Cefoxitin versus Cefepime for the Prevention of Perioperative Infection in Elderly Patients Undergoing Colorectal Cancer Surgery: A Retrospective Study

Cefoxitin versus Cefepime for the Prevention of Perioperative Infection in Elderly Patients Undergoing Colorectal Cancer Surgery: A Retrospective Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Cefoxitin versus Cefepime for the Prevention of Perioperative Infection in Elderly Patients Undergoing Colorectal Cancer Surgery: A Retrospective Study Yangxi Liu, Yang Luo, Jing Xu, Zaili Zhang, Bisheng Shi, Xiaojun Ni This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3815362/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background The optimal antibiotic prophylaxis in preventing perioperative infection in patients aged 70 who underwent colorectal cancer surgery of are unknown. We conducted a comparative analysis to evaluate the efficacy of cefoxitin and cefepime in preventing perioperative infections and assessed the inflammatory response to antibiotics during the perioperative period. Methods Patients over 70 years old and undergo surgery for colorectal cancer between January 2021 and June 2022 at the same ward of a tertiary teaching hospital in Shanghai, China were included. Demographic and clinical data were retrieved from hospital information system (HIS) to evaluate the body reaction of two antibiotic prophylaxis: patients in Group A received cefoxitin and in Group B accepted cefepime after surgery. Both antibiotics were intravenous 2000mg, two times daily, total 3 days. The effect of perioperative prevention was compared between two groups with any infection complications, hospital length of stay (HLOS), postoperative length of stay (POLS) and mortality during hospitalization. Results A total of 107 elderly patients (56 patients in Group A and 51 patients in Group B) with colorectal cancer were included. Two groups were similar in terms of tumor stage and other basic demographic. Patients received cefoxitin demonstrated lower infection complications (12.5% vs 13.7%, P = 0.851), among which surgical site infection (SSI) were most frequent complications in both groups (8.5% vs 9.8%, P = 0.877). However, patients with cefepime represented shorter HLOS (14.0 ± 4.7 days vs 13.9 ± 3.8 days, P = 0.912) and PLOS (9.4 ± 3.8 days vs 8.4 ± 2.1 days, P = 0.265). Additionally, the percentage of cluster of differentiation (CD) 4 + cell was significantly higher (29.2%±9.2 vs 46.5%±10.0, P = 0.001) and the percentage of CD8 + cell was statistical lower (26.1% [23.1, 34.4] vs 19.2% [15.5, 20.4], P = 0.004) in Group B compared to Group A at the third postoperative day. No death occurred in both groups. Conclusion Cefepime and cefoxitin both serve as useful prophylaxis to reduce infectious complications among elder patients underwent surgery for colorectal cancer. However, cefepime illustrated a more active inflammatory response and might enhance the body recovery in early post-operative rehabilitation. Cefoxitin Cefepime Perioperative prophylaxis Colorectal cancer surgery Elderly Figures Figure 1 Figure 2 Introduction Postoperative infections, especially surgical site infections (SSIs), have been associated with increased mortality rates, elevated hospitalization costs, and extended hospital stays. Colorectal surgery is among the procedures with the highest SSI incidence rates, potentially reaching up to 9.5%, even when adhering to antimicrobial prophylaxis guidelines [ 1 – 3 ]. Beyond SSIs, other postoperative infections such as intra-abdominal infections (IAIs), hospital-acquired pneumonia (HAP), and urinary tract infection (UTI) also significantly contributed to hospital readmissions, costs, and mortality [ 4 ]. Elderly patients, often presenting with poor nutritional status and comorbidities, are at an increased risk of postoperative infections [ 5 ]. Despite this, the majority of studies do not recommend age-based antibiotic prophylaxis, and the optimal regimen for elderly patients remains undetermined. Furthermore, the inflammatory responses to various antimicrobial prophylaxis are linked to biomarkers such white blood cell count (WBC), C-reactive protein (CRP), and lymphocyte subsets [ 6 , 7 ]. However, few studies focus on the fluctuation in these inflammation profile, particularly in the elder population. This lack of research complicates the selection of perioperative antimicrobial prophylaxis for elderly patients undergoing colorectal cancer surgery. Previous studies on colorectal surgery have recommended the use of perioperative antibiotics that are effective against enteric Gram-negative bacilli, Enterococcus and anaerobic pathogens [ 8 , 9 ]. Cefoxitin, a short-acting cephamycin with broad spectrum of antibacterial activity against gram-negative and anaerobic bacteria [ 10 ], has been recommended by guidelines in both United States (US) and China to prevent SSIs in colorectal surgery [ 11 , 12 ]. However, the efficacy of cefoxitin in perioperative setting is unclear in areas with increasing antibiotics resistance of Enterobacteriaceae . In clinical practice, fourth-generation cephalosporins are preferred in institutions with increasing resistance to second- and third-generation cephalosporins, especially in patients with risk factors such as age over 70 or cancer. Cefepime, a representative fourth-generation cephalosporin with good therapeutic efficacy in the treatment of IAIs, HAP and UTI, may be a potential choice for antibiotic prophylaxis in colorectal surgery [ 13 ]. Therefore, we conducted this retrospective study to assess the effectiveness of cefepime as a perioperative antimicrobial prophylaxis in elderly patients undergoing surgery for colorectal cancer compared to cefoxitin, and to evaluate the impact of both regimens on the immune system after operation. Methods Study Design and Setting This retrospectively study was designed to evaluate and compare the efficacy of cefoxitin and cefepime in preventing infectious complications in patients aged 70 and above, who underwent colorectal cancer surgery. The primary outcome measures encompassed any perioperative infectious complications, hospital length of stay (HLOS), postoperative length of stay (PLOS), and mortality during hospitalization. Secondary outcome measures comprised inflammation-associated biomarkers such as routine blood test, biochemical test, T lymphocyte subgroups, and other general body response to infection, including body temperature, renal and hepatic function. To accurately depict the dynamic changes in response to antimicrobial agents, relevant indicators were monitored preoperatively, on the third postoperative day, and one week postoperatively, respectively. Inclusion Patients and Perioperative Treatment Our study incorporated patients aged over 70 years old, diagnosed with colorectal cancer, who underwent elective laparoscopic colorectal resection at Ren Ji Hospital, School of Medicine, Shanghai Jiaotong University, from June 2021 to June 2022. Exclusion criteria were as follows: (1) severe liver, kidney, heart or lung, dysfunction, (2) antibiotic usage within 4 weeks preceding administration, (3) a documented history of cephalosporin allergy, (4) patients presenting with perforation and complete bowel obstruction. All patients accepted mechanical bowel preparation with 2L of polyethylene glycol orally on the day preceding surgery and were administered 2g of cefoxitin intravenously at least 30 minutes prior to skin incision. Postoperatively, patients who received 2g of cefoxitin at 12-hour intervals for 3 days were categorized as Group A (n = 56); while those administered 2g of cefepime at 12-hour intervals as a postoperative antibiotic regimen for 3 days were categorized as Group B (n = 51). Detailed information is depicted in Fig. 1 . The definition of infectious complications was established based on the presence of the following infections after the operation: SSIs, HAP, IAIs and UTIs. The attending surgeons and nurses conducted daily inspections of patients daily until discharge to identify these infections. Data Collection and Statistical Analysis Demographic data, including age, gender, body mass index (BMI), concomitant disease, and tumor stage were collected. Additionally, we obtained the following records from hospital information system (HIS) to assess physical changes: body temperature, white blood cell count (WBC), neutrophilic granulocyte percentage (NEU), and C-reactive protein (CRP), procalcitonin (PCT), liver and renal function, and T lymphocyte levels on the pre-operation day (Pre-O), the third day post-operation (POD-3), and the seventh day post-operation (POD-7). Descriptive statistics were calculated for all variables between the two groups. Mean values and standard deviations were calculated for continuous variables, while counts and percentages for categorical variables. The normality of data sets was assessed using Box plots and histograms. Continuous variables were described as mean ± standard deviation (SD) or median (interquartile range, IQR). Two-sample t-test or Wilcoxon rank-sum test were used to compare continuous variables between the two groups, and Pearson’s Chi-square test was used for categorical variables. All statistical analyses were performed using SPSS 24.0 statistical package (SPSS, Chicago, IL, USA). A significance level of P < 0.05 was considered statistically significant. Results Baseline Characteristics of Included Patients A total of 107 patients aged over 70 with colorectal cancer who underwent elective laparoscopic colorectal resection between January 2021 and June 2022 were included in the study. The patients were divided into two group based on their antibiotic prophylaxis regimen: Group A (56 patients) received cefoxitin, and Group B (51 patients) received cefepime for 3 days after surgery. Demographic data are summarized in Table 1 . All included patients had colorectal tumor stage II or III based on histopathological results. There were no significant differences between the two groups in terms of age, gender, body mass index, concomitant disease, and tumor stage. None of the patients in either group had taken corticosteroids, or other immunosuppressive agents, or chemotherapy regimens before or during hospitalization. Key Outcomes of Perioperative Antimicrobial Prophylaxis The preventive outcomes of perioperative prophylaxis were presented in Table 2 . The incidences of overall postoperative infection complications of Group A was 12.5%, while in Group B it was 13.7%, with no statistical difference between the two groups. Furthermore, there were no significant differences observed in SSIs, HAP, IAIs, and UTIs during the colorectal perioperative period between the two groups. The most common infection complication in both groups was SSIs, with rates of 8.9% in Group A and 9.8% in Group B. Patients receiving cefepime (Group B) had shorter hospitalization (14.2±4.7 vs 13.8±3.8) and postoperative hospital stay (9.5±3.8 vs 8.7±2.0), although these differences were not statistically significant. No cases of UTI or death were observed during hospitalization in either group. Secondary Outcomes Associated with Response to Perioperative Antimicrobial Prophylaxis Prior to the operation, there was no significant difference in the laboratory parameters indicative of infections and inflammatory changes, body temperature, and renal and hepatic function between Group A and Group B at Pre-O ( Table 3 ). However, on POD-3, the percentage of cluster of differentiation (CD) 4+ cell in Group B (46.5±10.0) were significantly higher than Group A (29.2±9.2, P=0.001), while the percentage of CD8+ cell in Group B (19.2[15.5, 20.4]) was significantly lower than in Group A (26.1[23.1, 34.4], P=0.004). Furthermore, on POD-7, there were no significant differences in any of the laboratory parameters between two groups. The dynamic changes of the patient's immune cell examination with cefepime were shown in Figure 2 . Discussion Recent clinical guidelines for antibiotic prophylaxis in colorectal procedure recommended agents such as the first- and second-generation cephalosporins ± metronidazole, and other evidence-based antibiotics, with cefoxitin being one of the most frequently utilized in clinical practice [ 11 , 14 , 15 ]. However, these existing agents do not take into account the risk stratification of patients. For instance, elderly patients with colorectal cancer will experience decrease of immunity, which can affect the prophylactic effect of antibiotics [ 14 , 15 ]. Moreover, previous principles of perioperative antibacterial prophylaxis included studies based on outdated bacterial resistance data. However, bacterial distribution and antibiotic resistance vary by region, for example, China posed significant therapeutic challenges in the rapid proliferation of antimicrobial resistant Gram-negative bacteria [ 16 ]. Consequently, the selection of appropriate antibiotics for patients with varying risks and regional differences requires further clinical evidence. Cefepime is widely recommended for the treatment of various infections, including but not limited to pneumonia, sepsis, IAI. However, the efficacy of cefepime as prophylactic antibiotics in elective colorectal procedure remains unexplored. We compared the infection prevention capabilities of cefepime and cefoxitin in elderly patients with an average age over 75, and underwent surgery for colorectal cancer. We found that the overall infection rate reached over 10% even with the fourth generation cephalosporins for infectious prophylaxis, which indicating we can’t rely on antibiotics solely to reduce the perioperative infection. The innate responses of pathogen are generally evaluated by biomarkers such as PCT, CRP, and WBC count based on risk of infectious complications and provided early opportunity for effective medical support [ 17 , 18 ]. Our study demonstrated that biomarkers PCT, CRP, and WBC count in both groups were higher in early postoperative period compared with pre-operation, and did not return to normal until the seventh day post operation. Other biomarkers such as lymphocyte subsets, especially the main lymphocyte subpopulations (CD4+, CD8+), were crucial in the different stages in the host defense. However, prior studies comparing CD4 + and CD8 + lymphocyte counts have primarily focused on patients with pulmonary tuberculosis (TB) or human immunodeficiency virus (HIV) [ 6 , 7 , 19 ]. Our findings revealed that CD4 + and CD8 + level value varied in early postoperative period with different antibiotics for prophylaxis. Both CD4 + and CD8 + plays a crucial role in immune defense against viruses, intracellular bacteria, and tumors. Previous research has indicated that alterations in CD4 + and CD8 + values typically occur in an opposite manner, thereby coordinating the regulation of immunity function [ 20 ]. Certain antibiotics, such as macrolides, exhibit potent and extensive immunomodulatory effects through various mechanisms, which facilitate the restoration of immune homoeostasis and bolster key antimicrobial defences[ 21 ]. In vitro, azithromycin suppresses CD4 + T-cell activation by directly modulating mTOR activity, potientially further diminishing the activation and mobilization of neutrophils [ 22 ]. Furthermore, it reported that low-dose azithromycin enhances CD8 T-cell granzyme B in patients with chronic obstructive pulmonary disease (COPD) [ 23 ]. β-lactams, apart from their antibacterial properties, have also been investigated for their immunomodulatory effects including allergic responses [ 24 ]. For instance, an in vitro study reported that clavulanic acid and cefoxitin were the most potent inhibitors of IFN-g activity, as assayed by the induction of CD54 on the surface of the lung epithelial cell line A549 [ 24 ]. Another reported β-lactams to possess both antibacterial and immunomodulatory functions was cefodizime, it can enhance the CD4 + value in elderly patients with community-acquired pneumonia (CAP) [ 25 , 26 ]. However, the mechanism in immune response of antibiotics remain incompletely understood in both vitro and in vivo studies. To the best of our knowledge, our research is the first to evaluate antimicrobial prophylaxis with combined outcomes of both infection complications and immune response in elderly. We corroborated that compared to cefoxitin, which might be a potent inhibitor for IFN-g activity, cefepime can enhance the percentage of CD4 + cells (46.5 ± 10) and reduce the percentage of CD8 + cells (19.2[15.5, 20.4]) at POD-3. The phenomenon suggesting that cefepime can improve cellular immunity and have a positive effect during the initial postoperative period in elderly patients undergoing colorectal cancer surgery. Our retrospective analysis also revealed that although cefoxitin exhibited a lower incidence of postoperative infectious complications compared to cefepime, patients receiving cefoxitin had longer HLOS and PLOS. Notably, these differences between the two groups were no statistically significant. Moreover, no significant difference was found in T lymphocytes at one week after surgery with both cefepime and cefoxitin. Therefore, cefepime was considered as efficiency as cefoxitin in preventing infectious complications in colorectal surgery, and it also enhance immunomodulatory properties in early postoperative recovery. We may need to consider the immunomodulation by antibacterial agents in the selection of antibiotics for perioperative prophylaxis in the future. No adverse events were reported and there is no obvious difference in safety between cefepime and cefoxitin. The main limitation of this study was largely attributable to its small sample size. A total of 107 patients in our hospital at the same ward were involved in this study. Systematic measures such as nursing process after operation also have an important effect on SSI rate and the systematic measures in different medical institutions varies. Thus, may have an impact on the infectious complications result. Another limitation was the nature of retrospective study. For example, the CD4 + and CD8 + data in POD-3 were significant different between two groups and further analysis required detailed immune-related cell test which were lacing. Future research should continue to elucidate optimal prophylaxis regimens which could widely applied to other institutions with implementation of quality control measures and immune mechanisms in the pathogenesis of postoperative infectious complications. Conclusion As a perioperative prophylaxis agents, cefepime did not have more advantages in reducing infectious complications compared with cefoxitin among elder patients with colorectal cancer underwent surgery for treatment. However, cefepime have positive effects on immune responses at the early postoperative period. Abbreviations CD, cluster of differentiation; COPD, chronic obstructive pulmonary disease; CRP, C-reactive protein; HAP, hospital-acquired pneumonia; HIS, hospital information system; HIV, human immunodeficiency virus; HLOS, hospital length of stay; IAIs, intra-abdominal infections; IQR, interquartile range; NEU, neutrophilic granulocyte percentage; PCT, procalcitonin; Pre-O, the pre-operation day; POD-3, the third day post-operation; POD-7, the seventh day post-operation; POLS, postoperative length of stay; SD, standard deviation; SSIs, surgical site infections; UTI, urinary tract infection; US, United States; WBC, white blood cell count. Declarations Ethics approval and consent to participate: This retrospective study was conducted based on data from medical records and with the approval of the Ethics Committee of Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine. The need for written informed consent was waived due to the retrospective nature of the study. Consent for publication: Not applicable. Availability of data and materials: All data included are available from the corresponding author on reasonable request. Competing interests: The authors declare that they have no competing interests. Funding : None. Authors’ contributions: 1) Yangxi Liu and Yang Luo designed and performed data analysis of the study; 2) Zaili Zhang collected the data; 3) Jing Xu, Bisheng Shi and Xiaojun Ni helped in solving professional and statistical problems encountered during the work. Acknowledgements: All authors would like to thank the medical statistician for their support and assistance to this research. References Berrios-Torres SI, Umscheid CA, Bratzler DW, Leas B, Stone EC, Kelz RR, Reinke CE, Morgan S, Solomkin JS, Mazuski JE et al. Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017. 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Tables Table 1 Baseline characteristics of patients Variables Group A (n=56) Group B (n=51) P value Age(years) 77.0±4.5 78.7±5.5 0.117 Gender, n (%) 0.263 Male 28(50.0) 31(60.8) Female 28(50.0) 20(39.2) BMI (kg/m 2 ) * 22.2±4.4 22.4±3.6 0.933 Concomitant disease , n (%) Diabetes mellitus 9(16.1) 12(23.5) 0.332 Hypertension 21(37.5) 27(52.9) 0.109 Cardiac disease 14(25.0) 12(23.5) 0.859 Cerebral infarction 4(7.1) 4(7. 8) 0.891 Pulmonary disease 2(3.6) 4(7.8) 0.337 Surgery 10(17.2) 11(19.6) 0.741 Immune system disease 4(7.1) 4(7.5) 0.891 Tumor stage 0.703 Ⅱ 29(64.4) 16(35.6) Ⅲ 26(68.4) 12(31.6) Proportions presented as number (percentage %), * Wilcoxon rank-sum test, BMI = body mass index. Table 2 Primary postoperative outcomes Variables Group A (n=56) Group B (n=51) P value HLOS (days) 14.2±4.7 13.8±3.8 0.823 PLOS (days) 9.5±3.8 8.7±2.0 0.668 Overall failure of prevention (%) 7(12.5) 7(13.7) 0.851 SSI 5(8.9) 5(9.8) 0.877 HAP 0(0.0) 2(3.9) 0.135 IAI 2(3.6) 0(0.0) 0.173 UTI 0 0 Postoperative mortality (%) 0 0 Proportions presented as number (percentage %), HLOS = hospital length of stay, HAP = hospital-acquired pneumonia, IAI = intra-abdominal infection, PLOS = postoperative length of stay, SSI= surgical site infection, UTI = urinary tract infection. Table 3 Details of Secondary postoperative outcomes Variables Pre-O POD-3 POD-7 Group A (n=56) Group B (n=51) P value Group A (n=56) Group B (n=51) P value Group A (n=56) Group B (n=51) P value Blood Routine and Biochemical Test WBC (*10 9 /L) 6.2[5.2,7.7] 5.4[5.2,7.7] *0.130 10.9[8.6,12.8] 11.0[7.8,12.9] *0.897 7.5[6.1,8.8] 6.2[5.0,8.4] *0.069 NEU (%) 64.6[57.9,70.3] 63.8[55.3,74.6] *0.977 86.0[83.2,89.2] 87.6[81.3,89.5] *0.904 78.0[71.9,84.3] 73.6[65.9,83.1] *0.078 CRP (mg/L) 0.7[0.5,3.7] 1.8[0.5,8.9] *0.260 43.0[22.1,85.6] 41.8[24.5,101.5] *0.297 68.6[21.5,109.9] 34.9[23.4,66.8] *0.122 PCT (ng/ml) 0.03[0.02,0.05] 0.04[0.02,0.07] *0.508 0.3[0.2,0.9] 0.8[0.3,2.3] *0.297 0.2[0.1,0.6] 0.3[0.1,0.8] *0.149 Body Temperature (℃) 37.0±0. 4 37.0±0.4 0.813 37.6±0. 5 37.4±0. 6 0.067 37.0[36.7,37.5] 37.0[36.8,37.3] *0.765 Renal Function Scr (μmol/L) 74 [61,79] 74[63,89] *0.434 67 [61,79] 74[59,88] *0.288 64 [55,74] 75 [56,87] *0.075 UA (μmol/L) 298.2±88.6 323.1±98.5 0.179 232 [191,271] 240[182,286] *0.739 138 [111,199] 181 [108,273] *0.326 Hepatic Function ALT (U/L) 11[8,16] 9[7,14] *0.102 12 [8,16] 9 [7,14] *0.079 11 [8,22] 10 [7,20] *0.272 AST (U/L) 16[14,20] 15[13,18] *0.352 15 [13,19] 16 [12,23] *0.844 15 [13,24] 15 [12,23] *0.744 DB (μmol/L) 3.7[2.6,4.7] 3.6[2.9,5.1] *0.418 4.2[3.2,6.4] 4.7[3.5,6.8] *0.411 4.9 [3.6,6.5] 4.9 [3.8,7.5] *0.893 TB (μmol/L) 9.4[6.6,12.9] 10.3[7.0,16.1] *0.283 11.9[7.5,15.6] 12.8[8.6,18.7] *0.341 11.4 [8.5,16.5] 11.7 [8.6,19.5] *0.580 ALB (g/L) 39.6[36.6,42.6] 38.3[35.6,41.6] *0.362 33.0[30.7,35.0] 31.9[28.2,35.8] *0.672 35.6±4. 1 36.1±4. 1 0.515 T Lymphocytes (%) CD3+ cell 63.6±9.5 65.2±12.2 0.587 58.4[56.4,70.7] 68.0[67.2,72.7] *0.102 68.8±8.3 65.9±11.0 0.495 CD4+ cell 38.4±7.0 41.4±9.3 0.182 29.2±9.2 46.5±10.0 0.001 44.2±9.2 44.7±7.5 0.890 CD8+ cell 25.5[18.0,30.7] 17.9[15.1,23.2] *0.131 26.1[23.1,34.4] 19.2[15.5,20.4] * 0.004 23.7±6.5 19.8±8.6 0.246 ALB = albumin, ALT = alamine aminotransferase, AST = aspartate aminotransferase, CRP= C-reactive protein, DB = direct bilirubin, NEU = neutrophilic granulocyte percentage, PCT = procalcitonin, Pre-O= Pre-operation, POD-3= the third day post-operation, POD-7= the third day post-operation, TB = total bilirubin, Scr = Serum Creatinine, UA = Uric acid, WBC= white blood cell count. * Wilcoxon rank-sum test. Font bold of P -values indicated that there was a statistically significant difference between two groups. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3815362","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":264600539,"identity":"b47c7373-e003-49e5-8247-6f66dca9c92c","order_by":0,"name":"Yangxi Liu","email":"","orcid":"","institution":"Ren Ji Hospital, Shanghai Jiaotong University School of Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yangxi","middleName":"","lastName":"Liu","suffix":""},{"id":264600540,"identity":"a7c728b7-b21d-4933-ad8d-6076fad4d79d","order_by":1,"name":"Yang Luo","email":"","orcid":"","institution":"Ren Ji Hospital, Shanghai Jiaotong University School of Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yang","middleName":"","lastName":"Luo","suffix":""},{"id":264600541,"identity":"976f731a-d1f5-488d-8104-d668fdf4631f","order_by":2,"name":"Jing Xu","email":"","orcid":"","institution":"Ren Ji Hospital, Shanghai Jiaotong University School of Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Jing","middleName":"","lastName":"Xu","suffix":""},{"id":264600542,"identity":"4a661aa4-1fbe-442c-b540-4efc5e569c10","order_by":3,"name":"Zaili Zhang","email":"","orcid":"","institution":"Ren Ji Hospital, Shanghai Jiaotong University School of Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Zaili","middleName":"","lastName":"Zhang","suffix":""},{"id":264600543,"identity":"6b22c222-9e38-4997-b943-c6ec149f5a92","order_by":4,"name":"Bisheng Shi","email":"","orcid":"","institution":"Ren Ji Hospital, Shanghai Jiaotong University School of Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Bisheng","middleName":"","lastName":"Shi","suffix":""},{"id":264600544,"identity":"621c5e7d-2488-4a0a-a82e-7127baca77ca","order_by":5,"name":"Xiaojun Ni","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAz0lEQVRIiWNgGAWjYDACZgaGAwwMbAwM7A1AHo8EKVp4DhCrBQ4kEohUaM7OY3jgRwVf4nbJtw8fF8hYMPC3d+PXbNnMlnCw5wxb4s7Z6cbGM4AOkzhzdgNeLQaHmQ8c4G1jS9xwO41NmgeoxUAil5AWxoaDf0Fabh5j/02kFuYDh8G23GBjYyZSC1vCYZkzbMYbzqQxgxzGQ9gv588Yf3xTcUx2w/FjjJ95e+rk+Nt78WuBgmMQirGHgYcY5SBQA6V/EKthFIyCUTAKRhIAAF3BQj0Hlq6OAAAAAElFTkSuQmCC","orcid":"","institution":"Ren Ji Hospital, Shanghai Jiaotong University School of Medicine","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Xiaojun","middleName":"","lastName":"Ni","suffix":""}],"badges":[],"createdAt":"2023-12-28 07:29:21","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3815362/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3815362/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":49134984,"identity":"df13b129-444c-404d-b984-5790a635a641","added_by":"auto","created_at":"2024-01-03 17:02:05","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":578789,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFlowchart to show the selection and perioperative antibiotic administration of patient.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-3815362/v1/ec92b7be89d846a19182b9fb.png"},{"id":49134985,"identity":"f134b36b-9583-4831-874d-c605391926db","added_by":"auto","created_at":"2024-01-03 17:02:05","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":2650230,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eScattergrams of lymphocytesfrom patients received cefepime in perioperative period.\u003c/strong\u003e A. lymphocytes isolated from whole blood; B. CD3+ isolated from lymphocytes; C. CD4+ and CD8+ isolated from lymphocytes. CD, cluster differentiation; POD-3, the third day post-operation; POD-7, the seventh day post-operation.\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-3815362/v1/4ee52c5b803e1b048e8d7199.png"},{"id":49310758,"identity":"53548a70-6bf7-4778-8f32-1cb1ad959a8e","added_by":"auto","created_at":"2024-01-08 13:22:25","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":979343,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3815362/v1/5294dc74-d505-49c5-9f30-5eb762050929.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Cefoxitin versus Cefepime for the Prevention of Perioperative Infection in Elderly Patients Undergoing Colorectal Cancer Surgery: A Retrospective Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePostoperative infections, especially surgical site infections (SSIs), have been associated with increased mortality rates, elevated hospitalization costs, and extended hospital stays. Colorectal surgery is among the procedures with the highest SSI incidence rates, potentially reaching up to 9.5%, even when adhering to antimicrobial prophylaxis guidelines [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Beyond SSIs, other postoperative infections such as intra-abdominal infections (IAIs), hospital-acquired pneumonia (HAP), and urinary tract infection (UTI) also significantly contributed to hospital readmissions, costs, and mortality [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Elderly patients, often presenting with poor nutritional status and comorbidities, are at an increased risk of postoperative infections [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Despite this, the majority of studies do not recommend age-based antibiotic prophylaxis, and the optimal regimen for elderly patients remains undetermined. Furthermore, the inflammatory responses to various antimicrobial prophylaxis are linked to biomarkers such white blood cell count (WBC), C-reactive protein (CRP), and lymphocyte subsets [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. However, few studies focus on the fluctuation in these inflammation profile, particularly in the elder population. This lack of research complicates the selection of perioperative antimicrobial prophylaxis for elderly patients undergoing colorectal cancer surgery.\u003c/p\u003e \u003cp\u003ePrevious studies on colorectal surgery have recommended the use of perioperative antibiotics that are effective against enteric Gram-negative bacilli, \u003cem\u003eEnterococcus\u003c/em\u003e and anaerobic pathogens [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Cefoxitin, a short-acting cephamycin with broad spectrum of antibacterial activity against gram-negative and anaerobic bacteria [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], has been recommended by guidelines in both United States (US) and China to prevent SSIs in colorectal surgery [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. However, the efficacy of cefoxitin in perioperative setting is unclear in areas with increasing antibiotics resistance of \u003cem\u003eEnterobacteriaceae\u003c/em\u003e. In clinical practice, fourth-generation cephalosporins are preferred in institutions with increasing resistance to second- and third-generation cephalosporins, especially in patients with risk factors such as age over 70 or cancer. Cefepime, a representative fourth-generation cephalosporin with good therapeutic efficacy in the treatment of IAIs, HAP and UTI, may be a potential choice for antibiotic prophylaxis in colorectal surgery [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTherefore, we conducted this retrospective study to assess the effectiveness of cefepime as a perioperative antimicrobial prophylaxis in elderly patients undergoing surgery for colorectal cancer compared to cefoxitin, and to evaluate the impact of both regimens on the immune system after operation.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design and Setting\u003c/h2\u003e \u003cp\u003eThis retrospectively study was designed to evaluate and compare the efficacy of cefoxitin and cefepime in preventing infectious complications in patients aged 70 and above, who underwent colorectal cancer surgery. The primary outcome measures encompassed any perioperative infectious complications, hospital length of stay (HLOS), postoperative length of stay (PLOS), and mortality during hospitalization. Secondary outcome measures comprised inflammation-associated biomarkers such as routine blood test, biochemical test, T lymphocyte subgroups, and other general body response to infection, including body temperature, renal and hepatic function. To accurately depict the dynamic changes in response to antimicrobial agents, relevant indicators were monitored preoperatively, on the third postoperative day, and one week postoperatively, respectively.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eInclusion Patients and Perioperative Treatment\u003c/h2\u003e \u003cp\u003eOur study incorporated patients aged over 70 years old, diagnosed with colorectal cancer, who underwent elective laparoscopic colorectal resection at Ren Ji Hospital, School of Medicine, Shanghai Jiaotong University, from June 2021 to June 2022. Exclusion criteria were as follows: (1) severe liver, kidney, heart or lung, dysfunction, (2) antibiotic usage within 4 weeks preceding administration, (3) a documented history of cephalosporin allergy, (4) patients presenting with perforation and complete bowel obstruction. All patients accepted mechanical bowel preparation with 2L of polyethylene glycol orally on the day preceding surgery and were administered 2g of cefoxitin intravenously at least 30 minutes prior to skin incision. Postoperatively, patients who received 2g of cefoxitin at 12-hour intervals for 3 days were categorized as Group A (n\u0026thinsp;=\u0026thinsp;56); while those administered 2g of cefepime at 12-hour intervals as a postoperative antibiotic regimen for 3 days were categorized as Group B (n\u0026thinsp;=\u0026thinsp;51). Detailed information is depicted in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The definition of infectious complications was established based on the presence of the following infections after the operation: SSIs, HAP, IAIs and UTIs. The attending surgeons and nurses conducted daily inspections of patients daily until discharge to identify these infections.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eData Collection and Statistical Analysis\u003c/h2\u003e \u003cp\u003eDemographic data, including age, gender, body mass index (BMI), concomitant disease, and tumor stage were collected. Additionally, we obtained the following records from hospital information system (HIS) to assess physical changes: body temperature, white blood cell count (WBC), neutrophilic granulocyte percentage (NEU), and C-reactive protein (CRP), procalcitonin (PCT), liver and renal function, and T lymphocyte levels on the pre-operation day (Pre-O), the third day post-operation (POD-3), and the seventh day post-operation (POD-7). Descriptive statistics were calculated for all variables between the two groups. Mean values and standard deviations were calculated for continuous variables, while counts and percentages for categorical variables. The normality of data sets was assessed using Box plots and histograms. Continuous variables were described as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD) or median (interquartile range, IQR). Two-sample t-test or Wilcoxon rank-sum test were used to compare continuous variables between the two groups, and Pearson\u0026rsquo;s Chi-square test was used for categorical variables. All statistical analyses were performed using SPSS 24.0 statistical package (SPSS, Chicago, IL, USA). A significance level of \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eBaseline Characteristics of Included Patients\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 107 patients aged over 70 with colorectal cancer who underwent elective laparoscopic colorectal resection between\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eJanuary 2021 and June 2022 were included in the study. The patients were divided into two group based on their antibiotic prophylaxis regimen: Group A (56 patients) received cefoxitin, and Group B (51 patients) received cefepime for 3 days after surgery. Demographic data are summarized in \u003cstrong\u003eTable 1\u003c/strong\u003e. All included patients had colorectal tumor stage II or III based on histopathological results. There were no significant differences between the two groups in terms of age, gender, body mass index, concomitant disease, and tumor stage. None of the patients in either group had taken corticosteroids, or other immunosuppressive agents, or chemotherapy regimens before or during hospitalization.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eKey Outcomes of Perioperative Antimicrobial Prophylaxis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe preventive outcomes of perioperative prophylaxis were presented in \u003cstrong\u003eTable 2\u003c/strong\u003e. The incidences of overall postoperative infection complications of Group A was 12.5%, while in Group B it was 13.7%, with no statistical difference between the two groups. Furthermore, there were no significant differences observed in SSIs, HAP, IAIs, and UTIs during the colorectal perioperative period between the two groups. The most common infection complication in both groups was SSIs, with rates of 8.9% in Group A and 9.8% in Group B. Patients receiving cefepime (Group B) had shorter hospitalization (14.2\u0026plusmn;4.7 vs 13.8\u0026plusmn;3.8) and postoperative hospital stay (9.5\u0026plusmn;3.8 vs 8.7\u0026plusmn;2.0), although these differences were not statistically significant. No cases of UTI or death were observed during hospitalization in either group.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSecondary Outcomes Associated with Response to Perioperative Antimicrobial Prophylaxis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePrior to the operation, there was no significant difference in the laboratory parameters indicative of infections and inflammatory changes, body temperature, and renal and hepatic function between Group A and Group B at Pre-O (\u003cstrong\u003eTable 3\u003c/strong\u003e). However, on POD-3, the percentage of cluster of differentiation (CD) 4+ cell in Group B (46.5\u0026plusmn;10.0) were significantly higher than Group A (29.2\u0026plusmn;9.2, P=0.001), while the percentage of CD8+ cell in Group B (19.2[15.5, 20.4]) was significantly lower than in Group A (26.1[23.1, 34.4], P=0.004). Furthermore, on POD-7, there were no significant differences in any of the laboratory parameters between two groups. The dynamic changes of the patient\u0026apos;s immune cell examination with cefepime were shown in \u003cstrong\u003eFigure 2\u003c/strong\u003e.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eRecent clinical guidelines for antibiotic prophylaxis in colorectal procedure recommended agents such as the first- and second-generation cephalosporins\u0026thinsp;\u0026plusmn;\u0026thinsp;metronidazole, and other evidence-based antibiotics, with cefoxitin being one of the most frequently utilized in clinical practice [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. However, these existing agents do not take into account the risk stratification of patients. For instance, elderly patients with colorectal cancer will experience decrease of immunity, which can affect the prophylactic effect of antibiotics [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Moreover, previous principles of perioperative antibacterial prophylaxis included studies based on outdated bacterial resistance data. However, bacterial distribution and antibiotic resistance vary by region, for example, China posed significant therapeutic challenges in the rapid proliferation of antimicrobial resistant Gram-negative bacteria [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Consequently, the selection of appropriate antibiotics for patients with varying risks and regional differences requires further clinical evidence. Cefepime is widely recommended for the treatment of various infections, including but not limited to pneumonia, sepsis, IAI. However, the efficacy of cefepime as prophylactic antibiotics in elective colorectal procedure remains unexplored. We compared the infection prevention capabilities of cefepime and cefoxitin in elderly patients with an average age over 75, and underwent surgery for colorectal cancer. We found that the overall infection rate reached over 10% even with the fourth generation cephalosporins for infectious prophylaxis, which indicating we can\u0026rsquo;t rely on antibiotics solely to reduce the perioperative infection.\u003c/p\u003e \u003cp\u003eThe innate responses of pathogen are generally evaluated by biomarkers such as PCT, CRP, and WBC count based on risk of infectious complications and provided early opportunity for effective medical support [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Our study demonstrated that biomarkers PCT, CRP, and WBC count in both groups were higher in early postoperative period compared with pre-operation, and did not return to normal until the seventh day post operation. Other biomarkers such as lymphocyte subsets, especially the main lymphocyte subpopulations (CD4+, CD8+), were crucial in the different stages in the host defense. However, prior studies comparing CD4\u0026thinsp;+\u0026thinsp;and CD8\u0026thinsp;+\u0026thinsp;lymphocyte counts have primarily focused on patients with pulmonary tuberculosis (TB) or human immunodeficiency virus (HIV) [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Our findings revealed that CD4\u0026thinsp;+\u0026thinsp;and CD8\u0026thinsp;+\u0026thinsp;level value varied in early postoperative period with different antibiotics for prophylaxis.\u003c/p\u003e \u003cp\u003eBoth CD4\u0026thinsp;+\u0026thinsp;and CD8\u0026thinsp;+\u0026thinsp;plays a crucial role in immune defense against viruses, intracellular bacteria, and tumors. Previous research has indicated that alterations in CD4\u0026thinsp;+\u0026thinsp;and CD8\u0026thinsp;+\u0026thinsp;values typically occur in an opposite manner, thereby coordinating the regulation of immunity function [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Certain antibiotics, such as macrolides, exhibit potent and extensive immunomodulatory effects through various mechanisms, which facilitate the restoration of immune homoeostasis and bolster key antimicrobial defences[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. In vitro, azithromycin suppresses CD4\u0026thinsp;+\u0026thinsp;T-cell activation by directly modulating mTOR activity, potientially further diminishing the activation and mobilization of neutrophils [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Furthermore, it reported that low-dose azithromycin enhances CD8 T-cell granzyme B in patients with chronic obstructive pulmonary disease (COPD) [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. β-lactams, apart from their antibacterial properties, have also been investigated for their immunomodulatory effects including allergic responses [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. For instance, an in vitro study reported that clavulanic acid and cefoxitin were the most potent inhibitors of IFN-g activity, as assayed by the induction of CD54 on the surface of the lung epithelial cell line A549 [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Another reported β-lactams to possess both antibacterial and immunomodulatory functions was cefodizime, it can enhance the CD4\u0026thinsp;+\u0026thinsp;value in elderly patients with community-acquired pneumonia (CAP) [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. However, the mechanism in immune response of antibiotics remain incompletely understood in both vitro and in vivo studies. To the best of our knowledge, our research is the first to evaluate antimicrobial prophylaxis with combined outcomes of both infection complications and immune response in elderly. We corroborated that compared to cefoxitin, which might be a potent inhibitor for IFN-g activity, cefepime can enhance the percentage of CD4\u0026thinsp;+\u0026thinsp;cells (46.5\u0026thinsp;\u0026plusmn;\u0026thinsp;10) and reduce the percentage of CD8\u0026thinsp;+\u0026thinsp;cells (19.2[15.5, 20.4]) at POD-3. The phenomenon suggesting that cefepime can improve cellular immunity and have a positive effect during the initial postoperative period in elderly patients undergoing colorectal cancer surgery.\u003c/p\u003e \u003cp\u003eOur retrospective analysis also revealed that although cefoxitin exhibited a lower incidence of postoperative infectious complications compared to cefepime, patients receiving cefoxitin had longer HLOS and PLOS. Notably, these differences between the two groups were no statistically significant. Moreover, no significant difference was found in T lymphocytes at one week after surgery with both cefepime and cefoxitin. Therefore, cefepime was considered as efficiency as cefoxitin in preventing infectious complications in colorectal surgery, and it also enhance immunomodulatory properties in early postoperative recovery. We may need to consider the immunomodulation by antibacterial agents in the selection of antibiotics for perioperative prophylaxis in the future. No adverse events were reported and there is no obvious difference in safety between cefepime and cefoxitin.\u003c/p\u003e \u003cp\u003eThe main limitation of this study was largely attributable to its small sample size. A total of 107 patients in our hospital at the same ward were involved in this study. Systematic measures such as nursing process after operation also have an important effect on SSI rate and the systematic measures in different medical institutions varies. Thus, may have an impact on the infectious complications result. Another limitation was the nature of retrospective study. For example, the CD4\u0026thinsp;+\u0026thinsp;and CD8\u0026thinsp;+\u0026thinsp;data in POD-3 were significant different between two groups and further analysis required detailed immune-related cell test which were lacing. Future research should continue to elucidate optimal prophylaxis regimens which could widely applied to other institutions with implementation of quality control measures and immune mechanisms in the pathogenesis of postoperative infectious complications.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eAs a perioperative prophylaxis agents, cefepime did not have more advantages in reducing infectious complications compared with cefoxitin among elder patients with colorectal cancer underwent surgery for treatment. However, cefepime have positive effects on immune responses at the early postoperative period.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCD, cluster of differentiation; COPD, chronic obstructive pulmonary disease; CRP, C-reactive protein; HAP, hospital-acquired pneumonia; HIS, hospital information system; HIV, human immunodeficiency virus; HLOS, hospital length of stay; IAIs, intra-abdominal infections; IQR, interquartile range; NEU, neutrophilic granulocyte percentage; PCT, procalcitonin; Pre-O, the pre-operation day; POD-3, the third day post-operation; POD-7, the seventh day post-operation; POLS, postoperative length of stay; SD, standard deviation; SSIs, surgical site infections; UTI, urinary tract infection; US, United States; WBC, white blood cell count.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u0026nbsp;\u003c/strong\u003eThis retrospective study was conducted based on data from medical records and with the approval of the Ethics Committee of Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine. The need for written informed consent was waived due to the retrospective nature of the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u0026nbsp;\u003c/strong\u003eAll data included are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e: None.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions:\u0026nbsp;\u003c/strong\u003e1) Yangxi Liu and Yang Luo designed and performed data analysis of the study; 2) Zaili Zhang collected the data; 3) Jing Xu, Bisheng Shi and Xiaojun Ni helped in solving professional and statistical problems encountered during the work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003eAll authors would like to thank the medical statistician for their support and assistance to this research.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBerrios-Torres SI, Umscheid CA, Bratzler DW, Leas B, Stone EC, Kelz RR, Reinke CE, Morgan S, Solomkin JS, Mazuski JE et al. Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017. \u003cem\u003eJAMA surgery\u003c/em\u003e 2017, 152(8):784\u0026ndash;791.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHo VP, Barie PS, Stein SL, Trencheva K, Milsom JW, Lee SW, Sonoda T. Antibiotic regimen and the timing of prophylaxis are important for reducing surgical site infection after elective abdominal colorectal surgery. Surg Infect. 2011;12(4):255\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang Q, Cao M, Tao H, Fei Z, Huang X, Liang P, Liu B, Liu J, Lu X, Ma P, et al. Evidence-based guideline for the prevention and management of perioperative infection. J evidence-based Med. 2023;16(1):50\u0026ndash;67.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDeierhoi RJ, Dawes LG, Vick C, Itani KM, Hawn MT. Choice of intravenous antibiotic prophylaxis for colorectal surgery does matter. 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Int J ImmunoPathol Pharmacol. 2019;33:2058738419840241.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNelson RL, Gladman E, Barbateskovic M. Antimicrobial prophylaxis for colorectal surgery. Cochrane Database Syst Rev. 2014;2014(5):CD001181.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWainberg SK, Santos NCL, Gabriel FC, de Vasconcelos LP, Nascimento JS, de Molino GRC, de Melo C. Clinical practice guidelines for surgical antimicrobial prophylaxis: Qualitative appraisals and synthesis of recommendations. J Eval Clin Pract. 2019;25(4):591\u0026ndash;602.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJeong WK, Park JW, Lim SB, Choi HS, Jeong SY. Cefotetan versus conventional triple antibiotic prophylaxis in elective colorectal cancer surgery. 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Surgery. 2013;154(2):190\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiao W, Liu Y, Zhang W. Virulence evolution, molecular mechanisms of resistance and prevalence of ST11 carbapenem-resistant Klebsiella pneumoniae in China: A review over the last 10 years. J global Antimicrob Resist. 2020;23:174\u0026ndash;80.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePlesko M, Suvada J, Makohusova M, Waczulikova I, Behulova D, Vasilenkova A, Vargova M, Stecova A, Kaiserova E, Kolenova A. The role of CRP, PCT, IL-6 and presepsin in early diagnosis of bacterial infectious complications in paediatric haemato-oncological patients. Neoplasma. 2016;63(5):752\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eXue X, Li N, Ren L. Effect of vacuum sealing drainage on healing time and inflammation-related indicators in patients with soft tissue wounds. Int Wound J. 2021;18(5):639\u0026ndash;46.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUppal SS, Tewari SC, Verma S, Dhot PS. Comparison of CD4 and CD8 lymphocyte counts in HIV-negative pulmonary TB patients with those in normal blood donors and the effect of antitubercular treatment: hospital-based flow cytometric study. Cytometry Part B Clinical cytometry. 2004;61(1):20\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSeder RA, Ahmed R. Similarities and differences in CD4\u0026thinsp;+\u0026thinsp;and CD8\u0026thinsp;+\u0026thinsp;effector and memory T cell generation. Nat Immunol. 2003;4(9):835\u0026ndash;42.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eReijnders TDY, Saris A, Schultz MJ, van der Poll T. Immunomodulation by macrolides: therapeutic potential for critical care. The Lancet Respiratory medicine. 2020;8(6):619\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRatzinger F, Haslacher H, Poeppl W, Hoermann G, Kovarik JJ, Jutz S, Steinberger P, Burgmann H, Pickl WF, Schmetterer KG. Azithromycin suppresses CD4(+) T-cell activation by direct modulation of mTOR activity. Sci Rep. 2014;4:7438.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHodge S, Hodge G, Holmes M, Jersmann H, Reynolds PN. Increased CD8 T-cell granzyme B in COPD is suppressed by treatment with low-dose azithromycin. Respirology. 2015;20(1):95\u0026ndash;100.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrooks BM, Hart CA, Coleman JW. Differential effects of beta-lactams on human IFN-gamma activity. J Antimicrob Chemother. 2005;56(6):1122\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e\u003cem\u003eClinicoEconomics and outcomes research: CEOR\u003c/em\u003e 2014, 6:83\u0026ndash;92.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhuang JX, Li WG, Qiu L, Zhong X, Zhou JJ, Chen QX. Inhibitory effects of Cefazolin and Cefodizime on the activity of mushroom tyrosinase. J Enzyme Inhib Med Chem. 2009;24(1):251\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1 Baseline characteristics of patients\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"96%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.42424242424242%\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariables\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.22222222222222%\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup A\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;(n=56)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.242424242424242%\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup B\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;(n=51)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.42424242424242%\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge(years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.22222222222222%\"\u003e\n \u003cp\u003e77.0\u0026plusmn;4.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.242424242424242%\"\u003e\n \u003cp\u003e78.7\u0026plusmn;5.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\"\u003e\n \u003cp\u003e0.117\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.42424242424242%\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.22222222222222%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.242424242424242%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\"\u003e\n \u003cp\u003e0.263\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.42424242424242%\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.22222222222222%\"\u003e\n \u003cp\u003e28(50.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.242424242424242%\"\u003e\n \u003cp\u003e31(60.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\"\u003e\u0026nbsp;\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.42424242424242%\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.22222222222222%\"\u003e\n \u003cp\u003e28(50.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.242424242424242%\"\u003e\n \u003cp\u003e20(39.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.42424242424242%\"\u003e\n \u003cp\u003e\u003cstrong\u003eBMI (kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/strong\u003e *\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.22222222222222%\"\u003e\n \u003cp\u003e22.2\u0026plusmn;4.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.242424242424242%\"\u003e\n \u003cp\u003e22.4\u0026plusmn;3.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\"\u003e\n \u003cp\u003e0.933\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.42424242424242%\"\u003e\n \u003cp\u003e\u003cstrong\u003eConcomitant disease\u003c/strong\u003e\u003cstrong\u003e, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.22222222222222%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.242424242424242%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.42424242424242%\"\u003e\n \u003cp\u003eDiabetes mellitus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.22222222222222%\"\u003e\n \u003cp\u003e9(16.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.242424242424242%\"\u003e\n \u003cp\u003e12(23.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\"\u003e\n \u003cp\u003e0.332\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.42424242424242%\"\u003e\n \u003cp\u003eHypertension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.22222222222222%\"\u003e\n \u003cp\u003e21(37.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.242424242424242%\"\u003e\n \u003cp\u003e27(52.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\"\u003e\n \u003cp\u003e0.109\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.42424242424242%\"\u003e\n \u003cp\u003eCardiac disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.22222222222222%\"\u003e\n \u003cp\u003e14(25.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.242424242424242%\"\u003e\n \u003cp\u003e12(23.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\"\u003e\n \u003cp\u003e0.859\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.42424242424242%\"\u003e\n \u003cp\u003eCerebral infarction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.22222222222222%\"\u003e\n \u003cp\u003e4(7.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.242424242424242%\"\u003e\n \u003cp\u003e4(7. 8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\"\u003e\n \u003cp\u003e0.891\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.42424242424242%\"\u003e\n \u003cp\u003ePulmonary disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.22222222222222%\"\u003e\n \u003cp\u003e2(3.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.242424242424242%\"\u003e\n \u003cp\u003e4(7.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\"\u003e\n \u003cp\u003e0.337\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.42424242424242%\"\u003e\n \u003cp\u003eSurgery\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.22222222222222%\"\u003e\n \u003cp\u003e10(17.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.242424242424242%\"\u003e\n \u003cp\u003e11(19.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\"\u003e\n \u003cp\u003e0.741\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.42424242424242%\"\u003e\n \u003cp\u003eImmune system disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.22222222222222%\"\u003e\n \u003cp\u003e4(7.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.242424242424242%\"\u003e\n \u003cp\u003e4(7.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\"\u003e\n \u003cp\u003e0.891\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.42424242424242%\"\u003e\n \u003cp\u003e\u003cstrong\u003eTumor stage\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.22222222222222%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.242424242424242%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\"\u003e\n \u003cp\u003e0.703\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.42424242424242%\"\u003e\n \u003cp\u003eⅡ\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.22222222222222%\"\u003e\n \u003cp\u003e29(64.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.242424242424242%\"\u003e\n \u003cp\u003e16(35.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.42424242424242%\"\u003e\n \u003cp\u003eⅢ\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.22222222222222%\"\u003e\n \u003cp\u003e26(68.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.242424242424242%\"\u003e\n \u003cp\u003e12(31.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eProportions presented as number (percentage %), * Wilcoxon rank-sum test, BMI = body mass index.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2 Primary postoperative outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"94%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.816326530612244%\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariables\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.46938775510204%\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup A\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;(n=56)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup B\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;(n=51)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.224489795918368%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.816326530612244%\"\u003e\n \u003cp\u003e\u003cstrong\u003eHLOS (days)\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.46938775510204%\"\u003e\n \u003cp\u003e14.2\u0026plusmn;4.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\"\u003e\n \u003cp\u003e13.8\u0026plusmn;3.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.224489795918368%\"\u003e\n \u003cp\u003e0.823\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.816326530612244%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePLOS (days)\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.46938775510204%\"\u003e\n \u003cp\u003e9.5\u0026plusmn;3.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\"\u003e\n \u003cp\u003e8.7\u0026plusmn;2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.224489795918368%\"\u003e\n \u003cp\u003e0.668\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.816326530612244%\"\u003e\n \u003cp\u003e\u003cstrong\u003eOverall failure of prevention\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;(%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.46938775510204%\"\u003e\n \u003cp\u003e7(12.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\"\u003e\n \u003cp\u003e7(13.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.224489795918368%\"\u003e\n \u003cp\u003e0.851\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.816326530612244%\"\u003e\n \u003cp\u003eSSI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.46938775510204%\"\u003e\n \u003cp\u003e5(8.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\"\u003e\n \u003cp\u003e5(9.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.224489795918368%\"\u003e\n \u003cp\u003e0.877\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.816326530612244%\"\u003e\n \u003cp\u003eHAP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.46938775510204%\"\u003e\n \u003cp\u003e0(0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\"\u003e\n \u003cp\u003e2(3.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.224489795918368%\"\u003e\n \u003cp\u003e0.135\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.816326530612244%\"\u003e\n \u003cp\u003eIAI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.46938775510204%\"\u003e\n \u003cp\u003e2(3.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\"\u003e\n \u003cp\u003e0(0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.224489795918368%\"\u003e\n \u003cp\u003e0.173\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.816326530612244%\"\u003e\n \u003cp\u003eUTI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.46938775510204%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.224489795918368%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.816326530612244%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePostoperative mortality (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.46938775510204%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.224489795918368%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eProportions presented as number (percentage %), HLOS = hospital length of stay, HAP = hospital-acquired pneumonia, IAI = intra-abdominal infection, PLOS = postoperative length of stay, SSI= surgical site infection, UTI = urinary tract infection.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3 Details of Secondary postoperative outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv align=\"center\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"107%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.387755102040817%\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariables\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.591836734693878%\" colspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePre-O\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003ePOD-3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.53061224489796%\" colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePOD-7\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.157894736842104%\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup A\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;(n=56)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.157894736842104%\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup B\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;(n=51)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.894736842105263%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.157894736842104%\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup A\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;(n=56)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.157894736842104%\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup B\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;(n=51)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.578947368421052%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.157894736842104%\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup A\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;(n=56)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.157894736842104%\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup B\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;(n=51)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.578947368421052%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20%\"\u003e\n \u003cp\u003e\u003cstrong\u003eBlood Routine and Biochemical\u0026nbsp;Test\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.315789473684211%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" colspan=\"2\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.2631578947368425%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.2631578947368425%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20%\" valign=\"top\"\u003e\n \u003cp\u003eWBC (*10\u003csup\u003e9\u003c/sup\u003e/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e6.2[5.2,7.7]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e5.4[5.2,7.7]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.315789473684211%\" valign=\"top\"\u003e\n \u003cp\u003e*0.130\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e10.9[8.6,12.8]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e11.0[7.8,12.9]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.2631578947368425%\" valign=\"top\"\u003e\n \u003cp\u003e*0.897\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e7.5[6.1,8.8]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e6.2[5.0,8.4]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.2631578947368425%\" valign=\"top\"\u003e\n \u003cp\u003e*0.069\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20%\" valign=\"top\"\u003e\n \u003cp\u003eNEU (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e64.6[57.9,70.3]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e63.8[55.3,74.6]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.315789473684211%\" valign=\"top\"\u003e\n \u003cp\u003e*0.977\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e86.0[83.2,89.2]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e87.6[81.3,89.5]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.2631578947368425%\" valign=\"top\"\u003e\n \u003cp\u003e*0.904\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e78.0[71.9,84.3]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e73.6[65.9,83.1]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.2631578947368425%\" valign=\"top\"\u003e\n \u003cp\u003e*0.078\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20%\" valign=\"top\"\u003e\n \u003cp\u003eCRP (mg/L)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e0.7[0.5,3.7]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e1.8[0.5,8.9]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.315789473684211%\" valign=\"top\"\u003e\n \u003cp\u003e*0.260\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e43.0[22.1,85.6]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e41.8[24.5,101.5]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.2631578947368425%\" valign=\"top\"\u003e\n \u003cp\u003e*0.297\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e68.6[21.5,109.9]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e34.9[23.4,66.8]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.2631578947368425%\" valign=\"top\"\u003e\n \u003cp\u003e*0.122\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20%\" valign=\"top\"\u003e\n \u003cp\u003ePCT (ng/ml)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e0.03[0.02,0.05]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e0.04[0.02,0.07]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.315789473684211%\" valign=\"top\"\u003e\n \u003cp\u003e*0.508\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.3[0.2,0.9]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e0.8[0.3,2.3]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.2631578947368425%\" valign=\"top\"\u003e\n \u003cp\u003e*0.297\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e0.2[0.1,0.6]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e0.3[0.1,0.8]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.2631578947368425%\" valign=\"top\"\u003e\n \u003cp\u003e*0.149\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eBody Temperature (℃)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e37.0\u0026plusmn;0. 4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e37.0\u0026plusmn;0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.315789473684211%\" valign=\"top\"\u003e\n \u003cp\u003e0.813\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e37.6\u0026plusmn;0. 5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e37.4\u0026plusmn;0. 6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.2631578947368425%\" valign=\"top\"\u003e\n \u003cp\u003e0.067\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e37.0[36.7,37.5]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e37.0[36.8,37.3]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.2631578947368425%\" valign=\"top\"\u003e\n \u003cp\u003e*0.765\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eRenal Function\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.315789473684211%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.2631578947368425%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.2631578947368425%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20%\" valign=\"top\"\u003e\n \u003cp\u003eScr (\u0026mu;mol/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e74 [61,79]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e74[63,89]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.315789473684211%\" valign=\"top\"\u003e\n \u003cp\u003e*0.434\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e67 [61,79]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e74[59,88]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.2631578947368425%\" valign=\"top\"\u003e\n \u003cp\u003e*0.288\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e64 [55,74]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e75 [56,87]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.2631578947368425%\" valign=\"top\"\u003e\n \u003cp\u003e*0.075\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20%\" valign=\"top\"\u003e\n \u003cp\u003eUA (\u0026mu;mol/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e298.2\u0026plusmn;88.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e323.1\u0026plusmn;98.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.315789473684211%\" valign=\"top\"\u003e\n \u003cp\u003e0.179\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e232 [191,271]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e240[182,286]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.2631578947368425%\" valign=\"top\"\u003e\n \u003cp\u003e*0.739\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e138 [111,199]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e181 [108,273]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.2631578947368425%\" valign=\"top\"\u003e\n \u003cp\u003e*0.326\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eHepatic Function\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.315789473684211%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.2631578947368425%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.2631578947368425%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20%\" valign=\"top\"\u003e\n \u003cp\u003eALT (U/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e11[8,16]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e9[7,14]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.315789473684211%\" valign=\"top\"\u003e\n \u003cp\u003e*0.102\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e12 [8,16]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e9 [7,14]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.2631578947368425%\" valign=\"top\"\u003e\n \u003cp\u003e*0.079\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e11 [8,22]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e10 [7,20]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.2631578947368425%\" valign=\"top\"\u003e\n \u003cp\u003e*0.272\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20%\" valign=\"top\"\u003e\n \u003cp\u003eAST (U/L) \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e16[14,20]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e15[13,18]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.315789473684211%\" valign=\"top\"\u003e\n \u003cp\u003e*0.352\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e15 [13,19]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e16 [12,23]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.2631578947368425%\" valign=\"top\"\u003e\n \u003cp\u003e*0.844\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e15 [13,24]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e15 [12,23]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.2631578947368425%\" valign=\"top\"\u003e\n \u003cp\u003e*0.744\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20%\" valign=\"top\"\u003e\n \u003cp\u003eDB (\u0026mu;mol/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e3.7[2.6,4.7]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e3.6[2.9,5.1]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.315789473684211%\" valign=\"top\"\u003e\n \u003cp\u003e*0.418\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e4.2[3.2,6.4]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e4.7[3.5,6.8]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.2631578947368425%\" valign=\"top\"\u003e\n \u003cp\u003e*0.411\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e4.9 [3.6,6.5]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e4.9 [3.8,7.5]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.2631578947368425%\" valign=\"top\"\u003e\n \u003cp\u003e*0.893\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20%\" valign=\"top\"\u003e\n \u003cp\u003eTB (\u0026mu;mol/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e9.4[6.6,12.9]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e10.3[7.0,16.1]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.315789473684211%\" valign=\"top\"\u003e\n \u003cp\u003e*0.283\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e11.9[7.5,15.6]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e12.8[8.6,18.7]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.2631578947368425%\" valign=\"top\"\u003e\n \u003cp\u003e*0.341\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e11.4 [8.5,16.5]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e11.7 [8.6,19.5]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.2631578947368425%\" valign=\"top\"\u003e\n \u003cp\u003e*0.580\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20%\" valign=\"top\"\u003e\n \u003cp\u003eALB (g/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e39.6[36.6,42.6]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e38.3[35.6,41.6]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.315789473684211%\" valign=\"top\"\u003e\n \u003cp\u003e*0.362\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e33.0[30.7,35.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e31.9[28.2,35.8]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.2631578947368425%\" valign=\"top\"\u003e\n \u003cp\u003e*0.672\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e35.6\u0026plusmn;4. 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e36.1\u0026plusmn;4. 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.2631578947368425%\" valign=\"top\"\u003e\n \u003cp\u003e0.515\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eT Lymphocytes (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.315789473684211%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.2631578947368425%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.2631578947368425%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20%\" valign=\"top\"\u003e\n \u003cp\u003eCD3+ cell\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e63.6\u0026plusmn;9.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e65.2\u0026plusmn;12.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.315789473684211%\" valign=\"top\"\u003e\n \u003cp\u003e0.587\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e58.4[56.4,70.7]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e68.0[67.2,72.7]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.2631578947368425%\" valign=\"top\"\u003e\n \u003cp\u003e*0.102\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e68.8\u0026plusmn;8.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e65.9\u0026plusmn;11.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.2631578947368425%\" valign=\"top\"\u003e\n \u003cp\u003e0.495\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20%\" valign=\"top\"\u003e\n \u003cp\u003eCD4+ cell\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e38.4\u0026plusmn;7.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e41.4\u0026plusmn;9.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.315789473684211%\" valign=\"top\"\u003e\n \u003cp\u003e0.182\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e29.2\u0026plusmn;9.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e46.5\u0026plusmn;10.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.2631578947368425%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e44.2\u0026plusmn;9.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e44.7\u0026plusmn;7.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.2631578947368425%\" valign=\"top\"\u003e\n \u003cp\u003e0.890\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20%\" valign=\"top\"\u003e\n \u003cp\u003eCD8+ cell\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e25.5[18.0,30.7]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e17.9[15.1,23.2]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.315789473684211%\" valign=\"top\"\u003e\n \u003cp\u003e*0.131\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e26.1[23.1,34.4]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e19.2[15.5,20.4]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.2631578947368425%\" valign=\"top\"\u003e\n \u003cp\u003e*\u003cstrong\u003e0.004\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e23.7\u0026plusmn;6.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e19.8\u0026plusmn;8.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.2631578947368425%\" valign=\"top\"\u003e\n \u003cp\u003e0.246\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.871287128712872%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"10%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"10%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"5.247524752475248%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"2.277227722772277%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"7.7227722772277225%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"10.693069306930694%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"5.247524752475248%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"10.693069306930694%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"10%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"5.247524752475248%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eALB = albumin, ALT = alamine aminotransferase, AST = aspartate aminotransferase, CRP= C-reactive protein, DB = direct bilirubin, NEU = neutrophilic granulocyte percentage, PCT = procalcitonin, Pre-O= Pre-operation, POD-3= the third day post-operation, POD-7= the third day post-operation, TB = total bilirubin, Scr = Serum Creatinine, UA = Uric acid, WBC= white blood cell count.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e*\u0026nbsp;Wilcoxon rank-sum test.\u003c/p\u003e\n\u003cp\u003eFont bold of \u003cem\u003eP\u003c/em\u003e-values indicated that there was a statistically significant difference between two groups.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Cefoxitin, Cefepime, Perioperative prophylaxis, Colorectal cancer surgery, Elderly","lastPublishedDoi":"10.21203/rs.3.rs-3815362/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3815362/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThe optimal antibiotic prophylaxis in preventing perioperative infection in patients aged 70 who underwent colorectal cancer surgery of are unknown. We conducted a comparative analysis to evaluate the efficacy of cefoxitin and cefepime in preventing perioperative infections and assessed the inflammatory response to antibiotics during the perioperative period.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003ePatients over 70 years old and undergo surgery for colorectal cancer between January 2021 and June 2022 at the same ward of a tertiary teaching hospital in Shanghai, China were included. Demographic and clinical data were retrieved from hospital information system (HIS) to evaluate the body reaction of two antibiotic prophylaxis: patients in Group A received cefoxitin and in Group B accepted cefepime after surgery. Both antibiotics were intravenous 2000mg, two times daily, total 3 days. The effect of perioperative prevention was compared between two groups with any infection complications, hospital length of stay (HLOS), postoperative length of stay (POLS) and mortality during hospitalization.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 107 elderly patients (56 patients in Group A and 51 patients in Group B) with colorectal cancer were included. Two groups were similar in terms of tumor stage and other basic demographic. Patients received cefoxitin demonstrated lower infection complications (12.5% vs 13.7%, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.851), among which surgical site infection (SSI) were most frequent complications in both groups (8.5% vs 9.8%, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.877). However, patients with cefepime represented shorter HLOS (14.0\u0026thinsp;\u0026plusmn;\u0026thinsp;4.7 days vs 13.9\u0026thinsp;\u0026plusmn;\u0026thinsp;3.8 days, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.912) and PLOS (9.4\u0026thinsp;\u0026plusmn;\u0026thinsp;3.8 days vs 8.4\u0026thinsp;\u0026plusmn;\u0026thinsp;2.1 days, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.265). Additionally, the percentage of cluster of differentiation (CD) 4\u0026thinsp;+\u0026thinsp;cell was significantly higher (29.2%\u0026plusmn;9.2 vs 46.5%\u0026plusmn;10.0, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.001) and the percentage of CD8\u0026thinsp;+\u0026thinsp;cell was statistical lower (26.1% [23.1, 34.4] vs 19.2% [15.5, 20.4], \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.004) in Group B compared to Group A at the third postoperative day. No death occurred in both groups.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eCefepime and cefoxitin both serve as useful prophylaxis to reduce infectious complications among elder patients underwent surgery for colorectal cancer. However, cefepime illustrated a more active inflammatory response and might enhance the body recovery in early post-operative rehabilitation.\u003c/p\u003e","manuscriptTitle":"Cefoxitin versus Cefepime for the Prevention of Perioperative Infection in Elderly Patients Undergoing Colorectal Cancer Surgery: A Retrospective Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-01-03 17:02:00","doi":"10.21203/rs.3.rs-3815362/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d29cce0a-2e11-445d-a919-4d9189d3f154","owner":[],"postedDate":"January 3rd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-01-08T13:14:19+00:00","versionOfRecord":[],"versionCreatedAt":"2024-01-03 17:02:00","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3815362","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3815362","identity":"rs-3815362","version":["v1"]},"buildId":"FbvkV6FR0MCFSLy54lSbu","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}