Optimizing surgical antibiotic prophylaxis in the era of antimicrobial resistance: a position paper

Francesco M. Labricciosa, MD, Specialist in Hygiene and Preventive Medicine

Antimicrobial resistance (AMR) represents a serious threat to global health because antibiotics are losing effectiveness in both prevention and treatment of infections. The rising incidence of multidrug-resistant organisms (MDROs) challenges the efficacy of conventional surgical antibiotic prophylaxis (SAP) regimens.

Addressing this issue requires a re-examination of perioperative protocols, with attention to individual patient risk factors for MDRO colonization. Therefore, a targeted SAP approach should be considered when MDROs represent a significant surgical site infection risk. Thus far, limited evidence provides guidance on SAP selection in high-risk patients.

For these reasons, a position paper has been recently publishedin Pathogens by the Italian Multidisciplinary Society for the Prevention of Healthcare-Associated Infections (SIMPIOS). Following the best scientific evidence from PubMed and EMBASE Library a multidisciplinary working group produced 15 recommendation statements to optimize SAP in a context of AMR. They were graded according to the GRADE hierarchy of evidence. Using a Delphi approach, statements reaching ≥80% agreement were approved as strong recommendations.

This position paper is structured in three sections.

The first one widely reviewed the core principles for appropriate SAP. Then, the second section examined screening, decolonization, and targeted SAP in patients colonized with MDROs focusing separately on Gram-positive bacteria (methicillin-resistant Staphylococcus aureus [MRSA] and vancomycin-resistant enterococci [VRE]), and Gram-negative bacteria (extended-spectrum beta-lactamase [ESBL]-producing and carbapenem-resistant Enterobacterales [CRE]).

The third section discussed the barriers to changing surgeons’ prescribing behaviours, focusing on surgeons’ awareness and dynamics within surgical teams that influence antibiotic prescribing practices. To track adherence and improvement in SAP, the authors listed the key performance indicators, and suggested a checklist, too.

Finally, they summarized all the 15 recommendation statements expressed by the multidisciplinary working group in order to provide practical guidance for optimising SAP in the context of an AMR era.

The authors concluded that in the AMR era the goal is to ensure that SAP remains effective in preventing infections while minimizing unnecessary antibiotic exposure. This can be achieved balancing patient safety with stewardship principles, tailoring SAP to epidemiological risk, and promoting a culture of shared responsibility across the surgical pathway.

Reference

Sartelli M, Labricciosa FM, Casini B, et al. Optimizing Surgical Antibiotic Prophylaxis in the Era of Antimicrobial Resistance: A Position Paper from the Italian Multidisciplinary Society for the Prevention of Healthcare-Associated Infections (SIMPIOS). Pathogens. 2025;14(10):1031.

A global evidence-based bundle for surgical antibiotic prophylaxis

Francesco M. Labricciosa, MD, Specialist in Hygiene and Preventive Medicine

Recommending a bundle with evidence-based measures for surgical antibiotic prophylaxis (SAP), easily applicable and helpful to improve antibiotic prescribing practices among surgeons worldwide. This is the aim of a narrative review just published in Antibiotics by Massimo Sartelli and colleagues.

Surgical site infections (SSIs) represent the most common healthcare-associated infections occurring in surgical patients. Therefore, all procedures aiming to prevent SSIs should be integrated before, during, and after surgery.

SAP is one of the most important measures to prevent SSIs. Nevertheless, many surgeons erroneously believe that SAP is peripheral to their clinical practice. But actually, surgeons play a central role in prevention SSIs.

Indeed, approximately 15% of all antibiotics in hospitals are prescribed for SAP. Using antibiotics appropriately, both for therapy and prophylaxis, is essential to improve treatment effectiveness and patient safety, reduce the risk of antibiotic-associated infections (e.g., Clostridioides difficile infection), and the selection and spread of antibiotic-resistant bacteria.

Several guidelines have been published regarding SSIs prevention, but measures stated in these guidelines are not self-implementing. Bundles are among the most used methods to adapt guidelines in local contexts, and improve acceptance and adherence to best practices.

As observed by the authors, bundles implemented as stand-alone interventions or as part of multimodal strategies were associated with decreased SSI rates.

For these reasons, an international working group of 30 physicians has been established by the Global Alliance for Infections in Surgery. The authors aimed to define a global evidence-based bundle for the appropriate SAP administration, and evaluated the evidence supporting it.

This bundle includes five different actions that may affect adequate SAP administration.

***A global evidence-based bundle for surgical antibiotic prophylaxis*** *[Adapted from Figure 1 in Ref. 1]*

In administering antibiotics for any indication, including for SAP, surgeons should always be responsible for handling antibiotics with care. Indeed, inappropriate prescriptions of these precious medications, as well as poor implementation of infection prevention and control measures, are contributing to the development and spread of bacterial antimicrobial-resistance.

The authors hope this bundle can be easily applied everywhere, and help to improve antibiotic prescribing practices among surgeons worldwide.

Reference

Sartelli M, Coccolini F, Labricciosa FM, Al Omari AH, Bains L, Baraket O, et al. Surgical Antibiotic Prophylaxis: A Proposal for a Global Evidence-Based Bundle. Antibiotics. 2024; 13(1):100.

Infection prevention and management in surgery: a global declaration

Francesco M. Labricciosa, MD, Specialist in Hygiene and Preventive Medicine

In a paper recently published in the World Journal of Emergency Surgery, seven surgical societies around the world shared an important declaration.

The authors – expert physicians representing the societies involved in this alliance – highlighted the threat posed by antimicrobial resistance (AMR), and the importance to prevent and manage infections appropriately across the surgical pathway.

The Global Alliance for Infections in Surgery (GAIS), the World Society of Emergency Surgery (WSES), the Surgical Infection Society (SIS), the Surgical Infection Society-Europe (SIS-E), the World Surgical Infection Society (WSIS), the American Association for the Surgery of Trauma (AAST), and the Panamerican Trauma Society (PTS) participated in the realization of this document.

The goal was to raise awareness among surgeons about AMR by focusing on the importance of actively participating in this challenge.

Surgeons really play a pivotal role in prevention and management of infections in their daily practice. Indeed, they are primarily responsible for preventing hospital-acquired infections, particularly surgical site infections. Moreover, they are prescribers of antibiotics, both for prophylaxis and therapy.

Nevertheless, among them adequate infection prevention and control (IPC) measures, and appropriate antibiotic prescribing practices are often disregarded. Why?

In healthcare facilities around the world, cultural, contextual, and behavioural determinants can influence surgeons’ clinical practice. Furthermore, other factors – such as the fear of clinical failure, time pressure, or organizational contexts – can limit their adherence to IPC procedures and antibiotic prescribing practices.

According to the authors, surgeons in hospital settings should be aware of their role and responsibility, and follow the fundamental principles for correct infection prevention and management across the surgical pathway.

***Fundamental principles for correct infect*****ion prevention and management across the surgical pathway**
*[Adapted from Figure 1 in Ref. 1].*

Changing clinical behaviour is extremely challenging.

A collaborative and multidisciplinary approach is paramount to optimize individual patients’ outcomes and overall healthcare delivery. Each healthcare provider of the team has to participate, and be responsible for its own contribution to patient care.

The authors concluded calling all surgeons around the world to take part in this global cause, by pledging support for this declaration, and accepting responsibility for maintaining the effectiveness of current and future antibiotics.

Reference

Sartelli M, Coccolini F, Ansaloni L, Biffl WL, Blake DP, Boermeester MA, Coimbra R, Evans HL, Ferrada P, Gkiokas G, et al. Declaration on infection prevention and management in global surgery. World J Emerg Surg. 2023 Dec 6;18(1):56.