Antimicrobial stewardship in surgical settings: A preventive medicine approach to combating surgical site infections and antibiotic resistance

Surgical site infections (SSIs) represent a major healthcare burden, affecting 2%–5% of surgical patients and contributing significantly to morbidity, mortality, and healthcare costs. The rise of antimicrobial resistance has made prevention and appropriate management of SSIs increasingly challenging. Antimicrobial stewardship programs (ASPs) in surgical settings offer a preventive medicine approach to optimize antibiotic use, reduce SSIs, and combat resistance. This narrative review examines evidence-based strategies for implementing surgical antimicrobial stewardship, including appropriate perioperative prophylaxis, diagnostic stewardship for postoperative infections, and de-escalation protocols. We explore the role of surgical safety checklists, enhanced recovery pathways, and multidisciplinary stewardship teams in reducing unnecessary antibiotic exposure. Novel approaches, including rapid diagnostic technologies, procalcitonin-guided therapy, and artificial intelligence applications, are discussed. The review addresses SSI epidemiology across different surgical specialties, highlighting varying risk profiles in digestive, urologic, gynecologic, orthopedic, and cardiac surgery. We examine multidisciplinary perspectives on SSI prevention, exploring differences in understanding and approaches among surgeons, infectious disease specialists, anesthesiologists, and preventive medicine physicians. The integration of antimicrobial stewardship with infection prevention bundles demonstrates synergistic effects in reducing SSI rates. Implementation barriers, including surgical culture, varying risk profiles across procedures, and resource limitations, are addressed. This review provides preventive medicine specialists, surgeons, infection preventionists, and hospital administrators with a comprehensive framework for developing and implementing surgical ASPs that balance infection prevention with antimicrobial conservation in the era of rising resistance.