Surgical site infection is a potential risk of surgery that
needs to be managed effectively as part of good patient care.
The advent of antibiotics in the 20th century and their
associated use as surgical antibiotic prophylaxis, often along with
other interventions such as oxygenation, glycaemic control and
surgical anti-sepsis and advances in practice, has enabled us to
minimise this procedural burden. However, the march of
antimicrobial resistance across the globe is limiting the ability
of the antibiotics we have at our disposal to provide safe and
effective care for our patients.
Many current infections are no
longer responsive to first line antibiotic choices. The overuse and
misuse of antibiotics, wherever this occurs, impacts the efficacy
of surgical antibiotic prophylaxis. This, compounded by the
decreased antibiotic development pipeline, means that managing
infections is no longer as simple as just selecting another
Complex infections are now being
treated with more toxic, costly and complicated regimens than in
the past, due to the reality of antimicrobial resistance.
This creates additional risks for our patients, including adverse
outcomes from the antibiotic choices and increased length of stay
due to a paucity of oral therapeutic choices. Patients with
unnecessary exposure to long courses of antibiotic prophylaxis are
also at higher risk of morbidity and mortality if they develop an
infection, as it is more likely the organism will be
The Australian Commission on
Safety and Quality in Health Care coordinates the Antimicrobial Use
and Resistance in Australia (AURA) program which provides a
platform for voluntary standardised audits of surgical prophylaxis
within the Hospital National Antimicrobial Prescribing Survey
(NAPS) framework. Data from participating hospitals in 2017
demonstrates that 30.5 per cent of surgical prophylaxis
prescriptions for inpatients extended 24 hours beyond the time of
surgery. This is despite guidelines generally recommending surgical
prophylaxis durations of less than 24 hours. Commonly,
surgical antibiotic prophylaxis was found to be too broad or too
narrow for the likely organisms; were inconsistent with guidelines
(with no indication of patient characteristics that would require
variation), or the wrong dose was prescribed.
In reality, variation in surgical
antibiotic prophylaxis prescription is often because of our own
individual prophylaxis preferences. There may be the perception of
reduced adverse outcome with longer and broader spectrum
intravenous courses, and topical or deep surgical site
administration has been reported. Despite evidence to the
contrary, some of these perceptions remain.1,2
The documented increased
healthcare-associated complications of prolonged or novel
intra-operative antibiotic use, also need to be considered,
particularly where the evidence base for alternative practices is
poor. As antibiotic prophylaxis is important in reducing
complications for our patients, attention should be paid to
relative benefits of these considerations.
Process issues still account for
many variations from guidelines-based practice. Improved
standardisation could harmonise our practice towards more
consistent and reliable delivery of antibiotic prophylaxis.
There are many opportunities for improvement including:
Consistency in documentation of fixed antibiotic duration
Development and adherence to evidence or consensus-based
Optimising administration timing for optimal concentration
during the procedure.
Simple changes such as elevating
the importance of correct surgical antimicrobial prophylaxis for
every procedure, rather than as a peripheral consideration to the
surgery at hand, could also increase consistent administration and
improve choice practices. Clarity in the ownership of the choice of
antibiotic between the anaesthetic and surgical specialties may aid
in more consistent administration practices within
Under the National Safety and
Quality Health Service (NSQHS) Standards, every hospital is
required to have a local antimicrobial stewardship program to
optimise use of antimicrobials and improve the use of surgical
antimicrobial prophylaxis within hospitals. They may
also be able to facilitate peer group or individual audit and
feedback procedures or dedicated quality improvement
projects. We all want the same outcome - the provision of
safe and effective care to our patients. To achieve this, we need
to understand how to balance the risks and benefits of
antimicrobial use by utilising specialty
The Commission is working with RACS to provide you with
resources to assist in this.
Visit the Commission web page and download a useful presentation and other resources to help you
improve surgical antibiotic prophylaxis in your organisation.
Harbarth S, Samore MH, Lichtenberg D, Carmeli Y. Prolonged
antibiotic prophylaxis after cardiovascular surgery and its effect
on surgical site infections and antimicrobial resistance.
Circulation. 2000 Jun 27;101(25):2916-21
Improvisation versus guideline concordance in surgical
antibiotic prophylaxis: a qualitative study, Broom, J., Broom, A.,
Kirby, E. et al. Infection (2018) 46: 541).
Understanding antibiotic decision making in surgery-a
qualitative analysis, Clinical Microbiology and Infection , Volume
23 , Issue 10 , 752 - 760, Charani, E. et al.