Surgical site infections after sarcoma resections in the peripelvic region: Do we need perioperative antibiotic prophylaxis?

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Alexander Klein, Chataut Chudamani, Andreas Wieser, Sophia Samira Goller, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4445116/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: Surgical site infections (SSI) are one of the most common complications after extensive sarcoma resections and represent a daily challenge. SSI occur in up to 50% of cases particularly in the peripelvic area. One possible approach to reduce infection rate is perioperative antibiotic prophylaxis. The aim of this study therefore was to investigate the influence of perioperative antibiotic prophylaxis on the infection rate and the possible influence of location-specific antibiotic prophylaxis with ampicillin/sulbactam. Methods and patients: This monocentric retrospective study included 366 patients who underwent sarcoma resections in the groin, proximal thigh, or gluteal region. All patients were operated on by 2 surgeons after neoadjuvant pretreatment if necessary. 3 groups of patients were defined. Group 1: In 60.4% of all cases, antibiotic prophylaxis was administered with cephalosporins (also clindamycin in case of penicillin allergy). Group2: In 9.8% of cases, ampicillin/sulbactam was used. Group 3: 29.8% of patients did not receive any antibiotic prophylaxis. In 31.1% of treated cases, antibiotic therapy was prolonged due to extented tumor resections. Results: Postoperative infections occurred in 23.2% (85 cases), in 77 cases within the first 90 days (on average after 20 days). The median operating time, blood loss, and tumor size were significantly higher in cases of infections, compared to patients without infection. In group 1 and 2 with perioperative single-shot prophylaxis, infection occurred in 24.1% of cases, compared to 13.5% of cases without prophylaxis (group 3) (p= 0.032). In the patients with prolonged antibiotic therapy, infection occurred in 31.6% of cases, compared to 16.3% of cases without prolongation (p< 0.001). In the ampicillin/sulbactam group, infection occurred in 19.4% of cases compared to 24.9% of cases in the cephalosporin group (p= 0.479). In univariate risk analysis, increased blood loss with erythrocyte substitution and neoadjuvant radiotherapy were proven to be risk factors for the occurrence of infections; in the multivariate analysis, neoadjuvant chemotherapy also proved to be a risk factor. Conclusions: Perioperative antibiotic prophylaxis may reduce the risk of infection after extended sarcoma resection in the peripelvic area. However, the particular bacterial spectrum of this anatomic region should be taken into account when deciding which antibiotics to use. Sarcoma surgical site infection antibiotic prophylaxis thigh groin gluteal area Figures Figure 1 1. Background Soft tissue sarcomas (STS) are rare diseases and occur with an incidence of around 50 per million inhabitants per year ( 1 ). Almost 50% of extraabdominal STS are located at the thigh or gluteal region ( 2 ). Due to the complex anatomy of this region and often large tumor extensions, the resection of these sarcomas is complex and causes long operation times. The complex dissection during surgery and proximity to the vessels also frequently cause a major loss of blood during or after surgery. The loss of soft tissues regularly causes large wound cavities in which hematomas and seromas may develop. In addition, neoadjuvant radiotherapy and/or chemotherapy increase the risk of wound healing disorders in many cases ( 3 , 4 ). All these factors lead to a significantly increased risk of infection after resection of sarcomas in the peripelvic region ( 5 – 7 ). This is aggravated by the particular spectrum of bacteria in this region, which differs significantly from other regions ( 8 – 10 ). In previous studies (also in our own patient collective ( 7 )), high proportions of gram-negative and anaerobic pathogens were found ( 5 , 6 ). It is also known that moist skin (as seen in the groin) has significantly more pathogenic germs ( 10 ). In respect to that, major efforts are and have been taken to reduce the infection rate in various studies. In addition to general antiseptic measures, this includes antibiotic prophylaxis. However, in recent literature some of the recommendations in musculoskeletal surgery are based on little evidence and there are hardly any studies on this topic. The recommendations from the 2000s recommend a differentiated approach to antibiotic prophylaxis ( 11 ). Published in 2013, the Surgical Infection Society did not recommend antibiotic prophylaxis for aseptic procedures without the implantation of prostheses at all ( 12 ). Due to the general high infection rate and the personal experience of the authors, antibiotic prophylaxis is nevertheless seems to be recommended for complex resections of sarcomas in the peripelvic area. Depending on the complexity of surgery, antibiotics may also be administered on a prolonged basis. However, these are clinically based individual decisions for which evidence is lacking, and only sparse preliminary work in the recent literature is seen. The aim of this study therefore was to evaluate the risk factors for the development of postoperative infections after resections of sarcomas in the groin, proximal thigh, and gluteal region. Furthermore, the effectiveness of perioperative antibiotic prophylaxis was evaluated also in cases with prolonged antibiotic administration. In addition, we evaluated the effectiveness of an adaption of antibiotics for prophylaxis, considering the particular spectrum of bacteria in this region found by previous evaluations of our cohort. 2. Patients and methods This study was designed as a monocentric study. Patients who underwent STS resections of the proximal thigh (till 15 cm distal to the groin), groin or gluteal region (peripelvic region) at our center between 2003 and 2020 were retrospectively evaluated. Patients with the following characteristics were included: - Resection of a STS in the peripelvic region - Tumor resection in our hospital - Exclusion of superficial sarcomas - Primary wound closure without application of vacuum-assisted closure systems (VAC) - Clinical follow-up time of at least 2 weeks - Occurrence of infection in the first 90 days after surgery - Availability of follow-up data. Almost all tumors were diagnosed in advance by biopsy (incisional or core-needle biopsy). The only exceptions were atypical lipomatous tumors (ALT), which were only diagnosed radiologically. Treatment decision was made in an interdisciplinary tumor board. Many tumors were neoadjuvantly treated in accordance with the ESMO (European Society for Medical Oncology) guidelines ( 13 ). Depending on the entity, grading, TNM classification of the tumor, and the individual age, patients received chemotherapy and/or radiotherapy. Patients were then operated on exclusively by 2 experienced surgeons. Depending on the interdisciplinary decision, adjuvant therapy was performed if necessary. While follow-up, patients were seen at our center at least in the first 3 months. The decision for preoperative antibiotic prophylaxis was based on clinical assessment and the complexity of the resection. Primarily, the 2nd generation cephalosporin (cefuroxime 1.5 g) was administered. In cases of known penicillin allergy, a lincosamide antibiotic substance (clindamycin 600 mg) was applied as an alternative. In cases of major blood loss, long operating times, and therefore a high probability of postoperative infection, prophylaxis was extended for 5–7 days. After the interim evaluation of the bacterial spectrum in wound infections has shown a high proportion of gram-negative and anaerobic bacteria, most of which were associated with intestinal flora, prophylaxis was changed to ampicillin/sulbactam 2 g/1 g in consecutive patients. In the event of a wound infection requiring revision, a surgical revision was performed. Postoperative infection was defined following the guidelines of the Center for Disease Control and Prevention (CDC) ( 14 ). The wound was explored, at least two microbiological swabs were taken, and the wound was debrided and closed either primarily or secondarily after VAC therapy. Antibiotics were administered according to the antimicrobiogram of the pathogens found. The following parameters were evaluated: gender, age of the patient, duration of surgery, intraoperative blood loss, substitution of erythrocyte concentrates, neoadjuvant and/or adjuvant therapy, tumor entity, tumor size, application and type of perioperative antibiotic prophylaxis, occurrence of infection, type of pathogens, change of pathogens during the treatment. For data analysis we used descriptive statistic methods (frequency, median value, spreading, standard deviation and Caplan-Meier curve). Significance analysis was performed using the Log-Rank, Chi-Square, or the t-test, defining a 95% confidence interval. Univariate (Cox proportional hazards regression) and multivariate analysis were used evaluate the influence of group characteristics on the infection rate. The level of significance was set at less than 0.05. The data analysis software used was IBM® SPSS® Statistics 25. 3. Results A total of 393 patients were evaluated. 27 patients were excluded from the evaluation because the data was incomplete or the minimum observation period of 3 months was not reached. In total, 366 patients could be evaluated. Of those, 204 patients (55.7%) were male. The median age of all patients was 61.3 years (range between 9 and 93 years). The median time of surgery was 79.8 min (range between 15 and 620 min). The median intraoperative blood loss was 474.9 ml (range between 40 and 8300 ml). The median maximum length of the resection specimen was 16.1 cm (range between 4 and 65 cm). Other group characteristics are shown in Table 1 . Table 1 Characteristics of patient cohort and treatment details (SSI: surgical site infection; CI: confidence interval) Total Number/Total Cohort Infection Free Group SSI Group Power (95% CI) Number of Patients 366 289 (79%) 77 (21%) Sex Female Male 162 204 128 (44.3%) 161 (55.7%) 34 (44.2%) 43 (55.8%) 0.983 Age (Years) 61.3 62.5 61 0.542 Surgery time (min) 79.8 73.9 101.1 < 0.001 Tumor size (cm) 16.1 15.5 18.5 0.009 Blood lost (ml) 474.9 397 767 0.005 Blood substitution Yes No 49 317 28 (9.7%) 261 (90.3%) 21 (27.3%) 56 (72.7%) < 0.001 Neoadjuvant Chemotherapy Yes No 126 240 104 (36%) 185 (64%) 22 (28.6%) 55 (71.4%) 0.250 Adjuvant Chemotherapy Yes No 109 257 86 (29.8%) 203 (70.2%) 23 (29.9%) 54 (70.1%) 0.906 Neoadjuvant Radiotherapy Yes No 103 263 77 (26.6%) 212 (73.4%) 30 (39%) 47 (61%) 0.026 Adjuvant Radiotherapy Yes No 123 243 98 (33.9%) 191 (66.1%) 25 (32.5%) 52 (67.5%) 0.871 Peri operative Prophylaxis Yes No 257 109 195 (67.5%) 94 (32.5%) 62 (80.5%) 15 (19.5%) 0.032 Post operative Prophylaxis Yes No 114 252 78 (27%) 211 (73%) 36 (46.8%) 41 (53.2%) < 0.001 Antibiotic prophylaxis was administered as a single shot perioperatively in 257 cases (70.2% of all patients), 29.8% of patients did not received any prophylaxis because of low risk constalation. Cefuroxime or clindamycin was administered in 221 cases (56.3% of all patients), and ampicillin/sulbactam was given in 36 cases (9.8% of all patients). In 114 cases (31.1% of all cases or 51.6% of cases with antibiotic prophylaxis), antibiotic prophylaxis was continued postoperatively due to the complexity of surgery (Table 1 ). SSI occurred in 85 cases (23.2% of all operations). Eight cases of infection occurred later than 90 days after the index surgery and were excluded from further analysis. They were considered as probable superinfections of the pre-existing seroma due to hematogenous spread. These cases were excluded for the evaluation of our study aim. In 77 cases (21% of all operations), the median time to surgical revision was 20 days (range between 3 and 90 days). The mean time of surgery, blood loss, and tumor size differed significantly (p < 0.05) between the group with and without infections (Table 1 ). 62 infections (out of 257, 24.1%) occurred in the group with perioperative antibiotic prophylaxis. In the group without antibiotic prophylaxis 15 infections occurred in 109 cases (13.8%; p = 0.032). However, both groups differed highly significantly in baseline values as tumor size (p = 0.007) or blood loss and duration of surgery (both p < 0.001, Table 2 ). Table 2 Subgroup characteristics and it’s comparison regarding tumor size (cm: centimeter); blood loss (ml: milliliter) and surgery time (min: minutes). Tumor Size (cm) Blood Loss (ml) Surgery Time (min) Peri operative Prophylaxis Yes No 16,78 p = 0.007 14,74 576,27 p < 0.001 229,36 88,11 p < 0.001 61,35 Prolonged p rophylaxis Yes No 18,78 p < 0.001 15,00 839,91 p < 0.001 309,71 110,11 p < 0.001 66,79 Prophylaxis with Cefuroxime or clindamycin vs. Ampicillin/Sulbactam 16,58p = 0.186 18,10 548,31p = 0.108 786,29 85,68p = 0.323 100,14 In the group with single shot antibiotics, 41 infections occurred in 252 cases (16.3%; p < 0.001) compared to 36 (31.6%) infections in 114 cases with prolonged antibiotic prophylaxis. Also here, the group characteristics (tumor size, blood loss and duration of surgery differed highly significantly (p < 0.001; Table 2 ). In comparison of the groups with cefuroxime (including clindamycin) and ampicillin/sulbactam, 55 infections occurred in 221 cases (24.9%) in the cefuroxime (and clindamycin) group, whereas 7 infections in 36 cases (19.4%; p = 0.479) occurred in the ampicillin/sulbactam group (Fig. 1 , n.s.). The groups were comparable in terms of tumor size (p = 0.186), blood loss (p = 0.108), and time of surgery (p = 0.323; Table 2 ). In univariate analysis, the substitution of erythrocyte concentrates (p < 0.001) and neoadjuvant radiotherapy (p = 0.026) were found to be significant risk factors for the development of infection. In multivariate analysis, the substitution of erythrocyte concentrates (p = 0.007) and neoaduvant radiotherapy (p = 0.013) were confirmed as a risk factor. In addition, the implementation of neoadjuvant chemotherapy (p = 0.01) significantly worsened the risk for SSI (Table 3 ). Table 3 univariate and multivariate analysis of the risk factors, influencing the infection rate. Factor Univariate Analysis Multivariate Analysis Tumor size > 15 cm 0.146 0.860 Blood substitution < 0.001 0.007 Neoadjuvant chemotherapy 0.251 0.010 Neoadjuvant radiotherapy 0.026 0.013 Adjuvant chemotherapy 0.521 0.404 Adjuvant radiotherapy 0.508 0.355 4. Discussion The resection of STS in the peripelvic region maybe a challenge for the surgeon. Complex anatomy and a large extent of the tumor often causes long surgery durations with high blood loss. Those are known risk factors for the development of SSI. This is frequently aggravated by neoadjuvant or adjuvant chemotherapy and radiotherapy. Precisely, these risk factors are confirmed in a large meta-analysis by Slump et al. ( 4 ): The evaluation of 21 studies on STS resections at all sites showed an overall complication rate of 30.2% with a surgical revision rate of 13.4%. The risk factors identified included large tumors, neoadjuvant radiotherapy, and high intraoperative blood loss. The infection rate in patient cohorts with mixed localizations is around 15–18% ( 15 , 16 ), while in pelvic bone sarcomas or soft tissue sarcomas in the peripelvic area the infection rate is about 20–25% ( 5 , 6 ). In concordance with these findings, the SSI rate was 21% ( 7 ). In current guidelines a uniform recommendation from different societies is seen: the American Surgical Infection Society recommends no antibiotic prophylaxis for aseptic orthopaedic operations without using implants ( 12 ). The recommendation of the German Paul-Ehrlich-Society is identical ( 17 ). However, risk factors for an increased risk of SSI in these procedures are also identified: Neoadjuvant radiation, surgery duration over 2 houers, long anesthesia time and high blood loss with blood transfusion. If these facts are taken into account, there is a tendency to advocate additional methods to reduce the infection rate. General aseptic measures have long been established in clinical practice: Aseptic washing, avoiding skin injuries, and using iodized films ( 12 ). However, there is no published evidence or recommendation for perioperative antibiotic prophylaxis in this cohort. The initial hypothesis of this study was that antibiotic prophylaxis reduces the infection rate after sarcoma resection in the peripelvic area. This could not be confirmed by our evaluation. The SSI rate in all subgroups was higher with antibiotic prophylaxis compared to no prophylaxis at all. However, significant differences between the groups were evident: Blood loss was higher in the group with antibiotic prophylaxis, the frequency of application of erythrocyte concentrates was higher, the duration of surgery was longer, and tumor size was more extensive. This confirms a profound selection bias regarding the administration of antibiotic prophylaxis. Other authors assume that the probability of postoperative infection in this group would even be higher without antibiotic prophylaxis. Infection rates of up to 50% have been described for these localizations ( 18 – 20 ). It is difficult to interpret the results in the group with prolonged antibiotic application: The infection rate was significantly higher in this group compared to a single shot (32 vs. 16%). Dadras et al. were also unable to achieve a reduction in the risk of infection through prolonged antibiotic administration ( 15 ), the Paris group showed the same results ( 20 ). Probably the only prospective and randomized study on the effectiveness of antibiotic prophylaxis in musculoskeletal oncology is the PARITY trial. Here, in a prospective double blinded and randomized trial, no benefit of prolonged antibiotic prophylaxis (1 day vs. 3 days) after bone sarcoma resection and implantation of tumor prostheses of the lower extremity could be shown ( 21 ). A study with a similar design would probably be useful to clarify this issue more precisely. The analysis of the bacterial spectrum in postoperative infections in the peripelvic area showed a significantly higher proportion of gram-negative and anaerobic pathogens, strongly associated with intestinal flora ( 7 ). Few studies investigated postoperative infection in sarcoma resections in this area, all showed similar results ( 5 , 6 ). Because of this, antibiotic prophylaxis with cephalosporins appears inadequate. We, therefore, changed the prophylaxis to ampicillin/sulbactam. The comparison of these 2 groups from our patient cohort shows a trend in the reduction of infection rate (19% versus 24%), but not significant. In a retrospective evaluation of Ramsey et al. ( 22 ) the addition of metronidazole as an antibiotic prophylaxis to cover anaerobes reduced significantly the complication rate after sarcoma resections (27% vs. 17%; p = 0.049) underlying our own findings. As far as our study design allows, we identified the following factors in the risk stratification for postoperative infection: Neoadjuvant radiotherapy and chemotherapy, duration of surgery, and substitution of erythrocyte concentrates as surrogate parameters for higher blood loss. The analysis of complications after surgery in nearly 1.000 STS at different locations ( 15 ) identified almost the same risk factors; further studies also confirm these results ( 3 , 16 ). 5. Conclusions The evaluation of treatment outcomes after resection of peripelvic STS in our patients could not demonstrate a benefit of perioperative antibiotic prophylaxis or prolonged antibiotic therapy in lowering the postoperative infection risk. We attribute that to a selection bias of antibiotic prophylaxis at all. However, in line with the published literature, we identified subgroups with an increased risk of infection: Longer duration of surgery, higher blood loss with the need for blood substitution, larger tumor extension, and the application of neoadjuvant radiotherapy and chemotherapy. In our opinion, patients with a combination of these risk factors should receive antibiotic prophylaxis that ideally considers the increased gram-negative and anaerobic bacterial spectrum in this body region. With that at least a trend for a lesser rate of SSI was seen. Abbreviations STS soft tissue sarcoma SSI Surgical site infections VAC vacuum-assisted closure systems cm centimeter g gram mg miligram min minute ml mililiter Declarations Ethics approval and consent to participate This study was approved by the institutional ethics committee (Ethics Committee of the Medical Faculty; ID 17-89). Written consent was obtained from all surviving patients. For non-surviving patients, data were irreversibly anonymized as recommended by the ethics committee. Children and young adults also provided informed consent from their parents. Consent for publication Not applicable. Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding Not applicable. Authors' contributions Conceptualization: AK and HRD; Methodology: AK, AW, HRD; Formal analysis and investigation: AK; Writing - original draft preparation: AK, HRD; Writing - review and editing: AW, SG, LB, DG, BH; Supervision: AW; BH. All authors read and approved the final manuscript. Acknowledgements Not applicable. References Stiller CA, Trama A, Serraino D et al. Descriptive epidemiology of sarcomas in Europe: report from the RARECARE project. 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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-4445116","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":308165628,"identity":"10765de1-b6d9-4c09-ae2e-8afcd4ec3a80","order_by":0,"name":"Alexander Klein","email":"data:image/png;base64,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","orcid":"","institution":"LMU University Hospital, LMU Munich","correspondingAuthor":true,"prefix":"","firstName":"Alexander","middleName":"","lastName":"Klein","suffix":""},{"id":308165629,"identity":"2a358334-0003-4fc7-9f1a-a01f483386d8","order_by":1,"name":"Chataut Chudamani","email":"","orcid":"","institution":"LMU University Hospital, LMU Munich","correspondingAuthor":false,"prefix":"","firstName":"Chataut","middleName":"","lastName":"Chudamani","suffix":""},{"id":308165630,"identity":"8dae0f15-2343-459d-be92-cebae081b3a2","order_by":2,"name":"Andreas Wieser","email":"","orcid":"","institution":"LMU University Hospital, LMU Munich","correspondingAuthor":false,"prefix":"","firstName":"Andreas","middleName":"","lastName":"Wieser","suffix":""},{"id":308165631,"identity":"b7602eed-28c1-44b3-b794-8df2a275a1bd","order_by":3,"name":"Sophia Samira Goller","email":"","orcid":"","institution":"LMU University Hospital, LMU Munich","correspondingAuthor":false,"prefix":"","firstName":"Sophia","middleName":"Samira","lastName":"Goller","suffix":""},{"id":308165632,"identity":"a34fb336-455e-47fd-9049-d05d57042ae3","order_by":4,"name":"Luc M. Berclaz","email":"","orcid":"","institution":"LMU University Hospital, LMU Munich","correspondingAuthor":false,"prefix":"","firstName":"Luc","middleName":"M.","lastName":"Berclaz","suffix":""},{"id":308165633,"identity":"c80f60c3-a61e-47f8-8b91-e4eb1a898a50","order_by":5,"name":"Dorit Di Gioia","email":"","orcid":"","institution":"LMU University Hospital, LMU Munich","correspondingAuthor":false,"prefix":"","firstName":"Dorit","middleName":"Di","lastName":"Gioia","suffix":""},{"id":308165634,"identity":"ee0685fe-8dbe-4449-8cf8-306aa67790c5","order_by":6,"name":"Boris M. Holzapfel","email":"","orcid":"","institution":"LMU University Hospital, LMU Munich","correspondingAuthor":false,"prefix":"","firstName":"Boris","middleName":"M.","lastName":"Holzapfel","suffix":""},{"id":308165635,"identity":"499f1482-7c10-4b6c-b05d-d945e7faf0a4","order_by":7,"name":"Hans Roland Dürr","email":"","orcid":"","institution":"LMU University Hospital, LMU Munich","correspondingAuthor":false,"prefix":"","firstName":"Hans","middleName":"Roland","lastName":"Dürr","suffix":""}],"badges":[],"createdAt":"2024-05-19 16:39:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4445116/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4445116/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":57802301,"identity":"5e8f67d4-e60a-4daf-8703-e4f63dfa327d","added_by":"auto","created_at":"2024-06-05 22:32:08","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":22950,"visible":true,"origin":"","legend":"\u003cp\u003eInfection free survival in comparison of the group of cefuroxime (or clindamycin) and ampicillin/sulbactam (p=0.775; 95% CI)\u003c/p\u003e","description":"","filename":"Picture1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4445116/v1/664af697e2b79146cd3d6913.jpg"},{"id":57803283,"identity":"a619cb82-b572-45fd-8cc9-56d1284792be","added_by":"auto","created_at":"2024-06-05 22:48:10","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":615207,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4445116/v1/ce465ea0-42e3-48d9-bf94-3791e031333a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Surgical site infections after sarcoma resections in the peripelvic region: Do we need perioperative antibiotic prophylaxis?","fulltext":[{"header":"1. Background","content":"\u003cp\u003eSoft tissue sarcomas (STS) are rare diseases and occur with an incidence of around 50 per million inhabitants per year (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Almost 50% of extraabdominal STS are located at the thigh or gluteal region (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Due to the complex anatomy of this region and often large tumor extensions, the resection of these sarcomas is complex and causes long operation times. The complex dissection during surgery and proximity to the vessels also frequently cause a major loss of blood during or after surgery. The loss of soft tissues regularly causes large wound cavities in which hematomas and seromas may develop. In addition, neoadjuvant radiotherapy and/or chemotherapy increase the risk of wound healing disorders in many cases (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). All these factors lead to a significantly increased risk of infection after resection of sarcomas in the peripelvic region (\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). This is aggravated by the particular spectrum of bacteria in this region, which differs significantly from other regions (\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). In previous studies (also in our own patient collective (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)), high proportions of gram-negative and anaerobic pathogens were found (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). It is also known that moist skin (as seen in the groin) has significantly more pathogenic germs (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn respect to that, major efforts are and have been taken to reduce the infection rate in various studies. In addition to general antiseptic measures, this includes antibiotic prophylaxis. However, in recent literature some of the recommendations in musculoskeletal surgery are based on little evidence and there are hardly any studies on this topic. The recommendations from the 2000s recommend a differentiated approach to antibiotic prophylaxis (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Published in 2013, the Surgical Infection Society did not recommend antibiotic prophylaxis for aseptic procedures without the implantation of prostheses at all (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Due to the general high infection rate and the personal experience of the authors, antibiotic prophylaxis is nevertheless seems to be recommended for complex resections of sarcomas in the peripelvic area. Depending on the complexity of surgery, antibiotics may also be administered on a prolonged basis. However, these are clinically based individual decisions for which evidence is lacking, and only sparse preliminary work in the recent literature is seen.\u003c/p\u003e \u003cp\u003eThe aim of this study therefore was to evaluate the risk factors for the development of postoperative infections after resections of sarcomas in the groin, proximal thigh, and gluteal region. Furthermore, the effectiveness of perioperative antibiotic prophylaxis was evaluated also in cases with prolonged antibiotic administration. In addition, we evaluated the effectiveness of an adaption of antibiotics for prophylaxis, considering the particular spectrum of bacteria in this region found by previous evaluations of our cohort.\u003c/p\u003e"},{"header":"2. Patients and methods","content":"\u003cp\u003eThis study was designed as a monocentric study. Patients who underwent STS resections of the proximal thigh (till 15 cm distal to the groin), groin or gluteal region (peripelvic region) at our center between 2003 and 2020 were retrospectively evaluated. Patients with the following characteristics were included:\u003c/p\u003e\n\u003cp\u003e- Resection of a STS in the peripelvic region\u003c/p\u003e\n\u003cp\u003e- Tumor resection in our hospital\u003c/p\u003e\n\u003cp\u003e- Exclusion of superficial sarcomas\u003c/p\u003e\n\u003cp\u003e- Primary wound closure without application of vacuum-assisted closure systems (VAC)\u003c/p\u003e\n\u003cp\u003e- Clinical follow-up time of at least 2 weeks\u003c/p\u003e\n\u003cp\u003e- Occurrence of infection in the first 90 days after surgery\u003c/p\u003e\n\u003cp\u003e- Availability of follow-up data.\u003c/p\u003e\n\u003cp\u003eAlmost all tumors were diagnosed in advance by biopsy (incisional or core-needle biopsy). The only exceptions were atypical lipomatous tumors (ALT), which were only diagnosed radiologically. Treatment decision was made in an interdisciplinary tumor board. Many tumors were neoadjuvantly treated in accordance with the ESMO (European Society for Medical Oncology) guidelines (\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e). Depending on the entity, grading, TNM classification of the tumor, and the individual age, patients received chemotherapy and/or radiotherapy. Patients were then operated on exclusively by 2 experienced surgeons. Depending on the interdisciplinary decision, adjuvant therapy was performed if necessary. While follow-up, patients were seen at our center at least in the first 3 months.\u003c/p\u003e\n\u003cp\u003eThe decision for preoperative antibiotic prophylaxis was based on clinical assessment and the complexity of the resection. Primarily, the 2nd generation cephalosporin (cefuroxime 1.5 g) was administered. In cases of known penicillin allergy, a lincosamide antibiotic substance (clindamycin 600 mg) was applied as an alternative. In cases of major blood loss, long operating times, and therefore a high probability of postoperative infection, prophylaxis was extended for 5\u0026ndash;7 days. After the interim evaluation of the bacterial spectrum in wound infections has shown a high proportion of gram-negative and anaerobic bacteria, most of which were associated with intestinal flora, prophylaxis was changed to ampicillin/sulbactam 2 g/1 g in consecutive patients.\u003c/p\u003e\n\u003cp\u003eIn the event of a wound infection requiring revision, a surgical revision was performed. Postoperative infection was defined following the guidelines of the Center for Disease Control and Prevention (CDC) (\u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e). The wound was explored, at least two microbiological swabs were taken, and the wound was debrided and closed either primarily or secondarily after VAC therapy. Antibiotics were administered according to the antimicrobiogram of the pathogens found.\u003c/p\u003e\n\u003cp\u003eThe following parameters were evaluated: gender, age of the patient, duration of surgery, intraoperative blood loss, substitution of erythrocyte concentrates, neoadjuvant and/or adjuvant therapy, tumor entity, tumor size, application and type of perioperative antibiotic prophylaxis, occurrence of infection, type of pathogens, change of pathogens during the treatment.\u003c/p\u003e\n\u003cp\u003eFor data analysis we used descriptive statistic methods (frequency, median value, spreading, standard deviation and Caplan-Meier curve). Significance analysis was performed using the Log-Rank, Chi-Square, or the t-test, defining a 95% confidence interval. Univariate (Cox proportional hazards regression) and multivariate analysis were used evaluate the influence of group characteristics on the infection rate. The level of significance was set at less than 0.05. The data analysis software used was IBM\u0026reg; SPSS\u0026reg; Statistics 25.\u003c/p\u003e"},{"header":"3. Results","content":"\u003cp\u003eA total of 393 patients were evaluated. 27 patients were excluded from the evaluation because the data was incomplete or the minimum observation period of 3 months was not reached. In total, 366 patients could be evaluated. Of those, 204 patients (55.7%) were male. The median age of all patients was 61.3 years (range between 9 and 93 years). The median time of surgery was 79.8 min (range between 15 and 620 min). The median intraoperative blood loss was 474.9 ml (range between 40 and 8300 ml). The median maximum length of the resection specimen was 16.1 cm (range between 4 and 65 cm). Other group characteristics are shown in Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of patient cohort and treatment details (SSI: surgical site infection; CI: confidence interval)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal Number/Total Cohort\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eInfection Free Group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSSI Group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePower (95% CI)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNumber of Patients\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e366\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e289 (79%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e77 (21%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eFemale\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eMale\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e162\u003c/p\u003e \u003cp\u003e204\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e128 (44.3%)\u003c/p\u003e \u003cp\u003e161 (55.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e34 (44.2%)\u003c/p\u003e \u003cp\u003e43 (55.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.983\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge (Years)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e61.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e62.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.542\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSurgery time (min)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e79.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e73.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e101.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTumor size (cm)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.009\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBlood lost (ml)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e474.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e397\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e767\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.005\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBlood substitution\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eYes\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eNo\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e49\u003c/p\u003e \u003cp\u003e317\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28 (9.7%)\u003c/p\u003e \u003cp\u003e261 (90.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21 (27.3%)\u003c/p\u003e \u003cp\u003e56 (72.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNeoadjuvant Chemotherapy\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eYes\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eNo\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e126\u003c/p\u003e \u003cp\u003e240\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e104 (36%)\u003c/p\u003e \u003cp\u003e185 (64%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22 (28.6%)\u003c/p\u003e \u003cp\u003e55 (71.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.250\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAdjuvant Chemotherapy\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eYes\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eNo\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e109\u003c/p\u003e \u003cp\u003e257\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e86 (29.8%)\u003c/p\u003e \u003cp\u003e203 (70.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23 (29.9%)\u003c/p\u003e \u003cp\u003e54 (70.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.906\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNeoadjuvant Radiotherapy\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eYes\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eNo\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e103\u003c/p\u003e \u003cp\u003e263\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e77 (26.6%)\u003c/p\u003e \u003cp\u003e212 (73.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30 (39%)\u003c/p\u003e \u003cp\u003e47 (61%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.026\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAdjuvant Radiotherapy\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eYes\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eNo\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e123\u003c/p\u003e \u003cp\u003e243\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e98 (33.9%)\u003c/p\u003e \u003cp\u003e191 (66.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25 (32.5%)\u003c/p\u003e \u003cp\u003e52 (67.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.871\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003ePeri\u003c/span\u003e\u003cb\u003eoperative Prophylaxis\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eYes\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eNo\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e257\u003c/p\u003e \u003cp\u003e109\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e195 (67.5%)\u003c/p\u003e \u003cp\u003e94 (32.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e62 (80.5%)\u003c/p\u003e \u003cp\u003e15 (19.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.032\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003ePost\u003c/span\u003e\u003cb\u003eoperative Prophylaxis\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eYes\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eNo\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e114\u003c/p\u003e \u003cp\u003e252\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e78 (27%)\u003c/p\u003e \u003cp\u003e211 (73%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36 (46.8%)\u003c/p\u003e \u003cp\u003e41 (53.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAntibiotic prophylaxis was administered as a single shot perioperatively in 257 cases (70.2% of all patients), 29.8% of patients did not received any prophylaxis because of low risk constalation. Cefuroxime or clindamycin was administered in 221 cases (56.3% of all patients), and ampicillin/sulbactam was given in 36 cases (9.8% of all patients). In 114 cases (31.1% of all cases or 51.6% of cases with antibiotic prophylaxis), antibiotic prophylaxis was continued postoperatively due to the complexity of surgery (Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSSI occurred in 85 cases (23.2% of all operations). Eight cases of infection occurred later than 90 days after the index surgery and were excluded from further analysis. They were considered as probable superinfections of the pre-existing seroma due to hematogenous spread. These cases were excluded for the evaluation of our study aim. In 77 cases (21% of all operations), the median time to surgical revision was 20 days (range between 3 and 90 days). The mean time of surgery, blood loss, and tumor size differed significantly (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) between the group with and without infections (Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e62 infections (out of 257, 24.1%) occurred in the group with perioperative antibiotic prophylaxis. In the group without antibiotic prophylaxis 15 infections occurred in 109 cases (13.8%; p\u0026thinsp;=\u0026thinsp;0.032). However, both groups differed highly significantly in baseline values as tumor size (p\u0026thinsp;=\u0026thinsp;0.007) or blood loss and duration of surgery (both p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSubgroup characteristics and it\u0026rsquo;s comparison regarding tumor size (cm: centimeter); blood loss (ml: milliliter) and surgery time (min: minutes).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTumor Size (cm)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBlood Loss (ml)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSurgery Time (min)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003ePeri\u003c/span\u003eoperative Prophylaxis\u003c/p\u003e \u003cp\u003eYes\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16,78\u003cb\u003ep\u0026thinsp;=\u0026thinsp;0.007\u003c/b\u003e\u003c/p\u003e \u003cp\u003e14,74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e576,27\u003cb\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003cp\u003e229,36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e88,11\u003cb\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003cp\u003e61,35\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eProlonged p\u003c/span\u003erophylaxis\u003c/p\u003e \u003cp\u003eYes\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18,78\u003cb\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003cp\u003e15,00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e839,91\u003cb\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003cp\u003e309,71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e110,11\u003cb\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003cp\u003e66,79\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProphylaxis with\u003c/p\u003e \u003cp\u003eCefuroxime or clindamycin vs.\u003c/p\u003e \u003cp\u003eAmpicillin/Sulbactam\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16,58p\u0026thinsp;=\u0026thinsp;0.186\u003c/p\u003e \u003cp\u003e18,10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e548,31p\u0026thinsp;=\u0026thinsp;0.108\u003c/p\u003e \u003cp\u003e786,29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e85,68p\u0026thinsp;=\u0026thinsp;0.323\u003c/p\u003e \u003cp\u003e100,14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIn the group with single shot antibiotics, 41 infections occurred in 252 cases (16.3%; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) compared to 36 (31.6%) infections in 114 cases with prolonged antibiotic prophylaxis. Also here, the group characteristics (tumor size, blood loss and duration of surgery differed highly significantly (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001; Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn comparison of the groups with cefuroxime (including clindamycin) and ampicillin/sulbactam, 55 infections occurred in 221 cases (24.9%) in the cefuroxime (and clindamycin) group, whereas 7 infections in 36 cases (19.4%; p\u0026thinsp;=\u0026thinsp;0.479) occurred in the ampicillin/sulbactam group (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, n.s.). The groups were comparable in terms of tumor size (p\u0026thinsp;=\u0026thinsp;0.186), blood loss (p\u0026thinsp;=\u0026thinsp;0.108), and time of surgery (p\u0026thinsp;=\u0026thinsp;0.323; Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eIn univariate analysis, the substitution of erythrocyte concentrates (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and neoadjuvant radiotherapy (p\u0026thinsp;=\u0026thinsp;0.026) were found to be significant risk factors for the development of infection. In multivariate analysis, the substitution of erythrocyte concentrates (p\u0026thinsp;=\u0026thinsp;0.007) and neoaduvant radiotherapy (p\u0026thinsp;=\u0026thinsp;0.013) were confirmed as a risk factor. In addition, the implementation of neoadjuvant chemotherapy (p\u0026thinsp;=\u0026thinsp;0.01) significantly worsened the risk for SSI (Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eunivariate and multivariate analysis of the risk factors, influencing the infection rate.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFactor\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnivariate Analysis\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMultivariate Analysis\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTumor size\u0026thinsp;\u0026gt;\u0026thinsp;15 cm\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.146\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.860\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBlood substitution\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.007\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNeoadjuvant chemotherapy\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.251\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.010\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNeoadjuvant radiotherapy\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e0.026\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.013\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAdjuvant chemotherapy\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.521\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.404\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAdjuvant radiotherapy\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.508\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.355\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThe resection of STS in the peripelvic region maybe a challenge for the surgeon. Complex anatomy and a large extent of the tumor often causes long surgery durations with high blood loss. Those are known risk factors for the development of SSI. This is frequently aggravated by neoadjuvant or adjuvant chemotherapy and radiotherapy. Precisely, these risk factors are confirmed in a large meta-analysis by \u003cem\u003eSlump et al.\u003c/em\u003e (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e): The evaluation of 21 studies on STS resections at all sites showed an overall complication rate of 30.2% with a surgical revision rate of 13.4%. The risk factors identified included large tumors, neoadjuvant radiotherapy, and high intraoperative blood loss. The infection rate in patient cohorts with mixed localizations is around 15\u0026ndash;18% (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e), while in pelvic bone sarcomas or soft tissue sarcomas in the peripelvic area the infection rate is about 20\u0026ndash;25% (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). In concordance with these findings, the SSI rate was 21% (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn current guidelines a uniform recommendation from different societies is seen: the American Surgical Infection Society recommends no antibiotic prophylaxis for aseptic orthopaedic operations without using implants (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). The recommendation of the German Paul-Ehrlich-Society is identical (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). However, risk factors for an increased risk of SSI in these procedures are also identified: Neoadjuvant radiation, surgery duration over 2 houers, long anesthesia time and high blood loss with blood transfusion. If these facts are taken into account, there is a tendency to advocate additional methods to reduce the infection rate. General aseptic measures have long been established in clinical practice: Aseptic washing, avoiding skin injuries, and using iodized films (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). However, there is no published evidence or recommendation for perioperative antibiotic prophylaxis in this cohort.\u003c/p\u003e \u003cp\u003eThe initial hypothesis of this study was that antibiotic prophylaxis reduces the infection rate after sarcoma resection in the peripelvic area. This could not be confirmed by our evaluation. The SSI rate in all subgroups was higher with antibiotic prophylaxis compared to no prophylaxis at all. However, significant differences between the groups were evident: Blood loss was higher in the group with antibiotic prophylaxis, the frequency of application of erythrocyte concentrates was higher, the duration of surgery was longer, and tumor size was more extensive. This confirms a profound selection bias regarding the administration of antibiotic prophylaxis. Other authors assume that the probability of postoperative infection in this group would even be higher without antibiotic prophylaxis. Infection rates of up to 50% have been described for these localizations (\u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). It is difficult to interpret the results in the group with prolonged antibiotic application: The infection rate was significantly higher in this group compared to a single shot (32 vs. 16%). \u003cem\u003eDadras et al.\u003c/em\u003e were also unable to achieve a reduction in the risk of infection through prolonged antibiotic administration (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e), the Paris group showed the same results (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Probably the only prospective and randomized study on the effectiveness of antibiotic prophylaxis in musculoskeletal oncology is the PARITY trial. Here, in a prospective double blinded and randomized trial, no benefit of prolonged antibiotic prophylaxis (1 day vs. 3 days) after bone sarcoma resection and implantation of tumor prostheses of the lower extremity could be shown (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). A study with a similar design would probably be useful to clarify this issue more precisely.\u003c/p\u003e \u003cp\u003eThe analysis of the bacterial spectrum in postoperative infections in the peripelvic area showed a significantly higher proportion of gram-negative and anaerobic pathogens, strongly associated with intestinal flora (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Few studies investigated postoperative infection in sarcoma resections in this area, all showed similar results (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Because of this, antibiotic prophylaxis with cephalosporins appears inadequate. We, therefore, changed the prophylaxis to ampicillin/sulbactam. The comparison of these 2 groups from our patient cohort shows a trend in the reduction of infection rate (19% versus 24%), but not significant. In a retrospective evaluation of \u003cem\u003eRamsey et al.\u003c/em\u003e (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e) the addition of metronidazole as an antibiotic prophylaxis to cover anaerobes reduced significantly the complication rate after sarcoma resections (27% vs. 17%; p\u0026thinsp;=\u0026thinsp;0.049) underlying our own findings.\u003c/p\u003e \u003cp\u003eAs far as our study design allows, we identified the following factors in the risk stratification for postoperative infection: Neoadjuvant radiotherapy and chemotherapy, duration of surgery, and substitution of erythrocyte concentrates as surrogate parameters for higher blood loss. The analysis of complications after surgery in nearly 1.000 STS at different locations (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e) identified almost the same risk factors; further studies also confirm these results (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e"},{"header":"5. Conclusions","content":"\u003cp\u003eThe evaluation of treatment outcomes after resection of peripelvic STS in our patients could not demonstrate a benefit of perioperative antibiotic prophylaxis or prolonged antibiotic therapy in lowering the postoperative infection risk. We attribute that to a selection bias of antibiotic prophylaxis at all. However, in line with the published literature, we identified subgroups with an increased risk of infection: Longer duration of surgery, higher blood loss with the need for blood substitution, larger tumor extension, and the application of neoadjuvant radiotherapy and chemotherapy. In our opinion, patients with a combination of these risk factors should receive antibiotic prophylaxis that ideally considers the increased gram-negative and anaerobic bacterial spectrum in this body region. With that at least a trend for a lesser rate of SSI was seen.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSTS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003esoft tissue sarcoma\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSSI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSurgical site infections\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eVAC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003evacuum-assisted closure systems\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ecm\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ecentimeter\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eg\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003egram\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003emg\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003emiligram\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003emin\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eminute\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eml\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003emililiter\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the institutional ethics committee (Ethics Committee of the Medical Faculty; ID 17-89). Written consent was obtained from all surviving patients. For non-surviving patients, data were irreversibly anonymized as recommended by the ethics committee. Children and young adults also provided informed consent from their parents.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConceptualization: AK and HRD; Methodology: AK, AW, HRD; Formal analysis and investigation: AK;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWriting - original draft preparation: AK, HRD; Writing - review and editing: AW, SG, LB, DG, BH;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSupervision: AW; BH.\u0026nbsp;All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eStiller CA, Trama A, Serraino D et al. 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Ann Oncol. 2021;32(11):1348\u0026thinsp;\u0026ndash;\u0026thinsp;65.10.1016/j.annonc.2021.07.006.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSurgical Site Infection Event (SSI). online2023 [ \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.cdc.gov/nhsn/pdfs/pscmanual/9pscssicurrent.pdf\u003c/span\u003e\u003cspan address=\"https://www.cdc.gov/nhsn/pdfs/pscmanual/9pscssicurrent.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDadras M, Koepp P, Wagner JM et al. Antibiotic prophylaxis for prevention of wound infections after soft tissue sarcoma resection: A retrospective cohort study. J Surg Oncol. 2020;122(8):1685\u0026thinsp;\u0026ndash;\u0026thinsp;92.10.1002/jso.26188.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSasaki H, Nagano S, Taniguchi N et al. Risk Factors for Surgical Site Infection after Soft-Tissue Sarcoma Resection, Including the Preoperative Geriatric Nutritional Risk Index. Nutrients. 2018;10(12).10.3390/nu10121900.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWacha H, Hoyme U, Isenmann R, et al. Perioperative Antibiotika-Prophylaxe. Chemother J. 2010;19(3):70\u0026ndash;84.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNakamura T, Nakamura K, Hagi T et al. Soft tissue sarcoma at the adductor compartment of the thigh may have a greater risk of tumor-associated events and wound complications. J Orthop Surg (Hong Kong). 2019;27(2):2309499019840813.10.1177/2309499019840813.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKito M, Ae K, Koyanagi H et al. Risk factor for wound complications following wide resection of soft tissue sarcoma in the adductor compartment of the thigh. Jpn J Clin Oncol. 2019;49(10):932\u0026thinsp;\u0026ndash;\u0026thinsp;7.10.1093/jjco/hyz101.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBensaid S, Contejean A, Morand P et al. Surgical site infection after pelvic bone and soft tissue sarcoma resection: Risk factors, microbiology, and impact of extended postoperative antibiotic prophylaxis. J Surg Oncol. 2023;128(2):344\u0026thinsp;\u0026ndash;\u0026thinsp;9.10.1002/jso.27271.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGhert M, Schneider P, Guyatt G et al. Comparison of Prophylactic Intravenous Antibiotic Regimens After Endoprosthetic Reconstruction for Lower Extremity Bone Tumors: A Randomized Clinical Trial. JAMA Oncol. 2022;8(3):345\u0026thinsp;\u0026ndash;\u0026thinsp;53.10.1001/jamaoncol.2021.6628.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRamsey DC, Walker JR, Wetzel R et al. Is the Addition of Anaerobic Coverage to Perioperative Antibiotic Prophylaxis During Soft Tissue Sarcoma Resection Associated With a Reduction in the Proportion of Wound Complications? Clin Orthop Relat Res. 2022;480(12):2409\u0026thinsp;\u0026ndash;\u0026thinsp;17.10.1097/corr.0000000000002308.\u003c/span\u003e\u003c/li\u003e \u003c/ol\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":"Sarcoma, surgical site infection, antibiotic prophylaxis, thigh, groin, gluteal area","lastPublishedDoi":"10.21203/rs.3.rs-4445116/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4445116/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eSurgical site infections (SSI) are one of the most common complications after extensive sarcoma resections and represent a daily challenge. SSI occur in up to 50% of cases particularly in the peripelvic area. One possible approach to reduce infection rate is perioperative antibiotic prophylaxis. The aim of this study therefore was to investigate the influence of perioperative antibiotic prophylaxis on the infection rate and the possible influence of location-specific antibiotic prophylaxis with ampicillin/sulbactam.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods and patients: \u003c/strong\u003eThis monocentric retrospective study included 366 patients who underwent sarcoma resections in the groin, proximal thigh, or gluteal region. All patients were operated on by 2 surgeons after neoadjuvant pretreatment if necessary.\u003c/p\u003e\n\u003cp\u003e3 groups of patients were defined. Group 1: In 60.4% of all cases, antibiotic prophylaxis was administered with cephalosporins (also clindamycin in case of penicillin allergy). Group2: In 9.8% of cases, ampicillin/sulbactam was used. Group 3: 29.8% of patients did not receive any antibiotic prophylaxis. In 31.1% of treated cases, antibiotic therapy was prolonged due to extented tumor resections.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003ePostoperative infections occurred in 23.2% (85 cases), in 77 cases within the first 90 days (on average after 20 days). The median operating time, blood loss, and tumor size were significantly higher in cases of infections, compared to patients without infection. In group 1 and 2 with perioperative single-shot prophylaxis, infection occurred in 24.1% of cases, compared to 13.5% of cases without prophylaxis (group 3) (p= 0.032). In the patients with prolonged antibiotic therapy, infection occurred in 31.6% of cases, compared to 16.3% of cases without prolongation (p\u0026lt; 0.001). In the ampicillin/sulbactam group, infection occurred in 19.4% of cases compared to 24.9% of cases in the cephalosporin group (p= 0.479). In univariate risk analysis, increased blood loss with erythrocyte substitution and neoadjuvant radiotherapy were proven to be risk factors for the occurrence of infections; in the multivariate analysis, neoadjuvant chemotherapy also proved to be a risk factor.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003ePerioperative antibiotic prophylaxis may reduce the risk of infection after extended sarcoma resection in the peripelvic area. However, the particular bacterial spectrum of this anatomic region should be taken into account when deciding which antibiotics to use.\u003c/p\u003e","manuscriptTitle":"Surgical site infections after sarcoma resections in the peripelvic region: Do we need perioperative antibiotic prophylaxis?","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-05 22:32:03","doi":"10.21203/rs.3.rs-4445116/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":"1ca33a46-e1bf-4c73-8b63-f381b685867d","owner":[],"postedDate":"June 5th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-06-05T22:32:05+00:00","versionOfRecord":[],"versionCreatedAt":"2024-06-05 22:32:03","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4445116","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4445116","identity":"rs-4445116","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}