The purpose of this study was to conduct a systematic review of the existing literature to determine the effect of bariatric surgery on various pharmacokinetic parameters of oral antibiotic absorption as well as overall patient outcomes.
Materials and Methods
MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL) were searched up to February 2020. Outcomes of interest included change in pharmacokinetic parameters of oral antibiotics administered to patients following bariatric surgery, using variables such as maximum plasma concentration (Cmax), time to reach maximum plasma concentration (Tmax), area under the concentration-time curve (AUC), clearance, and volume of distribution. MINORS and Cochrane risk of bias tools were used to assess quality of evidence.
Ten studies with 100 patients assessing 8 oral antibiotics were included. The majority (77%) of patients underwent Roux-en-Y gastric bypass (RYGB), with fewer undergoing ventral banded gastroplasty (VBG) (14%), jejunoileostomy (6%), and jejunoileal bypass (3%). Antibiotic classes investigated included beta-lactams (5 studies), fluoroquinolones (2 studies), macrolides (2 studies), and oxazolidinones (1 study). Heterogeneity between studies precluded meaningful pooling or meta-analysis of data. Overall risk of bias was fair.
Patients given oral beta-lactams and macrolides warrant close monitoring due to unpredictable absorption post-bariatric surgery, whereas oral fluoroquinolones and linezolid may not be affected. Several studies also showed decreased absorption following RYGB, as well as lower serum exposure in patients with obesity compared to non-obese controls. Clinicians should monitor patients on a case-by-case basis for signs of antibiotic failure or toxicity and reassess dosing accordingly.
This is a preview of subscription content, access via your institution.
Buy single article
Instant access to the full article PDF.
Tax calculation will be finalised during checkout.
Subscribe to journal
Immediate online access to all issues from 2019. Subscription will auto renew annually.
Tax calculation will be finalised during checkout.
Flegal KM, Carroll D, Kit BK, et al. Prevalence of obesity and trends in the distribution of body mass index among US adults, 1999-2010. JAMA - J Am Med Assoc. 2012;307:491–7.
Afshin A, Forouzanfar MH, Reitsma MB, et al. Health effects of overweight and obesity in 195 countries over 25 years. N Engl J Med. 2017;377:13–27.
Colquitt JL, Pickett K, Loveman E, et al. Surgery for weight loss in adults. Cochrane Database Syst Rev. 2014;
Buchwald H, Estok R, Fahrbach K, et al. Weight and type 2 diabetes after bariatric surgery: systematic review and meta-analysis. Am J Med. 2009;122:248–56.
Sjöström L, Lindroos AK, Peltonen M, et al. Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. N Engl J Med. 2004;351:2683–93.
Crémieux PY, Ledoux S, Clerici C, et al. The impact of bariatric surgery on comorbidities and medication use among obese patients. Obes Surg. 2010;20:861–70.
Mulla CM, Middelbeek RJW, Patti ME. Mechanisms of weight loss and improved metabolism following bariatric surgery. Ann N Y Acad Sci. 2018;1411:53–64.
Davies NK, O’Sullivan JM, Plank LD, Murphy R. Altered gut microbiome after bariatric surgery and its association with metabolic benefits: a systematic review. Surg Obes Relat Dis. Elsevier Inc.; 2019;15:656–665. Available from: https://doi.org/10.1016/j.soard.2019.01.033
Angrisani L, Santonicola A, Iovino P, et al. IFSO Worldwide Survey 2016: primary, endoluminal, and revisional procedures. Obes Surg. 2018;28:3783–94.
Huttunen R, Syrjänen J. Obesity and the risk and outcome of infection. Int J Obes. 2013;37:333–40.
Sioka E, Tzovaras G, Perivoliotis K, et al. Impact of laparoscopic sleeve gastrectomy on gastrointestinal motility. Gastroenterol Res Pract. 2018;
Dirksen C, Damgaard M, Bojsen-Møller KN, et al. Fast pouch emptying, delayed small intestinal transit, and exaggerated gut hormone responses after Roux-en-Y gastric bypass. Neurogastroenterol Motil. 2013;25:346–e255.
Thelen K, Dressman JB. Cytochrome P450-mediated metabolism in the human gut wall. J Pharm Pharmacol. 2009;61:541–58.
Smit C, De Hoogd S, Brüggemann RJM, et al. Obesity and drug pharmacology: a review of the influence of obesity on pharmacokinetic and pharmacodynamic parameters. Expert Opin Drug Metab Toxicol. 2018;14:275–85.
Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Open Med. 2009;3:e123–30.
Slim K, Nini E, Forestier D, et al. Methodological index for non-randomized studies (Minors): development and validation of a new instrument. ANZ J Surg. 2003;73:712–6.
Higgins JPT, Altman DG, Gøtzsche PC, et al. The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ. 2011;18:343–d5928.
De Smet J, Colin P, De Paepe P, et al. Oral bioavailability of moxifloxacin after Roux-en-Y gastric bypass surgery. J Antimicrob Chemother. 2012;67:226–9.
Hamilton R, Thai XC, Ameri D, et al. Oral bioavailability of linezolid before and after Roux-en-Y gastric bypass surgery: is dose modification necessary in obese subjects? J Antimicrob Chemother. 2013;68:666–73.
Kampmann JP, Klein H, Lumholtz B, et al. Ampicillin and propylthiouracil pharmacokinetics in intestinal bypass patients followed up to a year after operation. Clin Pharmacokinet. 1984;9:168–76.
Miskowiak J, Andersen B, Nielsen VG. Absorption of oral penicillin before and after gastroplasty for morbid obesity. Pharmacology. 1985;31:115–20.
Montanha MC, dos Santos Magon TF, de Souza AC, et al. Reduced bioavailability of oral amoxicillin tablets compared to suspensions in Roux-en-Y gastric bypass bariatric subjects. Br J Clin Pharmacol. 2019;85:2118–25.
Padwal RS, Ben-Eltriki M, Wang X, et al. Effect of gastric bypass surgery on azithromycin oral bioavailability. J Antimicrob Chemother. 2012;67:2203–6.
Prince RA, Pincheira JC, Mason EE, et al. Influence of bariatric surgery on erythromycin absorption. J Clin Pharmacol. 1984;24:523–7.
Rivas AB, Lopez-Picado A, del R S-BM, et al. Effect of Roux-en-Y gastric surgery on ciprofloxacin pharmacokinetics: an obvious effect? Eur J Clin Pharmacol. 2019;75:647–54.
Rocha MBS, De Nucci G, Lemos FN, et al. Impact of bariatric surgery on the pharmacokinetics parameters of amoxicillin. Obes Surg. 2019;29:917–27.
Terry SI, Gould JC, McManus JPA, et al. Absorption of penicillin and paracetamol after small intestinal bypass surgery. Eur J Clin Pharmacol. 1982;23:245–8.
Janson B, Thursky K. Dosing of antibiotics in obesity. Curr Opin Infect Dis. 2012;25:634–49.
Goday Arno A, Farré M, Rodríguez-Morató J, et al. Pharmacokinetics in morbid obesity: influence of two bariatric surgery techniques on paracetamol and caffeine metabolism. Obes Surg. 2017;27:3194–201.
Schmitt C, Kuhn B, Zhang X, et al. Disease-drug-drug interaction involving tocilizumab and simvastatin in patients with rheumatoid arthritis. Clin Pharmacol Ther. 2011;89:735–40.
Ulvestad M, Skottheim IB, Jakobsen GS, et al. Impact of OATP1B1, MDR1, and CYP3A4 expression in liver and intestine on interpatient pharmacokinetic variability of atorvastatin in obese subjects. Clin Pharmacol Ther. 2013;93:275–82.
Blouin RA, Warren GW. Pharmacokinetic considerations in obesity. J Pharm Sci. 1999;88:1–7.
Cheymol G. Effects of obesity on pharmacokinetics: implications for drug therapy. Clin Pharmacokinet. 2000;39:216–31.
Seeley RJ, Chambers AP, Sandoval DA. The role of gut adaptation in the potent effects of multiple bariatric surgeries on obesity and diabetes. Cell Metab. 2015;21:369–78.
Roy DJ, Langworthy DR, Thurber KM, et al. Comparison of oral antibiotic failure rates in post-Roux-en-Y gastric bypass patients versus controls. Surg Obes Relat Dis. 2017;13:1524–9.
Lee Y, Ellenbogen Y, Doumouras AG, et al. Single- or double-anastomosis duodenal switch versus Roux-en-Y gastric bypass as a revisional procedure for sleeve gastrectomy: a systematic review and meta-analysis. Surg Obes Relat Dis. 2019;15:556–66.
Conflict of Interest
The authors declare that they have no conflicts of interest.
This article does not contain any studies with human participants or animals performed by any of the authors.
Informed consent does not apply.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Electronic supplementary material
About this article
Cite this article
Anvari, S., Lee, Y., Lam, M. et al. The Effect of Bariatric Surgery on Oral Antibiotic Absorption: a Systematic Review. OBES SURG 30, 2883–2892 (2020). https://doi.org/10.1007/s11695-020-04623-z
- Bariatric surgery
- Gastric bypass
- Systematic review