Increased Risk of Infections with Anti-TNF Agents in Patients with Crohn's Disease After Elective Surgery: Meta-Analysis

Dig Dis Sci. 2022 Feb;67(2):646-660. doi: 10.1007/s10620-021-06895-6. Epub 2021 Feb 26.


Background: Postoperative complication rates in patients with inflammatory bowel disease (IBD) receiving preoperative biologics have been analyzed without considering the surgical context. Emergency surgery may be associated with an increased risk of infectious complications, compared to elective operations.

Aims: To conduct a systematic review and meta-analysis investigating the relationship between preoperative biologic therapy and postoperative outcomes in Crohn's disease (CD) and ulcerative colitis (UC), focusing on elective surgery.

Methods: Electronic databases were searched up to February 12, 2020, for studies of patients with IBD undergoing elective abdominal surgery receiving biologic therapy within 3 months before surgery compared to no therapy, or another biologic therapy. Certainty of evidence was evaluated using GRADE. The primary outcomes were the rate of infections and total complications within 30 days. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were calculated.

Results: Thirty-three studies were included. Preoperative treatment with anti-tumor necrosis factor (TNF) therapy in patients with CD undergoing elective surgery was associated with increased odds of infection (OR 2.05; 95% CI 1.40-3.01), but not total complications (OR 1.03; 95% CI 0.71-1.51). In elective surgery for UC, preoperative anti-TNF therapy was not associated with infectious (OR 1.03; 95% CI 0.34-3.07) or total complications (OR 0.67; 95% CI 0.29-1.58). Limited data indicate that emergency surgery did not significantly affect the rate of complications.

Conclusions: Anti-TNF therapy prior to elective surgery may increase the odds of postoperative infection in CD, although the certainty of evidence is very low. More evidence is needed, particularly for newer biologics.

Keywords: Biologic agent; Crohn’s disease; Infection; Ulcerative colitis.

Publication types

  • Meta-Analysis
  • Systematic Review

MeSH terms

  • Colitis, Ulcerative / drug therapy*
  • Crohn Disease / drug therapy*
  • Elective Surgical Procedures*
  • Humans
  • Postoperative Complications / epidemiology
  • Surgical Wound Infection / epidemiology*
  • Tumor Necrosis Factor Inhibitors / therapeutic use*


  • Tumor Necrosis Factor Inhibitors