Antibiotic Stewardship in the Preoperative Surgical Setting: Optimizing Prophylaxis to Reduce Antibiotic Use and Surgical Site Infections

Surgical Site Infections (SSIs) are prevalent healthcare-associated infections, affecting 0.-3% of surgical patients globally, leading to prolonged hospital stays, increased mortality and economic burdens [1,2]. In resource-limited settings, SSI rates may exceed 10% [3]. Antibiotic Stewardship Programs (ASPs) optimize preoperative antibiotic use to prevent SSIs, minimize antimicrobial resistance (AMR) and reduce costs [4]. Appropriate prophylaxis, administered within 60 minutes before incision, reduces SSI risk by 30-50% in clean and clean-contaminated surgeries [5,6]. However, prolonged postoperative antibiotic use contributes to AMR, complicating treatments and increasing costs [7]. The World Health Organization (WHO) and Centers for Disease Control and Prevention (CDC) report that up to 50% of surgical antibiotic prescriptions may be inappropriate [8,9].

Challenges to ASP implementation include guideline variability, non-compliance and cultural barriers in surgical teams [10]. Inconsistent timing or prolonged prophylaxis increases SSI risk and AMR. In the Middle East, limited data exist on single-dose prophylaxis efficacy, highlighting a research gap [12,13]. This study assesses the effect of an ASP in a single-center setting, comparing extended prophylaxis (Group A) with single-dose prophylaxis (Group B) to evaluate antibiotic use, SSI rates and readmissions.

Objectives

• Evaluate the impact of an ASP on optimizing preoperative antibiotic prophylaxis
• Compare extended versus single-dose prophylaxis in reducing antibiotic consumption (duration, DDD)
• Assess SSI and readmission rates under ASP-guided prophylaxis

Study Design and Setting

This retrospective cross-sectional chart review (January 2022-December 2024) at a single-center hospital followed Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines [14]. Ethical approval (IRB No. 309-25, approved September 28, 2025) was obtained, with consent waived per the Declaration of Helsinki. Data were anonymized.

Participants and Grouping

Inclusion: Adults (≥18 years) undergoing elective/emergency surgeries (general, orthopedic, gynecological, gastrointestinal, head and neck). Exclusion: Active infections, immunocompromised states, incomplete records. Sample size (n = 458) was calculated for 80% power, α = 0.05, to detect SSI differences (effect size 0.3). Patients were grouped: Group A (extended prophylaxis >24 hours, n = 306, 2022-2023) and Group B (single-dose preoperative, n = 152, 2023-2024). All surgical departments were included. Unequal group sizes resulted from longer pre-ASP data collection and gradual ASP adoption.

Data Collection

Data from electronic records included demographics, comorbidities, surgery type, antibiotic details (agent, dose, timing, duration, DDD) and outcomes (CDC-defined SSIs, readmissions). SSI adjudication was performed by two independent reviewers, with inter-rater reliability ensured via kappa statistics (κ = 0.85).

Statistical Analysis

Using SPSS v25, qualitative data were reported as frequencies/percentages, quantitative as Mean±SD (normality confirmed via Shapiro-Wilk test). Chi-square/ Fisher’s exact tests assessed associations; t-tests compared means. No statistical comparison for SSI was conducted due to zero events in Group B. The p<0.05 was significant 95% Confidence Intervals (CIs) were calculated for mean differences.

Groups were comparable in demographics and clinical characteristics (p>0.05; Table 1). Mean age was 43.90±14.90 years, with females comprising 68.3% and obesity present in 40.6% of the cohort. Comorbidities, including hypertension (7.6%) and diabetes (7.2%), showed no intergroup differences (Table 2). General surgery comprised 65.7% of procedures, with 92.6% elective. SSI rates were low (0.3% in Group A, n = 1; 0% in Group B, p = NA) and readmissions were rare (0.9% overall, p = 0.157; Table 2). Common antibiotics included cefuroxime (45%), ceftriaxone (30%) and cefazolin (20%), with no significant differences in agent selection between groups (p = 0.312).

Table 1: Demographic Characteristics of Patients (n = 458)

Chi-square test for categorical variables; t-test for continuous variables. BMI: Body Mass Index

Table 2: Clinical Features of Patients (n = 458)

Chi-square/Fisher’s exact test for categorical variables. SSI: Surgical Site Infection

Antibiotic use was significantly reduced in Group B (Table 3). Duration was shorter (2.51±3.00 vs. 3.18±3.11 days, p = 0.032, 95% CI: 0.06-1.28) and DDD was lower (5.46±6.92 vs. 6.73±6.63, p = 0.048, 95% CI: 0.01-2.53). Antibiotic patterns varied by surgery type (p<0.001; Table 4), with extended prophylaxis (>24 hours) most common in general surgery (53.4%) and orthopedics (22.1%). Orthopedic surgeries in Group A had longer durations (4.2±2.8 days) than Group B (1.8±1.5 days, p = 0.020). Gynecological surgeries showed moderate extended use (24.5%).

Table 3: Comparison of Antibiotic Use Among Groups (n = 458)

T-test for continuous variables. DDD: Defined Daily Dose

Table 4: Association of Antibiotic Use Patterns with Surgery Types (n = 458)

Chi-square test for associations

This study demonstrates that ASP-guided single-dose prophylaxis (Group B) significantly reduces antibiotic duration and DDD while maintaining low SSI rates, aligning with international guidelines from WHO and CDC [8,9]. Single-dose regimens, administered within 60 minutes before incision, are effective for clean and clean-contaminated surgeries, with systematic reviews confirming no additional benefit from extended prophylaxis [15-17]. This supports the adoption of ASPs to standardize preoperative antibiotic use, reducing unnecessary exposure and mitigating AMR risks.

The reduction in antibiotic duration (2.51 vs. 3.18 days) and DDD (5.46 vs. 6.73) in Group B highlights the ASP’s impact on optimizing antibiotic consumption. These findings are consistent with studies reporting 20%-36% reductions in antibiotic use through stewardship, particularly in general and orthopedic surgeries where extended prophylaxis was common (53.4% and 22.1%, respectively) [12,18]. Prolonged use in orthopedics may stem from perceived risks associated with implants, yet evidence supports single-dose cefazolin for most procedures [5,19]. Gynecological surgeries showed moderate extended use (24.5%), aligning with recommendations for single-dose ceftriaxone in cesarean sections [20]. The ASP’s success in reducing antibiotic use without increasing SSIs (0.3% in Group A, 0% in Group B) underscores its efficacy in high-risk populations, such as patients with diabetes (7.2%) or obesity (40.6%), where tailored dosing and glycemic control were sufficient [11,21,22].

Economically, reduced antibiotic use likely lowers costs, with studies estimating savings of $732-€247,000 per high-volume procedure [23]. In the Middle East, ASPs align with regional healthcare policies to curb AMR and optimize resources [12]. This study contributes to regional evidence by demonstrating practical ASP implementation in a single-center setting, overcoming barriers like surgeon resistance through education and multidisciplinary collaboration [18]. However, the retrospective design, unequal group sizes (306 vs. 152), lack of direct cost data, missing wound-classification data and potential under-reporting of minor SSIs limit generalizability. Future multicenter prospective trials, incorporating microbiome and cost-effectiveness analyses, are needed to validate these findings and enhance ASP integration into surgical quality metrics [16,24,25].

Strengths

• Large sample (n = 458)
• Contemporary data (2022-2024)
• Clear pre/post-ASP comparison

Single-dose prophylaxis via ASPs optimizes antibiotic use, reduces costs and sustains low SSI rates. This single-center retrospective study requires prospective multicenter validation. Surgical departments should integrate ASPs into quality metrics to enhance outcomes and counter AMR.

Limitations

• Single-center retrospective design
• Unequal group sizes (306 vs. 152)
• No direct cost data
• Missing wound-classification data
• Potential under-reporting of minor SSIs