Antibiotic prophylaxis and empirical therapy for intra-abdominal infections: a systematic review and network meta-analysis.

INTRODUCTION

This network meta-analysis (NMA) compared the efficacy and safety of antibiotic classes for empirical treatment of suspected intra-abdominal infections (IAIs) and for prophylaxis in at-risk populations.

METHODS

PubMed, Embase, SCOPUS, Web of Science, and CENTRAL were searched until 24 January 2026 (PROSPERO-CRD420251106514). Eligible studies assessed empiric antibiotic therapy or prophylaxis for IAI. Outcomes included treatment success, intra-abdominal and wound infection rates, morbidity, mortality, and adverse events. Treatment and prophylaxis data were analyzed as separate networks per outcome using frequentist random-effects NMA, with certainty graded via GRADE.

RESULTS

19 studies (2,910 patients) on treatment and 9 studies (3,014 patients) on prophylaxis, across eight antibiotic classes, were included. In treatment setting, carbapenems were associated with significantly higher treatment success than β-lactam/β-lactamase inhibitor [RR(95%CI)=1.06 (1.01-1.62)], and ranked highest by SUCRA for treatment success and adverse events. In prophylaxis setting, cephalosporin was associated with a lower risk of wound infection than carbapenem [RR(95%CI)=0.79 (0.70-0.88)] and β-lactam/β-lactamase inhibitor [RR(95%CI)=0.38 (0.16-0.91)]. Sensitivity analyses confirmed robustness; certainty ranged from moderate to very low, mainly due to imprecision.

CONCLUSION

Carbapenems provide the highest efficacy for empirical IAI treatment but require judicious use given resistance concerns. This benefit does not extend to prophylaxis, where narrower-spectrum agents such as cephalosporins performed well. Further high-quality trials incorporating newer agents and resistance outcomes are needed.