A nationwide analysis of more than 119,000 noncardiac surgeries suggests that gaps in adherence to Infectious Diseases Society of America–led perioperative antibiotic prophylaxis guidelines (IDSA/SIS/SHEA) remain common — and are associated with a significantly higher risk of surgical site infection (SSI).
In the cross-sectional study, published in JAMA Network Open, Bardia et al examined 119,236 adult surgical cases involving a skin incision between January 1, 2014, and August 31, 2022 across 37 US institutions, using merged data from the Multicenter Perioperative Outcomes Group (MPOG) and SSI outcomes from the National Surgical Quality Improvement Program (NSQIP) and/or Michigan Surgical Quality Collaborative (MSQC).
The investigators assessed adherence to four guideline-defined antibiotic metrics: appropriate antibiotic selection, weight-adjusted dosing, timing of the first dose relative to incision, and intraoperative redosing when indicated.
Overall, 26.1% of cases were nonadherent to at least one metric. The most frequent deviation was antibiotic choice (13.3%), followed by weight-adjusted dosing (9.0%), intraoperative redosing interval (4.8%), and timing relative to incision (3.0%). Overall, SSIs occurred in 4.4% of cases.
After multivariable adjustment, any nonadherence to the guideline antibiotic metrics was associated with a 34% higher relative risk of SSI (RR, 1.34; 95% CI, 1.26-1.43). When the individual components were examined separately, nonadherence to antibiotic choice was most strongly associated with SSI risk (RR, 1.43; 95% CI, 1.33-1.53), and failure to appropriately redose intraoperatively was also independently associated with increased risk (RR, 1.12; 95% CI, 1.02-1.24). In contrast, timing nonadherence was not significantly associated with SSI in adjusted analyses of this cohort (RR, 1.13; 95% CI, 0.98-1.31), a finding the authors interpret in the context of very high timing adherence, with only 3% of patients receiving antibiotics outside the recommended window.
The authors note that while adherence to SCIP timing metrics is near-universal, these more granular guidelines include procedure-specific antibiotic selection and redosing requirements that can make adherence challenging in the dynamic perioperative environment. Their findings suggest that improving antibiotic selection and ensuring appropriate redosing may yield greater reductions in SSI risk than further focusing on timing alone in contemporary practice.
Cefazolin, the first-line prophylactic antibiotic recommended for most clean and clean-contaminated noncardiac operations, was the predominant agent used. The study observed higher SSI rates among patients receiving non-cefazolin regimens; the authors note that, for many procedures, use of an antibiotic other than cefazolin typically reflects deviation from guideline-concordant agent selection (with exceptions such as MRSA colonization or cefazolin-resistant organisms). While confounding by indication cannot be fully excluded, the authors report similarity of demographic and comorbidity profiles across adherence groups, though measures of case acuity and complexity differed between adherent and nonadherent cases.
Institution-level analysis also demonstrated a weak but statistically significant correlation between higher rates of guideline nonadherence and higher SSI incidence (R = 0.4; P = .01).
Taken together, the results highlight a persistent and potentially modifiable contributor to postoperative infections. The authors suggest that improving compliance through strategies such as quality metric benchmarks, clinical decision support tools embedded within electronic health records, and clearer delineation of perioperative team responsibilities may help reduce SSIs.
Disclosures can be found in the study.
Source: JAMA Network Open
