49 The incidence of abdominal surgical site infections after abdominal birth defects surgery in infants Chapter 2 Fistula development following surgery for abdominal birth defects seems rare according to our results. Fistula development is more frequently seen after necrotizing enterocolitis (5%), which was not included in this review since it is an acquired disease.[195] Since infections can lead to serious morbidity and mortality, it is understandable that antibiotics are widely used during the course of surgical correction of many of the reported birth defects. Yet, ambiguity exists on the effectiveness and safety of antibiotics in this cohort. Proper administration of perioperative antibiotics in paediatric patients in general seems to reduce SSIs. . However, recent studies show that prolonged antibiotic exposure in infants could result in serious side effects: antibiotics alter gut microbiota, increase risk of necrotizing enterocolitis, late onset sepsis and even death.[196, 197] Additionally a recent systematic review showed that pre-operative antibiotic treatment did not influence the occurrence of surgical site infections in neonates.[198] Yet, this lack of effectiveness in neonates could be explained by a lack of appropriate timing of administration, which could be improved by correct protocol adherence.[205] This review has its limitations, one of which was the high statistical and clinical heterogeneity. This was lowered for wound infections, wound dehiscence and anastomotic leakage by stratifying per birth defect, which was not possible for fistula development and post-operative peritonitis. Since some birth defects such as gastroschisis only occur in neonates, this stratification might have led to differences in age between birth defects. This age-difference could be an important reason why certain birth defects are more at risk of SSIs. Since this review does not aim to compare SSI rates between birth defects we feel that not stratifying for age has not hampered the message of our review. Moreover, only including studies done in neonates would have led to the exclusion of important birth defects that tend to be diagnosed beyond the neonatal period but within the infantile age, such as Hirschsprung’s disease. Another limitation is that most studies did not describe a clear definition of the SSIs, which could result in observer bias. Scoring systems, which are suggested to be used to objectify wound infections, were not reported in any studies.[199] All these conceptual differences between studies will have increased clinical heterogeneity, which is not correctable. Furthermore, the reported pooled proportions are based on the available literature, which undeniably has led to the influence of forms of bias such as selection, publication and reporting bias. Therefore, the incidences in this review might be an underestimate of the true value. Although these limitations might have affected the pooled analyses, the presented data is the best available approximation of the incidences of the infectious complications in the infantile cohort.
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