000

15 per 1000
(1 to 359)

Vancomycin and cefazolin versus cefazolin (vascular surgery)

32 per 1000

71 per 1000
(14 to 375)

RR 2.21
(0.42 to 11.63)

118
(1 study)

⊕⊝⊝⊝
very low1,2

Vancomycin and cefazolin versus daptomycin and cefazolin (vascular surgery)

Moderate

RR 8.21
(0.45 to 148.84)

107
(1 study)

⊕⊝⊝⊝
very low1,2

5 per 1000

41 per 1000
(2 to 744)

Vancomycin versus teicoplanin (paediatric cardiac surgery)

No infection in either group

Not estimable

22
(1 study)

⊕⊝⊝⊝
very low1,2

Vancomycin versus cefuroxime (coronary artery bypass graft without valvular disease)

5 per 1000

5 per 1000
(1 to 32)

RR 1.01
(0.14 to 7.13)

884
(1 study)

⊕⊝⊝⊝
very low1,2

*The basis for the assumed risk is the control group risk in the study. When there were no events in either group, we have indicated so. When there were events in the intervention group but not in the control group, we have used a moderate proportion of 0.5% in the control group. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; RR: Risk ratio.

GRADE Working Group grades of evidence:
High quality: further research is very unlikely to change our confidence in the estimate of effect
Moderate quality: further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate
Low quality: further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate
Very low quality: we are very uncertain about the estimate

1 The risk of bias in the trial was high
2 The confidence intervals overlapped 1 and/or 0.75 and 1.25. There were fewer than 300 events in total in the intervention and control groups

Figures and Tables -
Summary of findings 3. Antibiotic prophylaxis for the prevention of methicillin‐resistant Staphylococcus aureus (MRSA) infections and related complications in surgical patients: MRSA surgical site infection
Summary of findings 4. Antibiotic prophylaxis for the prevention of methicillin‐resistant Staphylococcus aureus (MRSA) infections and related complications in surgical patients: overall MRSA infections

Overall MRSA infections

Patient or population: surgical patients
Settings: secondary
Intervention: comparison of different regimens of prophylactic antibiotic regimens

Comparisons

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Assumed risk

Corresponding risk

Control

Comparison of different regimens of prophylactic antibiotic regimens

One dose of cefotiam or cefmetazol versus four doses of cefotiam or cefmetazol (elective surgery for colon cancer)

29 per 1000

22 per 1000
(5 to 97)

RR 0.77
(0.17 to 3.36)

275
(1 study)

⊕⊝⊝⊝
very low1,2

Kanamycin, erythromycin and cefotiam versus cefotiam (surgery for colorectal diseases)

56 per 1000

111 per 1000
(35 to 353)

RR 1.97
(0.62 to 6.26)

143
(1 study)

⊕⊝⊝⊝
very low1,2

*The basis for the assumed risk is the control group risk in the study. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; RR: Risk ratio.

GRADE Working Group grades of evidence:
High quality: further research is very unlikely to change our confidence in the estimate of effect
Moderate quality: further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate
Low quality: further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate
Very low quality: we are very uncertain about the estimate

1 The risk of bias in the trial was high.
2 The confidence intervals overlapped 1 and/or 0.75 and 1.25. There were fewer than 300 events in total in the intervention and control groups.

Figures and Tables -
Summary of findings 4. Antibiotic prophylaxis for the prevention of methicillin‐resistant Staphylococcus aureus (MRSA) infections and related complications in surgical patients: overall MRSA infections
Comparison 1. Comparison of different regimens of prophylactic antibiotics

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Mortality Show forest plot

4

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

1.1 One dose of cefotiam or cefmetazol versus four doses of cefotiam or cefmetazol

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

1.2 Kanamycin, erythromycin and cefotiam versus cefotiam

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

1.3 Co‐amoxiclav or cefotaxime versus placebo

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

1.4 Vancomycin versus cefuroxime

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

2 Overall surgical site infection Show forest plot

11

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

2.1 Cefamendole versus cefamendole and gentamycin

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

2.2 Cefazolin and gentamycin versus cefamendole and gentamycin

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

2.3 Cefazolin versus cefamendole

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

2.4 Cefazolin versus cefazolin and gentamycin

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

2.5 Co‐amoxiclav or cefotaxime versus placebo

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

2.6 Daptomycin and cefazolin versus cefazolin

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

2.7 Kanamycin, erythromycin and cefotiam versus cefotiam

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

2.8 Levofloxacin versus ofloxacin

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

2.9 One day of piperacillin, cefazolin, cefmetazole, or cefotiam versus three days of piperacillin, cefazolin, cefmetazole, or cefotiam

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

2.10 One dose of cefotiam or cefmetazol versus four doses of cefotiam or cefmetazol

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

2.11 Pefloxacin versus cefazolin and oxacillin

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

2.12 Vancomycin and cefazolin versus cefazolin (open fractures)

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

2.13 Vancomycin and cefazolin versus cefazolin (vascular surgery)

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

2.14 Vancomycin and cefazolin versus daptomycin and cefazolin

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

2.15 Vancomycin versus teicoplanin

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

2.16 Vancomycin versus cefuroxime

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

3 MRSA surgical site infection Show forest plot

12

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

3.1 Cefamendole versus cefamendole and gentamycin

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

3.2 Cefazolin and gentamycin versus cefamendole and gentamycin

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

3.3 Cefazolin versus cefamendole

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

3.4 Cefazolin versus cefazolin and gentamycin

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

3.5 Co‐amoxiclav or cefotaxime versus placebo

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

3.6 Daptomycin and cefazolin versus cefazolin

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

3.7 Ertapenem versus cefotetan

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

3.8 Kanamycin, erythromycin and cefotiam versus cefotiam

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

3.9 Levofloxacin versus ofloxacin

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

3.10 One day of piperacillin, cefazolin, cefmetazole, or cefotiam versus three days of piperacillin, cefazolin, cefmetazole, or cefotiam

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

3.11 One dose of cefotiam or cefmetazol versus four doses of cefotiam or cefmetazol

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

3.12 Pefloxacin versus cefazolin and oxacillin

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

3.13 Vancomycin and cefazolin versus cefazolin (open fractures)

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

3.14 Vancomycin and cefazolin versus cefazolin (vascular surgery)

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

3.15 Vancomycin and cefazolin versus daptomycin and cefazolin

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

3.16 Vancomycin versus teicoplanin

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

3.17 Vancomycin versus cefuroxime

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

4 Overall MRSA infections Show forest plot

2

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

4.1 One dose of cefotiam or cefmetazol versus four doses of cefotiam or cefmetazol

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

4.2 Kanamycin, erythromycin and cefotiam versus cefotiam

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

Figures and Tables -
Comparison 1. Comparison of different regimens of prophylactic antibiotics
Comparison 2. Sensitivity analysis

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Mortality (kanamycin, erythromycin and cefotiam versus cefotiam) Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

1.1 Best‐best scenario

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

1.2 Worst‐worst scenario

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

1.3 Best‐worst scenario

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

1.4 Worst‐best scenario

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

2 Mortality (vancomycin versus cefuroxime) Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

2.1 Best‐best scenario

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

2.2 Worst‐worst scenario

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

2.3 Best‐worst scenario

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

2.4 Worst‐best scenario

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

3 Surgical site infection (kanamycin, erythromycin and cefotiam versus cefotiam) Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

3.1 Best‐best scenario

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

3.2 Worst‐worst scenario

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

3.3 Best‐worst scenario

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

3.4 Worst‐best scenario

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

4 Surgical site infection (vancomycin versus teicoplanin) Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

4.1 Best‐best scenario

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

4.2 Worst‐worst scenario

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

4.3 Best‐worst scenario

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

4.4 Worst‐best scenario

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

5 Surgical site infection (vancomycin and cefazolin versus daptomycin and cefazolin) Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

5.1 Best‐best scenario

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

5.2 Worst‐worst scenario

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

5.3 Best‐worst scenario

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

5.4 Worst‐best scenario

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

6 Surgical site infection (vancomycin and cefazolin versus cefazolin) Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

6.1 Best‐best scenario

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

6.2 Worst‐worst scenario

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

6.3 Best‐worst scenario

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

6.4 Worst‐best scenario

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

7 Surgical site infection (daptomycin and cefazolin versus cefazolin) Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

7.1 Best‐best scenario

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

7.2 Worst‐worst scenario

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

7.3 Best‐worst scenario

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

7.4 Worst‐best scenario

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

8 Surgical site infection (vancomycin versus cefuroxime) Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

8.1 Best‐best scenario

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

8.2 Worst‐worst scenario

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

8.3 Best‐worst scenario

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

8.4 Worst‐best scenario

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

9 MRSA surgical site infection (kanamycin, erythromycin and cefotiam versus cefotiam) Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

9.1 Best‐best scenario

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

9.2 Worst‐worst scenario

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

9.3 Best‐worst scenario

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

9.4 Worst‐best scenario

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

10 MRSA surgical site infection (vancomycin versus teicoplanin) Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

10.1 Best‐best scenario

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

10.2 Worst‐worst scenario

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

10.3 Best‐worst scenario

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

10.4 Worst‐best scenario

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

11 MRSA surgical site infection (vancomycin and cefazolin versus daptomycin and cefazolin) Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

11.1 Best‐best scenario

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

11.2 Worst‐worst scenario

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

11.3 Best‐worst scenario

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

11.4 Worst‐best scenario

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

12 MRSA surgical site infection (vancomycin and cefazolin versus cefazolin) Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

12.1 Best‐best scenario

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

12.2 Worst‐worst scenario

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

12.3 Best‐worst scenario

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

12.4 Worst‐best scenario

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

13 MRSA surgical site infection (daptomycin and cefazolin versus cefazolin) Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

13.1 Best‐best scenario

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

13.2 Worst‐worst scenario

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

13.3 Best‐worst scenario

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

13.4 Worst‐best scenario

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

14 MRSA surgical site infection (vancomycin versus cefuroxime) Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

14.1 Best‐best scenario

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

14.2 Worst‐worst scenario

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

14.3 Best‐worst scenario

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

14.4 Worst‐best scenario

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

15 Overall MRSA infections (kanamycin, erythromycin and cefotiam versus cefotiam) Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

15.1 Best‐best scenario

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

15.2 Worst‐worst scenario

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

15.3 Best‐worst scenario

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

15.4 Worst‐best scenario

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

Figures and Tables -
Comparison 2. Sensitivity analysis