Role of antibiotic prophylaxis in open inguinal hernioplasty – A prospective randomized clinical trial

Role of antibiotic prophylaxis in open inguinal hernioplasty ISSN: 2394-0026 (P)Original Research Article ISSN: 2394-0034 (O)Role of antibiotic prophylaxis in openinguinal hernioplasty – A prospective randomized clinical trial N Vinoth1, CRM Karthikeyan1, Hiren Parmar2*1Assistant Professor, Dhanlaxmi Shrinivasan Medical College, Perambalur, Tamil Nadu, India 2Associate Professor, GMERS Medical College, Gandhinagar, Gujarat, India *Corresponding author email: [email protected] to cite this article: N Vinoth, CRM Karthikeyan, Hiren Parmar. Role of antibiotic prophylaxis inopen inguinal hernioplasty – A prospective randomized clinical trial. IAIM, 2015; 2(3): 57-67. Available online at www.iaimjournal.comReceived on: 09-02-2015 Accepted on: 19-02-2015AbstractBackground: Inguinal hernia surgery is the most commonly performed surgery worldwide.Lichtenstein tension free repair using polypropylene mesh is the gold standard procedure foringuinal hernioplasty. Wound infection is the most common complication encountered in anysurgical procedure. Antibiotic prophylaxis for open inguinal hernioplasty in minimizing woundinfection has been a subject of debate since the beginning of mesh repair. We have conducted arandomized clinical trial in our hospital to analyze the usefulness of antibiotics in open inguinalhernioplasty.Material and methods: 60 patients were included in this prospective randomized control trial. 30 ofthem received 1 g of Injection Cefataxim half an hour before surgery and remaining 30 receivedinjection Multivitamin infusion. Lichtenstein tension free hernia repair using polypropylene meshwas done. Superficial SSI was diagnosed according to CDC criteria.Results: Totally 5 patients developed SSI (8.33%). Out of the five, 2 (6.67%) were in antibiotic groupand remaining 3 (10%) were in placebo group (p = 0.64). Odd’s ratio was 0.6429 (CI=0.0995 to4.1531). All 5 had only superficial SSI; there was no deep surgical site infection (SSI). 2 patients weremanaged with dressing alone and remaining 3 with antibiotics. After 2 weeks, 2 had wound gappingand at four weeks wound was normal in all patients. 2 out of 5 were above 60 years of age and noSSI occurred >30 years of age (p value = 0.59).Conclusion: Routine use of antibiotics is not necessary in all open inguinal hernioplasty. Antibioticscan be reserved only for patients who are in high risk of SSI. Regularizing the use of antibiotics willhave a good cost benefit and decrease the emergence of drug resistant organisms.International Archives of Integrated Medicine, Vol. 2, Issue 3, March, 2015. Page 57Copy right © 2015, IAIM, All Rights Reserved.

Role of antibiotic prophylaxis in open inguinal hernioplasty ISSN: 2394-0026 (P) ISSN: 2394-0034 (O)Key wordsOpen inguinal hernioplasty, Antibiotic prophylaxis, Surgical site infection.Introduction encountered in any surgical procedure. In case of open inguinal hernioplasty the incidence ofHernia is a protrusion of a viscus through an infection is reported to be very low, 0.4 – 2%abnormal opening in the walls of its containing [17, 18, 19]. Incision site infection has found tocavity [1]. 75% of all hernia occurs in groin and be the frequent problem faced in mesh repairinguinal hernia is the most common form of all [20, 21]. Most worrisome problem is mesh[2]. Inguinal hernias can be either congenital or rejection, occurring following deep surgical siteacquired. Congenital hernias usually occur when infection. Moreover infection following herniathere is impedance in normal developmental repair causes fourfold increased chance ofprocess rather than an acquired weakness [2]. hernia recurrence, but this is in particular withThis is because of patent processus vaginalis herniorraphies [22, 23]. It is well documented(PPV) and this explains the higher incidence of that antibiotic prophylaxis is recommended incongenital hernias in preterm babies. Acquired ‘clean-contaminated’ procedures like colorectalhernia can be direct, indirect or combination of resection as they can significantly decreaseboth. In adult males 65% of inguinal hernias are infectious complications such as incisionindirect and 55% of them are right sided [2]. infection [24]. The antibiotic prophylaxis is alsoCause of the hernia is multi-factorial. Increased indicated in ‘clean’ surgeries’ such as Hip orintra abdominal pressure and weak abdominal knee arthroplasties, cardiac or vascular graftwall are the basis of hernia formation. Inguinal where foreign material is used. It is uncertainhernia surgery is the most commonly performed whether antibiotic prophylaxis is necessary in allsurgery worldwide [3]. About one third of the hernia surgeries as the infection rate is very low,surgical interventions made by general surgeons even when a foreign body like mesh is used [12,are inguinal hernia repair [4]. Mesh repair has 25]. Therefore, antibiotic prophylaxis for openbecome the most popular technique in the West inguinal hernioplasty in minimizing woundfor inguinal hernia since 1975 [5, 6, 7, 8, 9]. In infection has been a subject of debate since thethe United States and Europe more than ten beginning of mesh repair in 1975 [11]. One triallakhs hernia surgeries are performed annually has reported a 10 fold decrease in SSI withand the figure is nearly equal in India [3, 10]. antibiotic prophylaxis [26] while two otherFirst mesh repair was used for recurrent hernia studies did not [27, 28]. One study have hasand then for all others [11]. Among the open concluded that antibiotic prophylaxis cannot bemesh repair procedures Lichtenstein technique recommended firmly or discarded blindly [29].is the most frequently performed technique Unnecessary use of antibiotics is discouraged for[12]. Lichtenstein repair for inguinal hernia is a its inherent complication. Routine use oftension free strengthening of posterior inguinal antibiotic prophylaxis in mesh repair of inguinalfloor using polypropylene mesh [13, 14]. It is hernia can lead to bacterial resistance andalso proven that recurrence of hernia is very low increase in hospital costs [30, 31, 32, 33]. Beingwith mesh repair [9]. As of now, numerous a commonly performed procedure worldwide,clinical trials and meta-analysis have concluded limiting the indiscriminate use of antibiotic willthat mesh repair is the “gold standard” in have greater influence in cost benefits,inguinal hernia repair [10, 15, 16]. Wound emergence of drug resistant bacteria and also ainfection is the most common complication possibility in reducing toxic or allergic effects ofInternational Archives of Integrated Medicine, Vol. 2, Issue 3, March, 2015. Page 58Copy right © 2015, IAIM, All Rights Reserved.

Role of antibiotic prophylaxis in open inguinal hernioplasty ISSN: 2394-0026 (P) ISSN: 2394-0034 (O)the antibiotics. Since the review of world between 14-80 years of age and who underwentliterature does not show any clear advantage in Lichtenstein hernia repair from September 2011using antibiotics in hernia surgery, we have to June 2013 were included in the study. Sixtyconducted a randomized clinical trial in our patients were included in the study.hospital to analyze the usefulness of antibiotics Exclusion criteria: Patients with diabetesin open inguinal hernioplasty. mellitus, on steroid therapy, immunocompromised status like HIV,Aim and objectives malignancy, local sepsis in incision site like Tinea• To assess the role of antibiotic cruris, complicated hernia (obstructed and prophylaxis in open inguinal strangulated hernia).hernioplasty. Randomization of treatment groupsMaterial and methods All the patients were double blinded randomly into one of the two groups – antibiotic orThis study was performed after getting approval placebo group. Randomization was done usingfrom the human ethical committee and the post simple randomization technique. Randomizationgraduate coordinating committee of Mahatma chart was made before starting the study, andGandhi Medical College and Research institute. patients were allotted to either of the groupThis study was conducted in Mahatma Gandhi based on their serial number in theMedical College and Research Institute. Faculty randomization chart.and residents in department of general surgeryperformed the surgeries. All the patients Surgical technique and antibiotic prophylaxisparticipated in the study were informed about Trial medication consisted of either 50 ml ofthe merits and demerits of the study and dextrose saline with multivitamin infusion or 50informed written consent was obtained. ml of dextrose saline with 1 g of CefotaximeCharacteristics of the study (third generation cephalosporin). Multivitamin infusion was chosen as placebo to match the • Participants: 60 patients who color of cefotaxime, so that the optical underwent inguinal hernia mesh repair. difference was excluded and the patient or the operating surgeon was not aware of the group • Group: Two groups (30 in each). to which the patient was belonging to. In short, • Type of study: Randomized control the groin of the patient was prepared by trimming or clipping of the groin hair in the clinical trial. previous night. Then the surgical site was cleaned with betadine scrub for 3 - 5 minutes • Randomization: Simple randomization. before the surgery. After anesthetizing the • Statistical analysis: Chi Square test. • Intervention: Surgery – Hernioplasty; Medication - Injection Cefotaxime 1 g inantibiotic group and injection patient, the trial medication was given. Then themultivitamin infusion in placebo group. incision site was painted at least four times with• Outcome analyzed: Superficial Surgical 5% betadine solution for 3 - 5 minutes. TheSite Infection (SSI). operation was performed by faculty or by resident assisted by a senior surgeon. ACharacteristics of the patients standard open Lichtenstein hernia repair wasInclusion criteria: Patients with primary or performed as described by Lichtenstein Herniarecurrent, unilateral or bilateral inguinal hernia Institute [14]. A monofilament polypropyleneInternational Archives of Integrated Medicine, Vol. 2, Issue 3, March, 2015. Page 59Copy right © 2015, IAIM, All Rights Reserved.

Role of antibiotic prophylaxis in open inguinal hernioplasty ISSN: 2394-0026 (P) ISSN: 2394-0034 (O)flat mesh was sutured in place using In the total study subjects, 28 (46.7%) hadmonofilament polypropylene (prolene). Types of hernia on right side. Among the 28 right sidedanesthesia and skin closure were not inguinal hernias, 11 were in antibiotic group andstandardized. If the procedure exceeded two 17 were in placebo group. Twenty two (36.7%)hours of time then the patients were excluded patients had left sided inguinal hernia, 13 infrom the study. antibiotic group and 9 in placebo group. Among 60 patients 10 (16.7%) patients had bilateralAll the collected data were recruited using a hernia. Among them 6 were in antibiotic grouppredesigned proforma. Data was entered in the and 4 in placebo group as per Table - 2.Microsoft excel sheet. Statistical analysis wasdone using chi-square test. Patients were first Among the 10 patients who had bilateral hernia,examined on second post operative day for SSI. only 6 patients underwent bilateral herniaThen patients were reviewed after two weeks repair. Remaining 4 underwent hernia repair onand four weeks. Thorough clinical examination one side (three in left side and one in right side).was done to rule out surgical site infection. So in 60 subjects, 66 hernia surgeries wereWound infection was defined by the Centers for performed. Out of the 66 surgeries, 37 (56.06%)Disease Control and prevention Criteria [30]. If of them were indirect type, 24 (36.36%) of themthe patient had developed SSI, he was initially were direct type and 5 (7.58%) of them weremanaged with dressing alone. If required even a pantaloon type as per Table - 3.suture was removed to let out the discharge. Ifthere was no response or infection was SSI incidence in the study population was 8.33%progressing, antibiotics were started. (5 out of 60). Out of the five, 2 (6.67%) were in antibiotic group and remaining 3 (10%) were inResults placebo group. That is 60% of SSI occurred in placebo group and 40% in antibiotic group. TheThis study was conducted in 60 patients who incidence of SSI in the two groups wasunderwent Lichtenstein Hernia repair. All statistically insignificant. p value was 0.6400 andpatients were randomized into two groups – Chi-Square value was 0.2180. Odd’s ratio wasAntibiotic group and Placebo group. 30 patients 0.6429 with 95% CI of 0.0995 to 4.1531.were included in each group. All the patientswere male in both the groups. Out of sixty patients, five of them developed SSI.All patients were evenly distributed among Among the five patients who developed SSI twodifferent age groups from 19 years to 80 years were above the age of 60 years. No patientsof age. The mean age in the antibiotic group was were less than 30 years of age. The correlation44.33 with standard deviation of 17.235 and between age and development of SSI was notthat in placebo group was 45.77 with SD of statistically significant. P value was 0.59 and chi-12.20. Maximum patients were in 19 - 30 years. Square value was 2.812 as per Table - 4.Minimum patients were in 41 - 50 years. The age In the five patients who developed SSI, SSIwise distribution of patients in both the groups occurred in 4th post operative day in 2 patientswas statistically insignificant (p value = 0.711). and on 5th post operative day in remaining 3. InAge wise distribution of two groups was as per the antibiotic group SSI occurred on 5th postTable – 1. operative day in both the patients. In the placebo group two patients developed SSI on 4thInternational Archives of Integrated Medicine, Vol. 2, Issue 3, March, 2015. Page 60Copy right © 2015, IAIM, All Rights Reserved.

Role of antibiotic prophylaxis in open inguinal hernioplasty ISSN: 2394-0026 (P) ISSN: 2394-0034 (O)post operative day and one developed on 5th intravenous cephalosporin or a placebo. Therepost operative day. were 8 infections (1.6%) in the antibiotic prophylaxis group and 9 (1.8%) in the placeboOut of five SSI, 2 (one in each group) were group (P 0.82). There was 1 deep infection in themanaged by wound dressing with or without antibiotic prophylaxis group and 2 in the placeboremoving a suture. Remaining three (1 in group (P 0.57).antibiotic group and 2 in placebo group) weremanaged with antibiotics and daily dressing. Perez AR, et al. [34] also concluded similarAmong the five patients who developed SSI, 2 results like Aufenacker TJ, et al. study. Whereaspatients had wound gapping after two weeks. Perez AR, et al. conducted a prospective,Both of them were in placebo group. There was randomized, double-blind, placebo-controlledno wound gapping in patients who did not trial comparing wound infection rates in 360develop SSI. After four weeks surgical site in all patients (lesser than Aufenacker TJ, et al.) whothe patients were healthy. underwent primary inguinal hernia repair electively using polypropylene mesh. OneDiscussion hundred and eighty patients received prophylactic antibiotics and 180 received aThis study was conducted in Mahatma Gandhi placebo. Superficial SSI developed in 3 patientsMedical College and Research Institute, (1.7%) from the antibiotic group and 6 (3.3%)Puducherry for a period of one and half years, from the placebo group (p = 0.50). One fromfrom September 2011 to June 2013. 60 patients each group developed deep SSI.who underwent inguinal hernioplasty wereincluded in the study. Main objective was to Both the above mentioned studies showed noanalyze the usefulness and necessity of significant difference in incidence of SSIprophylactic antibiotics in inguinal hernioplasty. between the antibiotic group and the placeboIn the present study, incidence of SSI in open group. This is very much comparable to theinguinal hernioplasty was 8.33% (5 out of 60). present study where the incidence of SSI inThe incidence of SSI in the present study was antibiotic group (6.67%) and that in placeboslightly higher than the study done by Yerdel group (10%) was statistically insignificant (pMA, et al. [26] in 280 patients. Aufenacker TJ, et value = 0.64).al. [12] did a study in 1040 patients and reportedSSI incidence as 1.7%. Both the studies showed Present study was also comparable to otherlower incidence of SSI than the present study, studies mentioned as per Table - 5. Odd’s ratiowhich could be attributed due to smaller study was less than one in all the studies. All thesepopulation. trials did not recommend routine use ofRegarding the usage of prophylactic antibiotics antibiotics in open inguinal hernioplasty.in open inguinal hernioplasty, there is still Certain studies showed results which are notconsiderable debate. Aufenacker TJ, et al. [12] in comparable to the present study. Yerdel MA, et2003 conducted a multicenter double blinded al. [26] performed a double-blinded prospective,randomized control trial in 1040 patients with a randomized trial in 1998 in 280 patientsprimary inguinal hernia scheduled for underwent mesh inguinal hernia repair. 140 ofLichtenstein repair. They were randomized to an them received prophylactic 1.5 g intravenouseither preoperative single dose of 1.5 g ampicillin-sulbactum and remaining 140International Archives of Integrated Medicine, Vol. 2, Issue 3, March, 2015. Page 61Copy right © 2015, IAIM, All Rights Reserved.

Role of antibiotic prophylaxis in open inguinal hernioplasty ISSN: 2394-0026 (P) ISSN: 2394-0034 (O)received placebo. SSI occurred at a rate of 0.7% al. and 2 out of 360 deep SSI in study conductedin the antibiotic group and 9% in the placebo by Perez AR, et al. All Superficial SSI weregroup (p = 0.00153). Out of twelve in placebo managed by either antibiotics or woundgroup, three patients suffered deep infections. dressing. No mesh rejection or mesh infectionThis study documented a significant (10-fold) was encountered in the present study.decrease in overall wound infections whensingle-dose intravenous antibiotic was used Potential drawback of this study is a smallerduring Lichtenstein hernia repair. Difference of study population. Depending on the sample sizeSSI between the two groups was significant, formula and base rate of SSI, to perform a RCTwhich is contradictory to the present study. with enough power to detect a 50% decrease SSI rates, it will be necessary to include 1600 toIn 2007, Sanabria A, et al. [21] conducted a 3000 patients. If we want to detect even smallermeta-analysis by compiling the databases of percentage decrease in SSI larger studyCochrane Hernia Trialists Collaboration, population is needed. Another drawback is weCochrane Collaboration, MEDLINE, EMBASE and followed up the patients only for four weeks butLILACS. Study included six randomized according to CDC criteria, if implant is used, thencontrolled trials that evaluated mesh inguinal any infection occurring up to 1 year will behernia. A total of 2507 patients were analyzed. considered as SSI. But development of SSI afterThe SSI frequency was 1.3% in the antibiotic one month of hernia surgery is rare. Anothergroup and 2.89% in the control group (odds ratio demerit of the study is culture & sensitivity of0.48, 95% confidence interval (CI) 0.27–0.85). the discharge from SSI site was not done, but itFrom this study it was reported that antibiotic is beyond the scope of the study.use in patients with mesh inguinal hernioplastydecreased the rate of SSI by almost 50%. Both Regularizing the use of antibiotics will have athe studies (Yerdel MA, et al. and Sanabria A, et good cost benefit effect on larger scale. It isal.) are contradictory to the present study, estimated that around 10 million Euros arewhere there was no significant difference spent annually for giving antibiotic prophylaxisbetween antibiotic and placebo group. in low risk patients in US and Europe [41, 42]. More over emergence of drug resistantAge is an important risk factor in the microbes because of unwarranted antibiotic usedevelopment of any surgical site infection [36, can be grossly minimized. There is an unknown38, 39]. But in the present study age was not impact on bacterial resistance because ofassociated to the development of SSI. P value routine use of antibiotics in primary inguinalwas 0.59 which is not significant. This is against repair [43]. Also patients can be free of the toxicanother study conducted by Taylor EW, et al. or allergic effects of the drugs.[40], which showed that age more than 70 yearsis a risk factor for SSI. This could be due to lesser Even after considering and analyzing all theseelder study population (11 out 60 were > data and trials, the argument about antibiotic60years of age) in the present study. prophylaxis is still open. There must be a detailed and clear analysis regarding the choiceAll five SSI occurred were only superficial, no of patients for antibiotic prophylaxis. It isdeep surgical site infection was encountered in unnecessary to give antibiotics as a routine forthe present study. But there were 3 out of 1040 all hernia repairs. Patients at high risk like olddeep SSI in study conducted by Aufenacker TJ, et age, co-morbid factors, and immuneInternational Archives of Integrated Medicine, Vol. 2, Issue 3, March, 2015. Page 62Copy right © 2015, IAIM, All Rights Reserved.

Role of antibiotic prophylaxis in open inguinal hernioplasty ISSN: 2394-0026 (P) ISSN: 2394-0034 (O)compromised status require antibiotic 4. Cainzos MA. Antibiotic prophylaxis. Newprophylaxis. But still large trials are required to Horiz, 1998; 6: 11–17.define high risk patients. Large randomized 5. Bay-Nielsen M, Kehlet M, Strand L.clinical trials involving both high risk and low risk Quality assessment of 26304groups are required to analyze the true herniorrhaphies in Denmark: Anecessity of antibiotics. prospective nationwide study. Lancet, 2001; 358: 1124 – 28.Present study though conducted in smaller 6. Hair A, Duffy K, McLean J. Groin herniapopulation did not show any difference in SSI repair in Scotland. Br J Surg, 2000; 87:between the two groups. So we do not 1722–26.recommend the use of antibiotics in inguinal 7. Nilsson E, Haapaniemi S, Gruber G.hernioplasty. Surgeons and hospitals should Methods of repair and risk foranalyse their own SSI rate in their hospital to reoperation in Swedish hernia surgeryassess the need of antibiotic prophylaxis. from 1992 to 1996. Br J Surg, 1998; 85: 1686–91.Conclusion 8. Nyhus LM, Alani A, O’Dwyer PJ. The problem: How to treat a hernia. In:The overall incidence of SSI in open inguinal Schumpelick V, Nyhus LM, eds. Meshes:hernioplasty is 8.3% (5 out of 60). Incidence of Benefits and Risks, 1st edition. Berlin:SSI in antibiotic group is 6.8% (2 out 30) and that Springer-Verlag, 2004; p. 3–30.in placebo group is 10% (3 out of 30).Development of SSI between the antibiotic and 9. EU Hernia Trialists Collaboration, Meshplacebo groups is statistically insignificant. Age is compared with non-mesh methods ofnot a significant risk factor for development of open groin hernia repair: SystematicSSI (p value = 0.59). Routine use of antibiotics is review of randomized controlled trials.not necessary in all open inguinal hernioplasty. Br J Surg, 2000; 87: 854–859.Antibiotics can be reserved only for patientswho are in high risk of SSI. 10. Rutkow IM. Demographic and socioeconomic aspects of hernia repair in the United States in 2003. Surg ClinReferences North Am, 2003; 83: 1045–51. 11. Patino JF, Garcia-Herreros LG, Zundel N. 1. Andrew N, Kingsworth, Giorgi G, David HB. Chapter 57: Hernia, umbilicus and Inguinal hernia repair: The Nyhus abdominal wall. Bailey & Love's Short posterior peritoneal operation. Surg Cil Practise of Surgery, 25th edition. North Am, 1998; 78: 1063–74. 12. Aufenacker TJ, van Geldere D, van 2. Vadim S, James RM, Chamrles FB. Mesdag T. The Role of Antibiotic Chapter26: Inguinal Hernias, Schwartz's Prophylaxis in Prevention of Wound Principles of Surgery, p. 1305-1342. Infection After Lichtenstein Open Mesh Repair of Primary Inguinal Hernia - A 3. Jain SK, Jayant M, Norbu C. The role of Multicenter Double-Blind Randomized antibiotic prophylaxis in mesh repair of Controlled Trial. Ann Surg, 2004; 240: primary inguinal hernias using prolene 955–961. hernia system: A randomized 13. Burger JW, Luijendijk RW, Hop WC, Halm prospective double-blind control trial. JA, Verdaasdonk EG, Jeekel J. Long term Trop Doct, 2008; 38: 80-2. follow-up of a randomized controlledInternational Archives of Integrated Medicine, Vol. 2, Issue 3, March, 2015. Page 63Copy right © 2015, IAIM, All Rights Reserved.

Role of antibiotic prophylaxis in open inguinal hernioplasty ISSN: 2394-0026 (P)trial of suture versus mesh repair of ISSN: 2394-0034 (O) operations: results of prospective,Incisional hernia. Ann Surg, 2004; 240: randomized, double-blind clinical study.578–585. Ann Surg, 1977; 186: 251-9.14. Lichtenstein IL, Shulman AG, Amid PK. 25. Jian-Fang Li, Dan-Dan Lai, Xiao-DongThe tension-free hernioplasty. Am J Zhang, Ai-Min Zhang,Kuan-Xue Sun,Surg, 1989; 157: 188–193. Heng-Gui Luo, ZhenYu. Meta-analysis of15. Vrijland WW, van den Tol MP, Luijendijk the effectiveness of prophylacticRW. Randomized clinical trial of non- antibiotics in the prevention ofmesh versus mesh repair of primary postoperative complications afteringuinal hernia. Br J Surg, 2002; 89: 293– tension-free hernioplasty. Can J Surg,297. 2012; 55: 112-14.16. Nordin P, Bartelmess P, Jansson C. 26. Yerdel MA, Akin EB, Dolalan S. Effect ofRandomized trial of Lichten-stein versus single-dose prophylactic ampicillin andShouldice hernia repair in general sulbactam on wound infection aftersurgical practice. Br J Surg, 2002; 89: 45– tension-free inguinal hernia repair with49. polypropylene mesh. Ann Surg, 2001;17. Stephenson BM. Complications of open 233: 26–33.groin hernia repair. Surg Clin North Am, 27. Morales R, Carmona A, Paga ́n A. Utility2003; 83: 1255-78. of antibiotic prophylaxis in reducing18. Condon RE, Wittmann DH. The use of wound infection in inguinal or femoralantibiotics in general surgery. Curr Probl hernia repair using polypropylene mesh.Surg, 1991; 28: 803–907. Cir Esp, 2000; 67: 51–59.19. Woods RK, Dellinger EP. Current 28. Gilbert AI, Felton LL. Infection in inguinalguidelines for antibiotic prophylaxis of hernia repair considering biomaterialssurgical wounds. Am Family Physician, and antibiotics. Surg Gynecol Obstet,1998; 57: 2731–2734. 1993; 177: 126–130.20. Bendavid R. Complications of groin 29. Sanchez-Manuel FJ, Seco-Gil JL.hernia surgery. Surg Clin North Am, Antibiotic prophylaxis for hernia repair1998; 78: 1089-103. (Cochrane Review). In: The Cochrane21. Sanabria A, Dominguez LC, Valdiviseso E. Library, Issue 2. Oxford: UpdateProphylactic antibiotics for mesh software, 2003.inguinal hernioplasty - A metaanalyis. 30. Mangram AJ, Horan TC, Pearson ML.Ann Surg, 2007; 245: 392–6. Guideline for prevention or surgical site22. Glassow F. Is postoperative wound infection, 1999. Infect Control Hospinfection following simple inguinal Epidemiol, 1999; 20: 247–280.herniorrhaphy a predisposing cause for 31. Das S. A Manual on Clinical Surgery.recurrent hernia? Can J Surg, 1964; 91: Chapter 38: Examination of a case of870–871. hernia, p. 436-448.23. Meyers RN, Shearburn EW. The problem 32. Platt R, Zaleznik DF, Hopkins CC,of recurrent inguinal hernia. Surg Clin Dellinger EP, Karchmer AW, Bryan CS.North Am, 1973; 53: 555–558. Perioperative antibiotic prophylaxis for24. Clarke JS, Condon RE, Bartlett JG. hernioraphy and breast surgery. N Engl JPreoperative oral anti- biotics reduce Med, 1990; 322: 153–60.septic complications of colonInternational Archives of Integrated Medicine, Vol. 2, Issue 3, March, 2015. Page 64Copy right © 2015, IAIM, All Rights Reserved.

Role of antibiotic prophylaxis in open inguinal hernioplasty ISSN: 2394-0026 (P)33. Othman I. Prospective randomized ISSN: 2394-0034 (O) role in musculoskeletal infections.evaluation of prophylactic antibiotic Orthop Clin North Am, 1984; 15: 517–usage in patients undergoing tension 35.free inguinal hernioplasty. Hernia, 2011; 39. Esposito S, Leone S, Noviello S, Ianniello15: 309-13. F, Marvaso A, Cuniato V, Bellitti F, J34. Perez AR, Roxas MF, Hilvano SS. A Chemother. Antibiotic prophylaxis inrandomized, double-blind, placebo- hernia repair and breast surgery: Acontrolled trial to determine prospective randomized studyeffectiveness of antibiotic prophylaxis comparing piperacillin/tazobactamfor tension-free mesh herniorrhaphy. J versus placebo, Journal ofAm Coll Surg, 2005; 200: 393-7 Chemotherapy, 2006; 18: 278-84.35. Tzovaras G, Delikoukos S, 40. Taylor EW, Duffy K, Lee K. Surgical siteChristodoulides G, Spyridakis M, infection after groin hernia repair. Br JMantzos F, Tepetes K, Athanassiou E, Surg, 2004; 91: 105-11.Hatzitheofilou C. The role of antibiotic 41. Weed HG. Antimicrobial prophylaxis inprophylaxis in elective tension-free the surgical patient. Med Clin North Am,mesh inguinal hernia repair: Results of a 2003; 87: 59-75.single-centre prospective randomised 42. Source: Z-index database of Koninklijketrial. Int J Clin Pract, 2007; 61: 236-9. Nederlandse Maatschappij ter36. Goyal A, Garg R, Jenaw R. K., Jindal DK. bevordering der Pharmacie (KNMP), TheRole of Prophylactic Antibiotics in Open Hague, The Netherlands.Inguinal Hernia Repair: A Randomised http://www.knmp.nl. Accessed inStudy. Indian Journal of Surgery, 2011; December 2003.73: 190-193. 43. Waldvogel FA, Vaudaux PE, Pittet D.37. Thakur L, Upadhyay s, Peters NJ, Saini N, Perioperative antibiotic prophylaxis ofDeodhar M. Prophylactic antibiotic wound and foreign body infections:usage in patients undergoing inguinal microbial factors affecting efficacy. Revmesh hernioplasty – A clinical study. Infect Dis, 1991; 13: 782–89.Indian J Surg, 2010; 72: 240–42.38. Gristina AG, Costerton JW. Bacterialadherence and the glycocalyx and theirSource of support: Nil Conflict of interest: None declared.International Archives of Integrated Medicine, Vol. 2, Issue 3, March, 2015. Page 65Copy right © 2015, IAIM, All Rights Reserved.

Role of antibiotic prophylaxis in open inguinal hernioplasty ISSN: 2394-0026 (P)Table – 1: Age wise distribution of two groups. ISSN: 2394-0034 (O)Sr. % Age distribution (in years) Antibiotic group % Placebo group 13.33No. 26.67 26.671 19 - 30 11 36.67 4 20 13.332 31 - 40 3 10 8 1003 41 - 50 2 6.67 84 51 - 60 7 23.33 65 > 60 7 23.33 46 Total 30 100 30Mean age in A group = 44.33 ± 17.235 and in P group = 45.77 ± 12.2; p value = 0.711Table – 2: Distribution of side of inguinal hernia.Side of hernia In antibiotic group % In placebo group %Right 11 36.67 17 56.67Left 13 43.33 9 30Bilateral 6 20 4 13.33Total 30 100 30 100Table – 3: Types of inguinal hernia.Type of hernia In antibiotic group % In placebo group %Indirect 22 62.86 15 48.39Direct 11 31.43 13 41.93Pantaloon 2 5.71 3 9.68Total 35 100 31 100Table – 4: Age wise distribution of SSI.Sr. Age group (in years) SSI distribution among age groups TotalNo. Yes No 151 < 30 0 15 112 31 - 40 1 10 103 41 - 50 19 134 51 - 60 1 12 115 > 60 29 606 Total 5 55p value = 0.59 Chi-Square value = 2.812International Archives of Integrated Medicine, Vol. 2, Issue 3, March, 2015. Page 66Copy right © 2015, IAIM, All Rights Reserved.

Role of antibiotic prophylaxis in open inguinal hernioplasty ISSN: 2394-0026 (P)Table – 5: Comparison of present study with other clinical trials. ISSN: 2394-0034 (O)Study Antibiotic SSI in SSI in Placebo group Antibiotic Placebo p valueThakur L, et al. [37] group groupOthman I, et al. [33] 29 3 groupTzovaras, et al. [35] 50 4 26Jain, et al. [3] 193 5 48 4 > 0.01Present study 60 1 193 6 0.47 60 2 60 9 0.4 60 1 > 0.01 3 0.64International Archives of Integrated Medicine, Vol. 2, Issue 3, March, 2015. Page 67Copy right © 2015, IAIM, All Rights Reserved.