Surgical site infections (SSIs) are one of the most common and troublesome complications of surgery, significantly affecting mortality, recovery, surgical outcomes, hospital length-of-stay, and healthcare costs. In 2016 alone, the cost burden of managing SSIs in the U.S. was estimated at $10 billion (Ban et al., 2017). Preventing surgical site infection requires attention before, during, and after surgery; one of the most effective tools for prevention is antibiotic prophylaxis. 

SSIs present a complex challenge, as many are diagnosed after discharge, and infection rates vary by surgical site. “Clean” procedures, such as cardiovascular surgery, carry relatively low infection risk, whereas surgeries involving areas with abundant microbial flora, such as the gastrointestinal tract, are associated with substantially higher infection rates, reaching as high as 10% in colorectal surgery (Garnier et al., 2025). SSIs can be classified as superficial, affecting only the skin and subcutaneous tissue; deep, involving muscle and fascia; or organ/space infections, which may involve internal organs or cavities. The severity and treatment of SSIs differ across these categories, emphasizing the importance of prevention. 

Perioperative antibiotic prophylaxis, typically administered shortly before surgical incision, is critical in the prevention of surgical site infection. Ideally, prophylactic antibiotics are given within 60 minutes before incision, ensuring adequate tissue concentrations at the time of potential microbial exposure. Intraoperative redosing is recommended for long procedures or procedures with significant blood loss. A meta-analysis found that appropriately timed and dosed perioperative antibiotics reduced SSI risk by approximately 70% across multiple surgical procedures (Motaghi et al., 2026). Antibiotic selection is guided by the most likely pathogens at the surgical site—for instance, Gram-positive coverage is prioritized for clean procedures, while gastrointestinal surgeries require broader coverage against Gram-negative and anaerobic bacteria. 

According to the Infectious Diseases Society of America (IDSA), four key elements maximize the benefit of prophylaxis: (1) selection of the appropriate antibiotic, (2) weight-based dosing, (3) timing of administration, and (4) intraoperative redosing. Despite clear evidence supporting these practices, adherence remains inconsistent in clinical practice. In a large pediatric surgical cohort, adherence to American College of Surgeons (ACS) perioperative antibiotic recommendations was variable: while appropriate timing of administration prior to incision was relatively high (~86–91% adherence), only about one‑third of cases met weight‑based dosing criteria, and fewer than 30% adhered to all guideline components (Berrondo et al., 2022). Even small lapses in adherence, such as delayed administration or incorrect dosing, have been associated with significantly higher SSI rates, underlining the importance of consistent practice. 

Several factors contribute to inconsistent adherence. Because multiple guidelines for perioperative antibiotic prophylaxis—including those from the IDSA, ACS, WHO, and others—exist and are periodically updated to reflect emerging evidence, perfect compliance is difficult. Case-specific factors, such as patient weight, renal or liver function, OR scheduling, and pharmacy availability, may also compromise the ability to follow recommendations precisely. 

Efforts to improve adherence focus on both system-level and clinician-focused interventions. Standardized protocols, checklists, and electronic reminders have been shown to increase compliance with timing and dosing recommendations. Multidisciplinary education for surgeons, anesthesiologists, and nursing staff reinforces the importance of perioperative antibiotic prophylaxis and addresses knowledge gaps. At the same time, stewardship principles must guide antibiotic use: prophylaxis should be limited to the recommended agent, dose, and duration to prevent the emergence of resistance and minimize adverse effects. Ultimately, combining evidence-based protocols with ongoing monitoring and feedback can reduce SSIs, improve patient outcomes, and optimize resource utilization.  

References 

1. Ban KA, Minei JP, Laronga C, Harbrecht BG, Jensen EH, Fry DE, et al. American college of surgeons and surgical infection society: surgical site infection guidelines, 2016 update. J Am College Surg. 2017;224:59–74. doi:10.1016/j.jamcollsurg.2016.10.029. 

2. Garnier M, Saint‑Genis Q, Roger C, Guilhaumou R, Leone M, Boisson M. Perioperative antimicrobial prophylaxis and surgical site infection prevention, what clinicians and researchers must know. Anaesth Crit Care Pain Med. 2025;44(6):101600. doi:10.1016/j.accpm.2025.101600. 

3. Motaghi S, Karam SG, Mulazzani F, et al. Antibiotic prophylaxis strategies and surgical site infections in colorectal surgery: a systematic review and network meta‑analysis. JAMA Netw Open. 2026;9(2):e2560095. doi:10.1001/jamanetworkopen.2025.60095. 

4. Berrondo C, Carone M, Katz C, Kenny A. Adherence to perioperative antibiotic prophylaxis recommendations and its impact on postoperative surgical site infections. Cureus. 2022;14(6):e25859. doi:10.7759/cureus.25859.