To the Editor, The study conducted by Tang et al (September 2024 issue) provides valuable insights into the role of antibiotic prophylaxis in reducing surgical site infections (SSIs), particularly in clean and clean-contaminated surgeries1. While the study effectively demonstrates the efficacy of antibiotic prophylaxis, especially in clean-contaminated surgeries, there are several concerns regarding the methods, interpretation of the results, and broader implications of routine antibiotic use in surgery2. These concerns are particularly important given the global challenge of antibiotic resistance, the diversity of surgical procedures, and the ongoing debate about the optimal use of antibiotics in different patient populations. First, while the study confirms that antibiotic prophylaxis significantly reduces SSIs, it does not fully resolve whether antibiotics are necessary in all clean surgeries. Clean surgeries, by definition, do not breach sterile tissue and carry a relatively low risk of postoperative infection. Despite this, the study includes a wide range of clean surgical procedures, many of which vary in their inherent infection risk. For example, clean orthopedic surgeries involving prosthetics carry a higher risk of infection compared to minor dermatologic surgeries3. This would prevent the unnecessary use of antibiotics in low-risk surgeries, where the benefits may be minimal. Second, while the study’s conclusions regarding antibiotic prophylaxis in clean-contaminated surgeries are valid, they fail to sufficiently address the critical issue of antibiotic resistance. The overuse of broad-spectrum antibiotics in surgical settings is a significant global health concern, contributing to the increasing prevalence of resistant organisms such as methicillin-resistant Staphylococcus aureus (MRSA) and extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli. Although the study demonstrates a reduction in SSIs, it does not consider the long-term implications of widespread antibiotic use and its potential to exacerbate antimicrobial resistance4. A follow-up study could address this gap by investigating whether alternative approaches, such as narrow-spectrum antibiotics or non-antibiotic methods like antiseptic measures, could effectively reduce SSIs without contributing to the development of resistant pathogens. Third, while the study shows that prophylactic antibiotics reduce hospital stays and SSI rates, it fails to adequately consider the potential adverse effects of antibiotic use, which may outweigh some of the benefits. Systemic antibiotics can cause side effects such as gastrointestinal disturbances and Clostridioides difficile infections. Additionally, allergic reactions, which can range from mild to severe, pose significant risks, especially for patients with a history of antibiotic exposure. These factors warrant careful consideration when evaluating the overall benefits of prophylactic antibiotic use5. By overlooking these risks, the study presents an incomplete assessment of the trade-offs associated with prophylactic antibiotic use. A more thorough analysis should evaluate these adverse effects, particularly in low-risk surgeries where infection rates are minimal. In such cases, the potential harms of antibiotic use may outweigh the benefits of preventing infection. Fourth, the study’s focus on short-term outcomes, such as reduced SSI rates and shorter hospital stays, overlooks important long-term factors, particularly the cost-effectiveness of routine antibiotic use. The financial implications of prophylactic antibiotics extend beyond the cost of the medications themselves6. Prolonged antibiotic use may lead to additional costs, such as those associated with treating antibiotic-related complications or managing infections caused by resistant organisms. Furthermore, the routine use of antibiotics in low-risk patients may unnecessarily increase healthcare costs, particularly in resource-limited settings7. Future research should incorporate cost-benefit analyses to determine whether the routine use of prophylactic antibiotics is economically viable. Such analyses would help ensure that antibiotics are used judiciously, with the potential benefits of infection prevention balanced against the costs of antibiotic-related complications and resistance management. Finally, the study fails to address the need for tailoring antibiotic regimens to patient- or surgery-specific factors, as current guidelines often adopt a one-size-fits-all approach. Emerging evidence suggests that patients with risk factors like immunosuppression, diabetes, or advanced age may require more aggressive prophylaxis, while lower-risk patients may not benefit as much8. Recent guidelines from American Society of Health-System Pharmacists (ASHP) and WHO advocate for a targeted approach, recommending a single antibiotic dose 30 to 60 minutes before surgery and discontinuation within 24 hours, effectively reducing SSIs and minimizing antibiotic resistance9. These guidelines recommend restricting antibiotics to high-risk patients or complex surgeries, such as those involving prosthetics. An individualized approach, tailored to patient risk and surgery type, could improve outcomes, minimize unnecessary antibiotic use, and better align with antibiotic stewardship principles10. In conclusion, while antibiotic prophylaxis is essential for preventing SSIs, recent evidence highlights the need for a more selective approach. Antibiotics should be reserved for high-risk surgeries or patients with specific risk factors. Adopting updated guidelines can reduce SSIs and combat antibiotic resistance. Future research should address the long-term effects, adverse outcomes, and personalized approaches to prophylaxis. Standardized protocols are crucial to ensuring optimal patient outcomes while safeguarding antibiotic efficacy for future use.
Sharma et al. (Mon,) studied this question.