JAMA Surgery Highlights Risk of Adverse Events Increases with Each Additional Day of Prophylactic Antimicrobial Exposure following Surgery

Apri 1, 2020

Takeaway: Surgical antibiotic prophylaxis for greater than 24 hours has more harms than benefits for major surgical procedures and limiting post-operative antibiotic exposure has the potential to improve post-operative outcomes while also reducing costs. Findings were highlighted as a “study that will change your practice” at the 2019 Annual Infectious Diseases Society of America Meeting; findings also were disseminated through the media and highlighted by The New England Journal of Medicine Journal Watch. Researchers also anticipate this work will be incorporated into the next iteration of VA surgical guidelines and will lead to improvements in patient and population health and reduce unnecessary healthcare spending.

National guidelines recommend surgical antimicrobial prophylaxis be initiated within 1 hour prior to incision and discontinued within 24 hours post-operatively for most procedures – and within 48 hours for cardiac surgery. Limited data are available regarding the risks of prolonged prophylaxis regimens. This national VA study determined the association of type and duration of prophylaxis with surgical site infection (SSI), acute kidney injury (AKI), and Clostridium difficile infection among all Veterans (n=79,058) undergoing major cardiac, orthopedic total joint replacement, colorectal, and vascular procedures between October 2008 and September 2013. Outcomes showed that:

• Surgical prophylaxis reduces infections when used appropriately. However, durations lasting for greater than 24 hours increase the incidence of adverse events, such as acute kidney injury and difficile, but do not reduce surgical site infections. Risk of harm increases with each additional day of antimicrobial exposure.

Findings can be used by antimicrobial stewardship programs to promote discontinuation of antimicrobials when they are no longer clinically necessary and to inform policy surrounding surgical prophylaxis. Potential future improvements include limiting the duration of surgical prophylaxis to perioperative doses only and limiting the use of vancomycin to patients at high risk for MRSA.

Branch-Elliman W, O’Brien W, Strymish J, Itani K, Wyatt C, and Gupta K. Association of duration and type of surgical prophylaxis with antimicrobial-associated adverse events. JAMA Surgery. July 1, 2019;590-598.