Expert Asks, Are We Wrong About the Benefits of Perioperative Antimicrobial Prophylaxis?

Perioperative antimicrobial prophylaxis has been a time-honored principle in the prevention of surgical site infection; however, its effectiveness has recently been questioned. In a commentary in World Journal of Emergency Surgery, Mark A. Malangoni, associate executive director of the American Board of Surgery, explores potential reasons for the lack of demonstrable efficacy and suggestions for re-examination of this concept.

As Malangoni explains, "The principles of perioperative antimicrobial prophylaxis were established more than 40 years ago. This concept has been applied to many areas of surgery and numerous prospective randomized trials have repeatedly demonstrated that surgical site infections (SSIs) are reduced when the right antibiotics are administered appropriately. This practice has been incorporated into standardized guidelines for perioperative use through the Surgical Care Improvement Project (SCIP) and serves as a major process measurement for appropriateness of practice."

Malangoni adds further that recent reports have demonstrated a lack of correlation between the use of guideline-directed perioperative antimicrobial prophylaxis, that is, administration of the right drug at the right time for the right duration and its primary outcome measure, prevention of SSI, and thus posits whether experts may have been wrong about the benefits of perioperative antimicrobial prophylaxis. As Malangoni writes, "There are a number of potential explanations for these observations. This principle has been so widely accepted that some propose that all patients receive antimicrobial prophylaxis

regardless of the operation and risk of infection ... Overuse blurs the advantage of prophylaxis, as many who wouldnt benefit would still receive prophylaxis and supports the concept of unrelated attribution. This is exemplified as 'if you want to show the benefit of a drug, give it to those who dont need it; it works every time.' Although it is recognized that perioperative prophylaxis is not the only preventive measure for SSI, failure to apply other measures such as appropriate skin cleansing, scrubbing of operating room personnel, use of aseptic technique, mechanical bowel preparation, and avoidance of undo contamination subjects patients to complications and can negate the beneficial effects of prophylaxis. In addition, the increasing prevalence of minimally invasive surgical procedures, which are associated with a lower risk of SSI than open operations for the same conditions, may also be impacting these observations."

To read the rest of the commentary in World Journal of Emergency Surgery, CLICK HERE.