Invited Commentary <\/p>\n\n\n\n
Anesthesiology<\/p>\n\n\n\n
Surgical site infections (SSIs) remain among the most common and costly complications following surgery, despite decades of quality improvement efforts. In this context, the multicenter cohort study by Bardia et al1<\/a><\/sup>\u00a0provides timely and compelling evidence that current perioperative antibiotic quality metrics may now be misaligned with the practices that most meaningfully influence infection risk. Using linked data from the Multicenter Perioperative Outcomes Group, the National Surgical Quality Improvement Program, and the Michigan Surgical Quality Collaborative, the authors evaluated more than 119\u202f000 noncardiac surgical cases across 37 US institutions. They examined adherence to 4 components of the Infectious Diseases Society of America (IDSA) perioperative antibiotic prophylaxis guidelines: (1) antibiotic selection, (2) weight-based dosing, (3) timing of administration, and (4) intraoperative redosing.1<\/a>,2<\/a><\/sup>\u00a0Their findings expose a critical gap between commonly measured perioperative metrics and the practices associated with reducing SSIs.<\/p>\n\n\n\n More than one-quarter of cases (26%) involved nonadherence to at least 1 IDSA guideline component, and these patients experienced higher rates of SSI.1<\/a><\/sup> Notably, the increased risk was primarily associated with incorrect antibiotic selection and missed intraoperative redosing.1<\/a><\/sup> In contrast, timing of the initial antibiotic dose relative to incision, a central focus of the Surgical Care Improvement Project, was not independently associated with SSI.1<\/a><\/sup>,3<\/a><\/sup>Together, these findings suggest that when antibiotic timing no longer discriminates risk, other components of prophylaxis, specifically antibiotic selection and redosing, become more clinically consequential.<\/a><\/p>\n\n\n\n These findings do not reflect a failure of prior SSI prevention efforts; they highlight the limits of timing-centered metrics as sole indicators of prophylactic quality.4<\/a><\/sup> Antibiotic selection and intraoperative redosing require real-time clinical judgment, procedure-specific knowledge, and coordination across surgical, anesthesia, and pharmacy teams. These features are less easily standardized yet more directly aligned with antimicrobial stewardship principles. By identifying these elements as key drivers of residual SSI risk, the study by Bardia et al1<\/a><\/sup> reframes perioperative antibiotic prophylaxis as a stewardship challenge rather than a checklist exercise.<\/a><\/p>\n\n\n\n The apparent disconnect between timing and outcomes in this analysis should not be interpreted as evidence that timing is unimportant. Instead, this pattern may reflect the success of prior quality initiatives. When nearly all patients receive antibiotics within the recommended window, timing ceases to discriminate risk.3<\/a><\/sup>,5<\/a><\/sup> In contrast, antibiotic selection and intraoperative redosing continue to vary across procedures, institutions, and clinical contexts. Unlike timing, these elements depend on procedure-specific decision-making and shared responsibility across surgical, anesthesia, and pharmacy teams, making them more vulnerable to workflow gaps and less amenable to simple process standardization.2<\/a><\/sup>,6<\/a><\/sup><\/a><\/p>\n\n\n\n Antibiotic selection, in particular, represents a stewardship decision, not a discrete process measure. The observation that patients who received antibiotics other than cefazolin experienced higher rates of SSI may reflect deviations from guideline-concordant prophylaxis for specific procedures, not inherent limitations of alternative agents.1<\/a><\/sup>,2<\/a><\/sup> Selection decisions are shaped by allergy histories, institutional formularies, prescribing culture, and perioperative workflow constraints. Together, these factors may promote unnecessary broad-spectrum coverage or inappropriate substitutions. Viewed through a stewardship lens, these findings reinforce that effective prophylaxis depends not simply on administering an antibiotic but on selecting the appropriate agent for the specific operation.2<\/a><\/sup>,7<\/a><\/sup><\/a><\/p>\n\n\n\n Intraoperative redosing is an equally important, yet frequently overlooked, component of effective prophylaxis. Appropriate redosing depends on operative duration, antibiotic pharmacokinetics, and evolving intraoperative events, but responsibility for executing this step is often diffuse. Anesthesiologists, surgeons, and nursing staff may each assume that another team member is monitoring the need for redosing, particularly during prolonged or complex procedures.2<\/a><\/sup> The independent association between missed intraoperative redosing and SSI observed in this study reinforces long-standing pharmacologic principles and underscores intraoperative redosing as a stewardship-relevant target for system-level intervention.1<\/a><\/sup>,2<\/a><\/sup><\/a><\/p>\n\n\n\n Taken together, these findings argue for a recalibration of perioperative antibiotic stewardship and quality improvement efforts. Continued reliance on timing-based metrics alone is unlikely to yield further reductions in SSIs.5<\/a><\/sup> Health systems should instead prioritize strategies that support correct antibiotic selection and reliable intraoperative redosing. Such strategies include procedure-specific order sets aligned with IDSA recommendations and real-time electronic decision support that incorporates patient weight and operative duration. Clear assignment of responsibility for redosing during prolonged or complex procedures is also essential.2<\/a><\/sup>,4<\/a><\/sup>,6<\/a><\/sup>,7<\/a><\/sup> These interventions should be framed as stewardship tools designed to improve patient outcomes, with emphasis on systems design rather than on individual clinician surveillance or blame.7<\/a><\/sup><\/a><\/p>\n\n\n\n Beyond clinical practice, this study has important implications for policy and performance measurement. Quality metrics do more than track care; they signal priorities and shape investment in clinical infrastructure. Bardia et al1<\/a><\/sup>found that antibiotic selection and intraoperative redosing are associated with residual SSI risk, which suggests that future quality initiatives should evolve to capture these dimensions of prophylactic care, with less exclusive emphasis on timing-based measures. Aligning performance metrics with stewardship-relevant processes may better incentivize the development of decision support tools, clarify perioperative ownership of these critical tasks, and ultimately improve patient outcomes.1<\/a><\/sup>,2<\/a>,6<\/a><\/sup><\/a><\/p>\n\n\n\n In summary, this large, multicenter analysis provides robust evidence that adherence to comprehensive IDSA perioperative antibiotic guidelines, particularly with respect to antibiotic selection and intraoperative redosing, is associated with a lower risk of SSI, even in settings with high timing compliance.1<\/a><\/sup> By clarifying where preventable variation persists, the study by Bardia et al1<\/a><\/sup> offers a roadmap for the next phase of SSI prevention. Improving outcomes will require not just giving antibiotics on time but also ensuring that the appropriate agents are selected and reliably maintained throughout the operation. In the era of antibiotic stewardship, timing is necessary, but it is no longer sufficient.<\/p>\n","protected":false},"excerpt":{"rendered":" Invited Commentary Anesthesiology Antibiotic Sele […]<\/p>\n","protected":false},"author":3,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":[],"categories":[24,23],"tags":[],"_links":{"self":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts\/30282"}],"collection":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=30282"}],"version-history":[{"count":1,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts\/30282\/revisions"}],"predecessor-version":[{"id":30283,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts\/30282\/revisions\/30283"}],"wp:attachment":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=30282"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=30282"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=30282"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}