Opportunities for system level improvement across antibiotic use in the surgical pathway

Optimising antibiotic prescribing across the surgical pathway (before, during and after surgery) is a key aspect of tackling important drivers of antimicrobial resistance (AMR), and simultaneously decreasing the burden of infection at global level. In the UK alone, 10 million patients undergo surgery every year, which is equivalent to 60% of the annual hospital admissions having a surgical intervention. The overwhelming majority of surgical procedures require effectively limited delivery of antibiotic prophylaxis to prevent infections. Evidence from around the world indicates that antibiotics for surgical prophylaxis are administered ineffectively, or are extended for an inappropriate duration of time postoperatively. Ineffective antibiotic prophylaxis can contribute to the development of surgical site infections (SSI), which represent a significant global burden of disease. The WHO estimates SSI rates of up to 50% in postoperative surgical patients (depending on the type of surgery), with a particular problem in low and middle income countries (LMIC), where SSI are the most frequently reported Healthcare Associated Infection (HCAI). Across European hospitals SSI alone comprise 19.6% of all healthcare acquired infections10. Much of the scientific research in infection management in surgery is related to infection prevention and control in the operating room, surgical prophylaxis and the management of SSI, with many studies focusing on infection within the 30-day post-operative period. However it is important to note that SSI represents only one of the many infections that can occur post-operatively. In this article we provide an overview of the surgical pathway and consider infection management and antibiotic prescribing at each step of the pathway. We aim to identify the implications for research, and opportunities for system improvement.