Current perspectives on surgical antibiotic prophylaxis: guideline recommendations, prescribing patterns, antimicrobial resistance and future directions
DOI:
https://doi.org/10.18203/2320-6012.ijrms20263143Keywords:
Surgical antibiotic prophylaxis, Surgical site infection, Antimicrobial resistance, Prescribing patterns, Guideline adherence, Antimicrobial stewardship, Perioperative antibioticsAbstract
Surgical antibiotic prophylaxis is an essential component of peri-operative infection prevention and plays an important role in reducing surgical site infections. Although guidelines and evidence-based approaches have been agreed upon on an international level, there is still a great deal of variation between healthcare institutions in the way that they prescribe, which can result in antimicrobial resistance, higher healthcare costs and morbidity among patients. This review highlights existing guidance for the use of surgical antibiotic prophylaxis (SAP), reviews the current antibiotic use trends, explores typical prescribing errors and adherence to guidelines, and explores their impact on AMR and clinical outcomes. A literature review was undertaken using international guidelines, peer-reviewed publications, surveillance reports and systematic reviews with a particular focus on antibiotic selection, timing of antibiotic prophylaxis, Duration of antibiotic prophylaxis, interventions to support antimicrobial stewardship and antibiotic prescribing practices in tertiary care, and emerging strategies to optimize SAP. There is evidence that proper implementation of the SAP guidelines lessens the risk of surgical site infections (SSIs). Inappropriate practices, such as the use of broad-spectrum antibiotics, delayed treatment and extended antibiotic coverage after surgery, however, are still common and lead to greater AMR, healthcare costs, and poor clinical outcomes. Rational antibiotic use can be achieved with antimicrobial stewardship initiatives, prescription audits, clinical pharmacist involvement, and/or electronic decision-support systems. While SAP continues to play a key role in preventing SSIs, it must be implemented in accordance with evidence-based recommendations. Enhancing antimicrobial stewardship, optimizing prescribing and implementing supportive technologies can optimize SAP, limit AMR, and improve surgical patient outcomes.
References
Allegranzi B, Zayed B, Bischoff P, Kubilay NZ, de Jonge S, de Vries F, et al. New WHO recommendations on intraoperative and postoperative measures for surgical site infection prevention: an evidence-based global perspective. Lancet Infect Dis. 2016;16(12):e288-e303.
Centers for Disease Control and Prevention. Surgical site infection basics. Atlanta: CDC, 2024. Available at: https://www.cdc.gov/surgical-site-infections/about/index.html. Accessed on 1 June 2026.
Badia JM, Casey AL, Petrosillo N, Hudson PM, Mitchell SA, Crosby C. Impact of surgical site infection on healthcare costs and patient outcomes: a systematic review in six European countries. J Hosp Infect. 2017;96(1):1-15.
Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70(3):195-283.
de Jonge SW, Gans SL, Atema JJ, Solomkin JS, Dellinger PE, Boermeester MA. Timing of preoperative antibiotic prophylaxis in 54,552 patients and the risk of surgical site infection: a systematic review and meta-analysis. Medicine (Baltimore). 2017;96(29):e6903.
World Health Organization. Global guidelines for the prevention of surgical site infection. Geneva: WHO; 2018. Available at: https://www.who.int/publications/i/item/9789241550475. Accessed on 1 June 2026.
Khan F, Chaudhary B, Sultan A, Alvi Y, Ahmad M, Kumar P, et al. Surgical antimicrobial prophylaxis. J Patient Saf Infect Control. 2021;9(2):40-7.
Branch-Elliman W, O'Brien W, Strymish J, Itani K, Wyatt C, Gupta K. Association of duration and type of surgical prophylaxis with antimicrobial-associated adverse events. JAMA Surg. 2019;154(7):590-98.
World Health Organization. Antimicrobial resistance. Copenhagen: WHO Regional Office for Europe; 2024. Available at: https://www.who.int/europe/news-room/fact-sheets/item/antimicrobial-resistance#. Accessed on 1 June 2026.
National Institute for Health and Care Excellence. Surgical site infections: prevention and treatment. London: NICE; 2019. Available at: https://www.nice.org.uk/guidance/ng125/chapter/Recommendations. Accessed on 1 June 2026.
National Institute for Health and Care Excellence. Quality statement 2: antibiotic prophylaxis. Surgical site infection quality standard. London: NICE; 2013. Available at: https://www.nice.org.uk/guidance/qs49/chapter/Quality-statement-2-Antibiotic-prophylaxis. Accessed on 1 June 2026.
American Society of Health-System Pharmacists, Infectious Diseases Society of America, Surgical Infection Society, Society for Healthcare Epidemiology of America. ASHP therapeutic guidelines: clinical practice guidelines for antimicrobial prophylaxis in surgery. Available at: https://www.ashp.org/surgical-guidelines. Accessed on 1 June 2026.
European Centre for Disease Prevention and Control. Systematic review and evidence-based guidance on peri-operative antibiotic prophylaxis. Stockholm: ECDC; 2013. Available at: https://www.ecdc.europa.eu/en/publications-data/systematic-review-and-evidence-based-guidance-peri-operative-antibiotic. Accessed on 1 June 2026.
Solomkin JS, Mazuski J, Blanchard JC, Itani KMF, Ricks P, Dellinger EP, et al. Introduction to the Centers for Disease Control and Prevention and the Healthcare Infection Control Practices Advisory Committee Guideline for the Prevention of Surgical Site Infections. Surg Infect (Larchmt). 2017;18(4):385-93.
National Centre for Antimicrobial Stewardship. Surgical antimicrobial prophylaxis. 2021. Available at: https://www.ncas-australia.org/surgical-antimicrobial-prophylaxis. Accessed on 1 June 2026.
Ban KA, Minei JP, Laronga C, Harbrecht BG, Jensen EH, Fry DE, et al. American College of Surgeons and Surgical Infection Society: Surgical Site Infection Guidelines, 2016 update. J Am Coll Surg. 2016;224(1):59-74.
Bull A, Russo P, Friedman N, Bennett N, Boardman C, Richards M. Compliance with surgical antibiotic prophylaxis – reporting from a statewide surveillance programme in Victoria, Australia. J Hosp Infect. 2006;63(2):140-7.
Steinberg JP, Braun BI, Hellinger WC, Kusek L, Bozikis MR, Bush AJ, et al. Timing of antimicrobial prophylaxis and the risk of surgical site infections. Ann Surg. 2009;250(1):10-6.
Saleem Z, Hassali MA, Godman B, Versporten A, Hashmi FK, Saeed H, et al. Point prevalence surveys of antimicrobial use: a systematic review and the implications. Expert Rev Anti Infect Ther. 2020;18(9):897-910.
Gouvêa M, Novaes CO, Pereira DM, Iglesias AC. Adherence to guidelines for surgical antibiotic prophylaxis: a review. Braz J Infect Dis. 2015;19(5):517-24.
Weber WP, Marti WR, Zwahlen M, Misteli H, Rosenthal R, Reck S, et al. The timing of surgical antimicrobial prophylaxis. Ann Surg. 2008;247(6):918-26.
Hawn MT, Richman JS, Vick CC, Deierhoi RJ, Graham LA, Henderson WG, et al. Timing of surgical antibiotic prophylaxis and the risk of surgical site infection. JAMA Surg. 2013;148(7):649-57.
Moges G, Belete L, Mengesha Y, Ahmed S. Evaluation of surgical antimicrobial prophylaxis and incidence of surgical site infection at Borumeda Hospital, Northeast Ethiopia: retrospective cross-sectional study. Drug Healthc Patient Saf. 2020;12:257-68.
Anderson DJ, Podgorny K, Berríos-Torres SI, Bratzler DW, Dellinger EP, Greene L, et al. Strategies to prevent surgical site infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014;35(6):605-27.
Ayoade F, Li D, Mabrouk A, Todd JR. Periprosthetic joint infection. Treasure Island (FL): StatPearls Publishing; 2023.
Nelson RL, Gladman E, Barbateskovic M. Antimicrobial prophylaxis for colorectal surgery. Cochrane Database Syst Rev. 2014;(5):CD001181.
Davey P, Marwick CA, Scott CL, Charani E, McNeil K, Brown E, et al. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev. 2017;2(2):CD003543.
Tacconelli E, Carrara E, Savoldi A, Harbarth S, Mendelson M, Monnet DL, et al. Discovery, research, and development of new antibiotics: the WHO priority list of antibiotic-resistant bacteria and tuberculosis. Lancet Infect Dis. 2018;18(3):318-27.
Tourmousoglou CE, Yiannakopoulou ECh, Kalapothaki V, Bramis J, Papadopoulos JS. Adherence to guidelines for antibiotic prophylaxis in general surgery: a critical appraisal. J Antimicrob Chemother. 2008;61(1):214-8.
van Kasteren ME, Kullberg BJ, de Boer AS, Mintjes-de Groot J, Gyssens IC. Adherence to local hospital guidelines for surgical antimicrobial prophylaxis: a multicentre audit in Dutch hospitals. J Antimicrob Chemother. 2003;51(6):1389-96.
Tarchini G, Liau KH, Solomkin JS. Antimicrobial stewardship in surgery: challenges and opportunities. Clin Infect Dis. 2017;64(Suppl 2):S112-4.
de Lissovoy G, Fraeman K, Hutchins V, Murphy D, Song D, Vaughn BB. Surgical site infection: incidence and impact on hospital utilization and treatment costs. Am J Infect Control. 2009;37(5):387-97.
Bratzler DW, Houck PM; Surgical Infection Prevention Guideline Writers Workgroup. Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project. Am J Surg. 2005;189(4):395-404.
Dellit TH, Owens RC, McGowan JE Jr, Gerding DN, Weinstein RA, Burke JP, et al. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis. 2007;44(2):159-77.
Bhutta R, Shneker T, Currier S, Caskey A, Relli-Dempsey V, Franzen M, et al. Perioperative antibiotic administration review: an analysis of outpatient surgeries at OhioHealth Doctors Hospital. Cureus. 2025;17(10): e95443.
Hohmann C, Eickhoff C, Radziwill R, Schulz M. Adherence to guidelines for antibiotic prophylaxis in surgery patients in German hospitals: a multicentre evaluation involving pharmacy interns. Infection. 2012;40(2):131-37.
Holmes AH, Moore LS, Sundsfjord A, Steinbakk M, Regmi S, Karkey A, et al. Understanding the mechanisms and drivers of antimicrobial resistance. Lancet. 2016;387(10014):176-87.
Berríos-Torres SI, Umscheid CA, Bratzler DW, Leas B, Stone EC, Kelz RR, et al. Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017. JAMA Surg. 2017;152(8):784-91.
Teshome BF, Vouri SM, Hampton N, Kollef MH, Micek ST. Duration of exposure to antipseudomonal β-lactam antibiotics in the critically ill and development of new resistance. Pharmacotherapy. 2019;39(3):261-70.
Barlam TF, Cosgrove SE, Abbo LM, MacDougall C, Schuetz AN, Septimus EJ, et al. Implementing an antibiotic stewardship program: guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Clin Infect Dis. 2016;62(10):e51-e77.
Laxminarayan R, Sridhar D, Blaser M, Wang M, Woolhouse M. Achieving global targets for antimicrobial resistance. Science. 2016;353(6302):874-75.
Alexander JW, Solomkin JS, Edwards MJ. Updated recommendations for control of surgical site infections. Ann Surg. 2011;253(6):1082-93.
Hou Y, Collinsworth A, Hasa F, Griffin L. Incidence and impact of surgical site infections on length of stay and cost of care for patients undergoing open procedures. Surg Open Sci. 2022;11:1-18.
Barth JH, Misra S, Aakre KM, Langlois MR, Watine J, Twomey PJ, et al. Why are clinical practice guidelines not followed? Clin Chem Lab Med. 2016;54(7):1133-9.
Schuts EC, Hulscher MEJL, Mouton JW, Verduin CM, Stuart JWTC, Overdiek HWPM, et al. Current evidence on hospital antimicrobial stewardship objectives: a systematic review and meta-analysis. Lancet Infect Dis. 2016;16(7):847-56.
Broom A, Broom J, Kirby E, Gibson A, Davis M. Antibiotic optimisation in 'the bush': local know-how and core-periphery relations. Health Place. 2017;48:56-62.
Ayukekbong JA, Ntemgwa M, Atabe AN. The threat of antimicrobial resistance in developing countries: causes and control strategies. Antimicrob Resist Infect Control. 2017;6:47.
Broom J, Broom A, Adams K, Plage S. What prevents the intravenous to oral antibiotic switch? A qualitative study of hospital doctors' accounts of what influences their clinical practice. J Antimicrob Chemother. 2016;71(8):2295-9.
Curtis CE, Bahar FA, Marriott JF. The effectiveness of computerised decision support on antibiotic use in hospitals: a systematic review. PLoS One. 2017;12(8):e0183062.
Pollack LA, van Santen KL, Weiner LM, Dudeck MA, Edwards JR, Srinivasan A. Antibiotic stewardship programs in U.S. acute care hospitals: findings from the 2014 National Healthcare Safety Network annual hospital survey. Clin Infect Dis. 2016;63(4):443-9.
World Health Organization. Antimicrobial resistance. Geneva: WHO; 2023. Available at: https://www.who.int/news-room/fact-sheets/detail/antimicrobial-resistance. Accessed on 1 June 2026.
Ventola CL. The antibiotic resistance crisis: part 1: causes and threats. P T. 2015;40(4):277-83.
O'Neill J. Tackling drug-resistant infections globally: final report and recommendations. London: Review on Antimicrobial Resistance, Wellcome Trust and HM Government; 2016.
Cassini A, Högberg LD, Plachouras D, Quattrocchi A, Hoxha A, Simonsen GS, et al. Attributable deaths and disability-adjusted life-years caused by infections with antibiotic-resistant bacteria in the EU and the European Economic Area in 2015: a population-level modelling analysis. Lancet Infect Dis. 2019;19(1):56-66.
Turner NA, Sharma-Kuinkel BK, Maskarinec SA, Eichenberger EM, Shah PP, Carugati M, et al. Methicillin-resistant Staphylococcus aureus: an overview of basic and clinical research. Nat Rev Microbiol. 2019;17(4):203-18.
Peirano G, Pitout JDD. Extended-spectrum β-lactamase-producing Enterobacteriaceae: update on molecular epidemiology and treatment options. Drugs. 2019;79(14):1529-41.
Centers for Disease Control and Prevention. 2019 antibiotic resistance threats report. Atlanta: CDC; 2025. Available at: https://www.cdc.gov/antimicrobial-resistance/data-research/threats/index.html. Accessed on 1 June 2026.
Cosgrove SE. The relationship between antimicrobial resistance and patient outcomes: mortality, length of hospital stay, and health care costs. Clin Infect Dis. 2005;42(Suppl 2):S82-9.
Naylor NR, Atun R, Zhu N, Kulasabanathan K, Silva S, Chatterjee A, et al. Estimating the burden of antimicrobial resistance: a systematic literature review. Antimicrob Resist Infect Control. 2018;7:58.
Prestinaci F, Pezzotti P, Pantosti A. Antimicrobial resistance: a global multifaceted phenomenon. Pathog Glob Health. 2015;109(7):309-18.
Levy SB, Marshall B. Antibacterial resistance worldwide: causes, challenges and responses. Nat Med. 2004;10(12 Suppl):S122-9.
Nelson RE, Hatfield KM, Wolford H, Samore MH, Scott RD, Reddy SC, et al. National estimates of healthcare costs associated with multidrug-resistant bacterial infections among hospitalized patients in the United States. Clin Infect Dis. 2021;72(Suppl 1):S17-S26.
Murray CJL, Ikuta KS, Sharara F, Swetschinski L, Aguilar GR, Gray A, et al. Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis. Lancet. 2022;399(10325):629-55.
Laxminarayan R, Duse A, Wattal C, Zaidi AKM, Wertheim HFL, Sumpradit N, et al. Antibiotic resistance - the need for global solutions. Lancet Infect Dis. 2013;13(12):1057-98.
Dyar O, Huttner B, Schouten J, Pulcini C. What is antimicrobial stewardship? Clin Microbiol Infect. 2017;23(11):793-98.
Bond CA, Raehl CL. Clinical pharmacy services, pharmacy staffing, and hospital mortality rates. Pharmacotherapy. 2007;27(4):481-93.
MacDougall C, Polk RE. Antimicrobial stewardship programs in health care systems. Clin Microbiol Rev. 2005;18(4):638-56.
Ivers N, Jamtvedt G, Flottorp S, Young JM, Odgaard-Jensen J, French SD, et al. Audit and feedback: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev. 2012;(6):CD000259.
Baysari MT, Lehnbom EC, Li L, Hargreaves A, Day RO, Westbrook JI. The effectiveness of information technology to improve antimicrobial prescribing in hospitals: a systematic review and meta-analysis. Int J Med Inform. 2016;92:15-34.
Sintchenko V, Coiera E, Gilbert GL. Decision support systems for antibiotic prescribing. Curr Opin Infect Dis. 2008;21(6):573-79.
Roberts JA, Abdul-Aziz MH, Lipman J, Mouton JW, Vinks AA, Felton TW, et al. Individualised antibiotic dosing for patients who are critically ill: challenges and potential solutions. Lancet Infect Dis. 2014;14(6):498-509.
Tamma PD, Cosgrove SE. Antimicrobial stewardship. Infect Dis Clin North Am. 2011;25(1):245-60.
Peiffer-Smadja N, Rawson T, Ahmad R, Buchard A, Georgiou P, Lescure F, et al. Machine learning for clinical decision support in infectious diseases: a narrative review of current applications. Clin Microbiol Infect. 2020;26(5):584-95.
European Centre for Disease Prevention and Control. Antimicrobial resistance (AMR). Stockholm: ECDC; 2010. Available at: https://www.ecdc.europa.eu/en/antimicrobial-resistance. Accessed on 1 June 2026.
Downloads
Published
How to Cite
Issue
Section
