# Guideline Adherence of Perioperative Antibiotics and Surgical Site Infections in Noncardiac Surgery

## TL;DR

This study shows that not following detailed antibiotic guidelines increases the risk of surgical infections, even when timing guidelines are met.

## Contribution

The study demonstrates that adherence to comprehensive IDSA antibiotic guidelines, beyond timing, reduces surgical site infections.

## Key findings

- Nonadherence to IDSA antibiotic guidelines occurred in 26.1% of cases and was linked to higher surgical site infection rates.
- Failure to redose antibiotics intraoperatively and incorrect antibiotic choice were independently associated with increased infection risk.
- Improving adherence to IDSA guidelines could significantly reduce surgical site infections.

## Abstract

What is the association of adherence to Infectious Diseases Society of America (IDSA) perioperative antibiotic prophylaxis guidelines, covering antibiotic choice, dosing, timing, and intraoperative redosing, with surgical site infections (SSIs) after noncardiac surgery?

In this cross-sectional study of 119 236 patients who underwent noncardiac surgery across 37 US institutions, nonadherence to at least 1 IDSA antibiotic metric occurred in 26.1% and was associated with higher SSI incidence (4.4% overall). Nonadherence to antibiotic choice and failure to redose intraoperatively were each independently associated with increased SSI risk.

These findings suggest that improving adherence to IDSA antibiotic prophylaxis guidelines, particularly for antibiotic selection and redosing, may reduce SSIs and improve surgical outcomes.

This cross-sectional study evaluates how many institutions adhere to Infectious Diseases Society of America guidelines for perioperative antibiotics and how often surgical site infections (SSIs) occur.

Despite nearly universal adherence to the Surgical Care Improvement Project (SCIP), surgical site infections (SSIs) persist. Compared with SCIP, which largely focuses on antibiotic timing, the Infectious Diseases Society of America (IDSA) guidelines provide a more comprehensive framework of antibiotic metrics, including procedure-specific antibiotic selection, weight-adjusted dosing, timing of the first dose, and appropriate redosing.

To assess whether nonadherence to each antibiotic administration metric of IDSA guidelines is associated with SSIs.

In this nationwide, multicenter, cross-sectional study, patients aged 18 years or older who underwent noncardiac surgeries involving a skin incision between January 1, 2014, and August 31, 2022, were included from merged data of the Multicenter Perioperative Outcomes Group, National Surgical Quality Improvement Program, and Michigan Surgical Quality Collaborative registries. Analyses were conducted between July 2, 2024, and April 24, 2025.

Nonadherence to IDSA-defined antibiotic metrics.

The primary end point was SSI, defined as any superficial, deep tissue, or organ-space infection as recorded in the National Surgical Quality Improvement Program and Michigan Surgical Quality Collaborative registries. The association of nonadherence to IDSA guidelines (both overall and individually) was examined using hierarchical generalized linear mixed models.

Of 134 413 eligible surgical cases, a total of 119 236 patients (mean [SD] age, 56.2 [15.9] years; 58.1% women) from 37 institutions met the inclusion criteria, among whom 6796 (5.7%) had incomplete covariate data. Failure to adhere to any IDSA metric was common in 26.1% of cases, with individual nonadherence rates as follows: 13.3% for antibiotic choice, 9.0% for weight-adjusted dosing, 3.0% for timing relative to incision, and 4.8% for correct intraoperative redosing interval. Overall, SSIs occurred in 4.4% of cases. After adjusted analysis, guideline-nonadherent antibiotic administration was significantly associated with SSIs (relative risk [RR], 1.34 [95% CI, 1.26-1.43]). Nonadherence to antibiotic choice (RR, 1.43 [95% CI, 1.33-1.53]) and failure to appropriately redose intraoperatively (RR, 1.12 [95% CI, 1.02-1.24]) were significantly associated with SSIs.

This cross-sectional study found that IDSA guideline nonadherence, including incorrect antibiotic choice and missed intraoperative redosing, was common and associated with increased SSI risk, despite high adherence to SCIP timing metrics. Improving adherence to IDSA-recommended antibiotic selection and redosing may meaningfully reduce SSIs.