Prevention of surgical site infection: focus on perioperative antimicrobial prophylaxis

Perioperative antimicrobial prophylaxis (PAP) is a cornerstone in the prevention of surgical site infection. As an increasing share of procedures shifts to the ambulatory setting, this review examines aspects of PAP that are of particular relevance to ambulatory anesthesiology.

Empirical data show suboptimal use of PAP (e.g. unnecessary indication, substance choice, and excessive duration) in many settings, including ambulatory surgery. Focusing on substance choice, penicillin allergy remains a frequent, largely unverified barrier to β-lactam use in PAP. Recent evidence supports structured risk-stratification to safely expand cephalosporin use despite penicillin allergy, in order to reduce adverse effects of second-line antibiotics. Logistically, the widely used 60-min preincision timing rule for PAP was established for intravenous administration and cannot be directly applied to oral prophylaxis, where bioavailability varies substantially between agents and must inform both substance choice and timing. Lastly, the peri-interventional use of endocarditis prophylaxis is part of recent European guidelines on infective endocarditis, including some modifications to previous iterations.

Ambulatory anesthesiology presents structurally different conditions from inpatient care - high case turnover, limited time for allergy work-up, variable use of intravenous access, and no postoperative in-house monitoring after discharge. Addressing PAP overuse, allergy label mismanagement, and oral-versus-intravenous administration challenges specifically in this setting offers a concrete pathway toward safer and more evidence-based ambulatory surgical care.