Do changes in antimicrobial resistance necessitate reconsideration of surgical antimicrobial prophylaxis strategies?

The potential need for re-evaluation of guidelines on surgical antimicrobial prophylaxis (AMP) in an era of advancing antimicrobial resistance is a matter of a considerable controversy.

Review of the pertinent literature.

Over the last decade, the prevalence of methicillin-resistant Staphylococcus aureus (MRSA) has increased significantly, as illustrated by several surveillance studies. The blending of community acquisition and long-term carriage may increase the probability of unrecognized MRSA carriers being admitted to the hospital. Thus, MRSA is considered a major epidemiological threat in most parts of the world, exerting pressure for reconsideration of the guidelines for surgical AMP. The use of a glycopeptide as first-choice prophylaxis in major procedures such as cardiac surgery generally is not recommended but is not ruled out. Current recommendations are based on trials performed almost a decade ago at the latest and do not reflect the contemporary epidemiology of resistance. A few recent studies suggested that vancomycin in combination with gentamicin and rifampicin reduces the incidence of surgical site infections significantly in high-risk patients. These developments led some surgeons and infectious diseases clinicians to consider advanced antimicrobial coverage in surgical AMP. On the other hand, other clinicians are rightfully skeptical about extensive administration of glycopeptides or other agents beyond first- or second-generation cephalosporins because of the risk of further emergence and dissemination of antimicrobial resistance.

Properly designed randomized trials are needed urgently to determine whether standard perioperative AMP should be reconsidered in settings with changing etiology of surgical infections.