Oral antibiotics alone for bowel preparation in colorectal surgery: time to rethink tradition?

Soo Young Lee

doi:10.3393/ac.2025.01102.0157

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Editorial Complications Oral antibiotics alone for bowel preparation in colorectal surgery: time to rethink tradition?: Soo Young Lee; Annals of Coloproctology 2025;41(5):367-368.
DOI: https://doi.org/10.3393/ac.2025.01102.0157
Published online: October 29, 2025

Department of Surgery, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea

Correspondence to: Soo Young Lee, MD, PhD Department of Surgery, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, 322 Seoyang-ro, Hwasun 58128, Korea Email: syleecrs@jnu.ac.kr

• Received: September 16, 2025 • Accepted: September 21, 2025

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Enhanced Recovery After Surgery (ERAS) pathways have transformed perioperative care in colorectal surgery by emphasizing strategies that minimize surgical stress, reduce complications, and accelerate patient recovery [1]. Within these pathways, bowel preparation has remained a matter of debate. Mechanical bowel preparation (MBP) combined with oral antibiotics (OAB) has long been considered the standard approach in colorectal surgery, largely based on evidence showing reductions in surgical site infections (SSIs) [2]. However, MBP is burdensome for patients, carries risks of dehydration and electrolyte imbalance, and its independent benefit remains uncertain.

The necessity of MBP has been examined in parallel with the use of preoperative OAB. Recent meta-analyses consistently indicate that MBP alone confers little to no benefit, whereas the combination of MBP and OAB is associated with lower SSI risk [2, 3]. Consequently, current ERAS guidelines do not recommend MBP as a stand-alone intervention but endorse its use in combination with OAB [1, 4, 5]. Still, whether MBP adds value when OAB is already administered remains unresolved. Evidence supporting OAB without MBP has been limited, as prior analyses were often constrained by small trial numbers or heterogeneous study designs [2].

The randomized controlled trial by Mallesh et al. [6] addresses this evidence gap directly. In this prospective, double-blind, placebo-controlled study, patients undergoing elective colorectal surgery were randomized to receive OAB with ciprofloxacin and metronidazole or no bowel preparation, with both groups also receiving standard intravenous prophylaxis. The results were striking: the OAB group showed a significantly lower SSI rate (14.0% vs. 41.9%), as well as shorter hospital stays and fewer complications, without adverse antibiotic-related effects. The trial’s rigorous design minimizes bias, reinforcing the reliability of these findings. Nonetheless, as the authors noted, the trial was single-center, relatively small in scale, and conducted primarily in open surgery. In addition, colon and rectal procedures were analyzed together, although differences in SSI risk between these operations may influence the effects of bowel preparation. These factors necessitate cautious interpretation.

Even so, the implications are significant. If OAB alone is sufficient to lower SSI risk, eliminating MBP could offer several advantages: reduced patient discomfort, prevention of dehydration and electrolyte imbalance, lower resource utilization, and simpler preoperative care. This approach aligns closely with ERAS principles, which emphasize minimizing unnecessary interventions while optimizing patient-centered outcomes. Nevertheless, guideline recommendations are unlikely to change immediately. The most recent ERAS guidelines from international, American, and Korean societies continue to endorse OAB combined with MBP, reflecting the larger body of evidence supporting this regimen [1, 4, 5]. To formally adopt OAB monotherapy, larger multicenter trials, ideally stratified by surgical approach and procedure type, will be required.

Nonetheless, this study contributes important evidence to the growing view that OAB may be the main determinant of benefit, while MBP adds little. As ERAS pathways continue to evolve, the potential to simplify bowel preparation warrants serious consideration. The trial by Mallesh et al. [6] may not resolve the debate, but it represents an important step toward reconsidering long-standing practices in colorectal surgery.

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Conflict of interest

Soo Young Lee is an associate editor of this journal. No other potential conflict of interest relevant to this article was reported.

Funding

None.

REFERENCES

1. Lee KY, Lee SY, Choi M, Kim M, Kim JH, Song JM, et al. The 2024 Korean Enhanced Recovery After Surgery (ERAS) guidelines for colorectal cancer: a secondary publication. Ann Coloproctol 2025;41:3–26. Article PubMed PMC PDF
2. Jalalzadeh H, Wolfhagen N, Harmsen WJ, Griekspoor M, Boermeester MA. A network meta-analysis and GRADE assessment of the effect of preoperative oral antibiotics with and without mechanical bowel preparation on surgical site infection rate in colorectal surgery. Ann Surg Open 2022;3:e175. Article PubMed PMC
3. Tan J, Ryan ÉJ, Davey MG, McHugh FT, Creavin B, Whelan MC, et al. Mechanical bowel preparation and antibiotics in elective colorectal surgery: network meta-analysis. BJS Open 2023;7:zrad040.Article PubMed PMC PDF
4. Irani JL, Hedrick TL, Miller TE, Lee L, Steinhagen E, Shogan BD, et al. Clinical practice guidelines for enhanced recovery after colon and rectal surgery from the American Society of Colon and Rectal Surgeons and the Society of American Gastrointestinal and Endoscopic Surgeons. Dis Colon Rectum 2023;66:15–40. Article PubMed PMC
5. Gustafsson UO, Rockall TA, Wexner S, How KY, Emile S, Marchuk A, et al. Guidelines for perioperative care in elective colorectal surgery: Enhanced Recovery After Surgery (ERAS) Society recommendations 2025. Surgery 2025;184:109397.Article PubMed
6. Mallesh K, Theakarajan R, G B, Penumadu P, Kalayarasan R, Nagarajan R. Effect of oral antibiotic bowel preparation versus no preparation on surgical site infections in elective colorectal surgery: a randomized trial. Ann Coloproctol 2025;41:393–9. Article

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