Controversies in Perioperative Antimicrobial Prophylaxis

Brooke K. Decker, M.D.; Alexander Nagrebetsky, M.D.; Pamela A. Lipsett, M.D.; Jeanine P. Wiener-Kronish, M.D.; Naomi P. O'Grady, M.D.

Disclosures

Anesthesiology. 2020;132(3):586-597. 

In This Article

Abstract and Introduction

Abstract

Although clinical guidelines for antibiotic prophylaxis across a wide array of surgical procedures have been proposed by multidisciplinary groups of physicians and pharmacists, clinicians often deviate from recommendations. This is particularly true when recommendations are based on weak data or expert opinion. The goal of this review is to highlight certain common but controversial topics in perioperative prophylaxis and to focus on the data that does exist for the recommendations being made.

Introduction

Mandates to improve antibiotic stewardship and reduce unnecessary antibiotic use[1–4] have compelled healthcare institutions to take a closer look at the divide between guidelines for perioperative antibiotic prophylaxis and clinical practice,[5,6] highlighting the fact that human nature makes providing less inherently more controversial than providing more when it comes to antibiotic prophylaxis. Some of the more common reasons for using antibiotics unnecessarily in the perioperative setting include entrance into abdominal cavity, higher estimated blood loss, and longer procedures.[7] Although clinical guidelines for antibiotic prophylaxis across a wide array of surgical procedures have been proposed by a collaborative, multidisciplinary group of physicians and pharmacists,[8] widely cited, and reiterated,[9] clinicians often deviate from recommendations, especially when recommendations are based on weak data. The goal of this review is to highlight certain common but controversial topics in perioperative prophylaxis.

The principles of perioperative antibiotic prophylaxis are evidenced-based, but there are limitations. Available studies may include outdated surgical techniques, antibiotics that are no longer used, and newer antibiotics that have not been studied in the perioperative setting. Additionally, the operating environment has evolved over time to include significant reductions in circulating air particles and improvements in how those particles move relative to the patient. This has the potential to reduce infection rates and confound the impact of antibiotic prophylaxis.

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