Antibiotics are used in surgical practice for a number of reasons 1. Different antibiotics are used at different doses and for different durations across surgical contexts depending on clinical needs, and numerous antibiotics or combinations of antibiotics have been shown to provide comparable results for both prophylactic and therapeutic indications. Through research, formal and informal surgical practice guidelines have been developed, with certain antibiotics being the most common due to their relative advantages.
Prophylactic antibiotics may be administered preoperatively to reduce the incidence of surgical site infection. The efficacy of prophylactic antibiotics is well established, with level I evidence available for numerous indications across clinical contexts. By now, the routine administration of prophylactic antibiotics is actually standard in cases in which a patient will receive an artificial implant or have a foreign body implanted as part of the procedure, bone grafting procedures, and other surgeries with extensive dissections and expectations of high amounts of blood loss 2.
Multiple antibiotic classes are recommended for use in preoperative antibiotic prophylaxis. The antibiotics utilized tend to be bactericidal instead of bacteriostatic, and the majority are administered intravenously. The three most common antibiotics used in adult surgical prophylaxis, where weight-based dosing is recommended, tend to be cefazolin, vancomycin, and gentamicin. Pediatric surgical prophylaxis dosages should never exceed the usual adult dose, and, unless there is a known infection, prophylactic antibiotics must be discontinued within 24 hours 2.
Adjunctive therapeutic antimicrobial agents can be administered for the operative management of infections such as secondary peritonitis or necrotizing fasciitis. Metronidazole, clindamycin, and penicillin are all examples of common antibiotics for such surgical cases 3, for which the timing, regimen, dose and duration depend on the specific clinical context. Where possible, conversion to oral antimicrobial agents having high oral bioavailability (such as fluoroquinolones) may be considered.
It is important to note, meanwhile, that evidence for the benefits of antibiotics in surgical intervention for infection remains mitigated. Some studies still suggest that the use of systemically administered antibiotics as an adjunct to surgical interventions for infections such as peri-implantitis cannot be justified as a part of a standard treatment protocol 4. The role of antimicrobial agents as adjunctive therapy during surgery for abdominal infections is less clear. This is partially due to the fact that, overall, evidence from clinical trials of adjunctive antibiotic treatment tends to be obscured by confounding determinants of treatment failure. Until clinical investigators have developed methods to define and control for such variables, level I evidence will remain difficult to achieve 5.
The overuse of antibiotics is widely accepted as a major driver of some emerging infections (such as Clostridium difficile) and the rapid and continued development of antimicrobial resistance across the United States and globally 6. The growing emergence of multi-drug resistant organisms and the limited development of new agents available to counteract them have resulted, today, in an impending public health crisis at an international scale.
It is therefore critical that all common antibiotics used in surgical practice be very conservatively used, with care and caution. Whether in the United States or globally, the appropriate use of antimicrobials forms an integral part of good clinical practice, and clinicians need to remain aware of their role and responsibility for maintaining the effectiveness of current and future antibiotics 6.
In order to best inform the development of antibiotic administration guidelines globally, however, high-quality systematic reviews and research reflecting diverse populations and settings are still very much required 7.In addition, newer areas of exploration in antibiotic therapy in the surgical patient are likely, in future studies, to focus on the optimization of pharmacologic, toxic, and economic features while preserving clinical outcomes.
References
1. Fry, D. E. Antibiotics in surgery. An overview. Am. J. Surg. (1988). doi:10.1016/S0002-9610(88)80206-X
2. Crader, M. F. & Varacallo, M. Preoperative Antibiotic Prophylaxis. StatPearls (2023).
3. Baus-Domínguez, M. et al. A Systematic Review and Meta-Analysis of Systemic and Local Antibiotic Therapy in the Surgical Treatment of Peri-Implantitis. Antibiot. 2023, Vol. 12, Page 1223 12, 1223 (2023). doi: 10.3390/antibiotics12071223
4. Øen, M., Leknes, K. N., Lund, B. & Bunæs, D. F. The efficacy of systemic antibiotics as an adjunct to surgical treatment of peri-implantitis: a systematic review. BMC Oral Health (2021). doi:10.1186/s12903-021-02020-1
5. Bohnen, J. M. A. Antibiotics in surgery: evidence of anecdote? (2001).
6. Antibiotics in Surgery – Global Alliance for Infections in Surgery. Available at: https://infectionsinsurgery.org/2174-2/. (Accessed: 13th September 2023)
7. Brocard, E. et al. Antibiotic prophylaxis for surgical procedures: A scoping review. Revista Panamericana de Salud Publica/Pan American Journal of Public Health (2021). doi:10.26633/RPSP.2021.62