Perioperative antimicrobial prophylaxis and surgical site infection prevention, what clinicians and researchers must know

Surgical site infections (SSIs) are among the most common healthcare-associated infections, leading to increased morbidity, prolonged hospital stays, and significant healthcare costs. Surgical antimicrobial prophylaxis (SAP) is a critical strategy for SSI prevention, yet its effectiveness is threatened by antimicrobial resistance and variability in clinical practice. This narrative review provides an evidence-based update on the pathophysiology of SSIs, highlighting the interplay between endogenous microbiota, surgical stress, and perioperative factors such as hypoxia, immune modulation, and microbiome disruption. The current state-of-the-art in SAP is reviewed, including antibiotic selection, timing, dosing, intraoperative redosing, and the avoidance of unnecessary postoperative administration. Key intra- and postoperative measures to reduce the risk of SSI are covered, including glycaemic control, body temperature management, goal-directed fluid therapy, and skin antisepsis. A critical appraisal of the supporting evidence is included, with emphasis on areas of ongoing debate. The final section outlines future research priorities: optimizing dosing in obese patients, evaluating continuous infusion, tailoring prophylaxis to surgical site and microbiome, and addressing the management of patients colonized with multidrug-resistant organisms. Non-antibiotic strategies and rapid diagnostic tests are also discussed as promising avenues to enhance precision in infection prevention. By integrating current knowledge with emerging perspectives, this review aims to support the refinement of SSI prevention strategies and contribute to antimicrobial stewardship in modern surgical practice.