Utilization of combination bowel preparation (CBP) is protective against the development of post-operative Clostridium difficile infection (CDI), decreases septic complications, and provides a survival benefit.

Background: The current standard recommended by the American Society of Colon and Rectal Surgeons (ASCRS) is to utilize a combined bowel preparation (CBP) that involves both mechanical (MBP) and oral antibiotic (ABP) components. The current literature is equivocal on whether ABP predisposes to post-operative Clostridium difficile infection (CDI). CDI following colorectal surgery is a significant complication leading to increase in significant morbidity and mortality. Objective was to further delineate the association between CBP and CDI.

Methods: Retrospective review of the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) registry was performed. Specifically the main and targeted colectomy/proctectomy databases for 2015 and 2016 were analyzed. 64,449 colorectal surgeries were contained. Exclusion of non-elective cases and cases that did not utilize a bowel preparation or used ABP alone resulted in 24,000 cases for final analysis. Primary endpoint was post-operative CDI development. Secondary analysis involved surgical site infections (SSIs), anastomotic leaks, and sepsis development. 30-day mortality rates, rapidity of return of bowel function, and length of stay were also evaluated.

Results: Approximately two-thirds of the cases analyzed involved CBP and the remaining third used MBP alone. Cases that utilized CBP had statistically significant lower rates of all infectious complications evaluated. CBP was found to be protective in regard to the development of CDI with an odds ratio (OR) of 0.58. Our results collaborate the current literature that CBP decreases SSIs and anastomotic leaks with ORs of 0.58 and 0.79, respectively. CBP had its most profound effect on lowering septic shock and mortality rates halving the incidence of both.

Conclusion: Our findings support the ASCRS guidelines for routine utilization of CBP to optimize post-operative outcomes. CBP does not increase the risk of CDI and in fact is significantly protective. CBP potentially also provides decreased risk of sepsis and mortality.