This review concluded that prophylactic ceftriaxone was more effective than most other prophylactic antibiotics and reduced incisional surgical site infection, urinary tract infection and pneumonia in surgery procedures that had an increased risk of infections. The conclusions should be interpreted cautiously given the limited quality of most of the included studies.

To assess the efficacy of ceftriaxone compared with other prophylactic antibiotics in the prevention of infection across a range of low- and high-risk surgical procedures.

MEDLINE, EMBASE and The Cochrane Library were searched from 1983 (first published paper on ceftriaxone) to January 2005. There were no language restrictions. Search terms were reported. Reference lists of retrieved publications and relevant conference proceedings were screened. The study authors and manufacturer were contacted for additional studies.

Randomised controlled trials (RCTs) that compared ceftriaxone with other prophylactic antibiotics (single/multiple doses and more than one antibiotic used) for the prevention of infection in patients who underwent elective or emergency surgery were eligible for inclusion. Studies that compared ceftriaxone with placebo for the prevention of chest or urinary infection were included. Studies that assessed pharmacokinetic or other infections (such as colonisation with Clostridium difficile) were excluded. Studies were included if they used additional anaerobic cover in both treatment arms or used it as a comparator antibiotic. The review outcomes were incidences of incision surgical site infection (wound infection), urinary tract infection and pneumonia.

Most of the included studies involved controls of antibiotics with multiple doses and clearly stated the Centres for Disease Control (CDC) definition of wound infection. Controls involved four types of antibiotics: aminoglycosides, first- and second-generation cephalosporins, third-generation cephalosporins and penicillins. Patients underwent various types of surgical procedures that included abdominal-gastrointestinal surgery, pelvic surgery and clean surgery (such as cardiac surgery, neurosurgery). Many studies assessed infection in the hospital and others assessed infection at 30 days post operation.

Two reviewers independently assessed studies for inclusion, with any disagreement resolved by consensus.

The validity of study was assessed using the Jadad scale, a five-point scale of randomisation, blinding and withdrawal.

Two reviewers independently performed validity assessment. Any disagreement was resolved by consensus.

Data were extracted on event rate to enable calculation of odds ratios (ORs) with 95% confidence intervals (CIs).

The authors did not state how many reviewers performed data extraction.

The studies were combined in meta-analyses. Pooled odds ratios with 95% CIs were calculated using a fixed-effect model. Separate analyses were conducted on different types of infections. Subgroup analyses were conducted on the basis of different types of comparator antibiotics or surgical procedures. Statistical heterogeneity was assessed using the Q statistic and I². Summary statistics for primary analyses were generated by exclusion of outlying studies identified from a funnel plot. Sensitivity analyses were performed on studies with double blinding, a CDC definition of infection and a Jadad score of at least 4, and by removal of each individual study. Sensitivity analyses were conducted by combining studies with double blinding and a CDC definition of infection. Publication bias was assessed using a funnel plot.

Ninety RCTs were included in the review. Sixty-four studies assessed incisional surgical site infection (n=22,888 participants), 44 studies assessed urinary tract infection (n=14,907) and 38 studies assessed pneumonia (n=13,889). A Jadad score of at least 4 was achieved by 11 trials in the analysis of incisional surgical site infection, eight in the analysis of urinary tract infection and seven in the analysis of pneumonia.

Ceftriaxone was associated with a significant reduction in incisional surgical site infection compared with other antibiotics (OR 0.68, 95% CI 0.53 to 0.7; 61 RCTs). Significant benifit was observed for abdominal-gastrointestinal surgery, but there was no significant difference between the two groups for pelvic or clean surgery.

There was a significant reduction in urinary tract infection in the ceftriaxone group compared with other antibiotics (OR 0.52, 95% CI 0.43 to 0.63; 35 RCTs). The significant benefit was observed only for abdominal-gastrointestinal and pelvic surgery.

There was a significant reduction in pneumonia in the ceftriaxone group compared with other antibiotics (OR 0.66, 95% CI 0.54 to 0.81; 37 RCTs). The significant benefit was only observed for abdominal-gastrointestinal surgery.

No significant heterogeneity was observed for these outcomes. Sensitivity analyses did not materially alter the results. No evidence of publication bias was identified. Results for subgroup analyses of different types of comparator antibiotics were reported.

Prophylactic ceftriaxone was more effective than most other prophylactic antibiotics and reduced incisional surgical site infection, urinary tract infection and pneumonia in surgery procedures where there was an increased risk of infections.

This review's inclusion criteria were clear. Relevant databases were searched. Efforts were made to find both published and unpublished studies, which reduced potential for publication bias. Publication bias was assessed and no evidence of it was found. No language restriction was applied to the search, which minimised the risk of language bias. Steps were made to minimise errors and biases in the processes of study selection and validity assessment; it was unclear whether data extraction was performed in duplicate. Details of the primary studies were not provided. Appropriate criteria were used to assess study quality, but the results were not reported in full. Statistical heterogeneity was assessed and appropriate methods were used to pool the results.

This review was generally well conducted. A degree of caution might be required to interpret the authors' conclusions given the limited quality of most of the included studies.

Practice: The authors stated that data from this review supported used of ceftriaxone as a first-line prophylactic antibiotic in surgical procedures with an increased risk of infection.

Research: The authors did not state any implications for research.

Not stated.

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.