Background: Surgical antimicrobial prophylaxis (SAP) is a cornerstone for reducing surgical site infections (SSIs), yet its implementation remains inconsistent. This study evaluates the impact of adherence to local SAP guidelines (GDSAP) versus surgeon-directed practices (SDSAP) on SSI outcomes. Methodology: A prospective cohort of 827 surgical patients in two Jordanian hospitals was evaluated. After filtering for eligibility and outcome availability, 464 patients were analysed—232 in each group (GDSAP vs. SDSAP). SSI by day 90 was the primary outcome. Data were collected through patient monitoring, medical records, and post-discharge surveillance. Missing data (<5%, except SSI at 33.4%) were imputed using Multivariate Imputation by Chained Equations (MICE). Logistic regression identified SSI predictors. Results: Groups were demographically and clinically balanced. Post-discharge antibiotic use was higher in SDSAP (75%) compared to GDSAP (59%) (P < 0.001). SSIs were more frequent in the SDSAP group (16%) than in GDSAP (7.4%) (P = 0.004; OR = 3.12; RR = 1.27). Multivariate analysis revealed anaemia (OR = 2.86), multiple comorbidities (OR = 1.93), and BMI (OR = 1.01) as significant SSI predictors. GDSAP adherence independently predicted lower SSI risk (OR = 0.41; P = 0.006). Conclusion: Adherence to SAP guidelines has significantly reduced SSI rates and reflects a decrease in post-discharge antimicrobial overuse. Hospitals should implement tailored SAP protocols and multidisciplinary stewardship to ensure safer surgical outcomes.
References
[1]
Bratzler, D.W., Dellinger, E.P., Olsen, K.M., Perl, T.M., Auwaerter, P.G., Bolon, M.K., Fish, D.N., Napolitano, L.M., Sawyer, R.G., Slain, D. and Steinberg, J.P. (2013) Clinical Practice Guidelines for Antimicrobial Prophylaxis in Surgery. Surgical Infections, 14, 73-156. https://doi.org/10.1089/sur.2013.9999
[2]
Dhole, S., Mahakalkar, C., Kshirsagar, S. and Bhargava, A. (2023) Antibiotic Prophylaxis in Surgery: Current Insights and Future Directions for Surgical Site Infection Prevention. Cureus, 15, e47858. https://doi.org/10.7759/cureus.47858
[3]
Vippadapu, P., Gillani, S.W., Thomas, D., Ahmed, F., Gulam, S.M., Mahmood, R.K., et al. (2022) Choice of Antimicrobials in Surgical Prophylaxis-Overuse and Surgical Site Infection Outcomes from a Tertiary-Level Care Hospital. Frontiers in Pharmacology, 13, Article 849044. https://doi.org/10.3389/fphar.2022.849044
[4]
Bratzler, D.W., Dellinger, E.P., Olsen, K.M., Perl, T.M., Auwaerter, P.G., Bolon, M.K., et al. (2013) Clinical Practice Guidelines for Antimicrobial Prophylaxis in Surgery. American Journal of Health-System Pharmacy, 70, 195-283. https://doi.org/10.2146/ajhp120568
[5]
Berríos-Torres, S.I., Umscheid, C.A., Bratzler, D.W., Leas, B., Stone, E.C., Kelz, R.R., Reinke, C.E., Morgan, S., Solomkin, J.S., Mazuski, J.E. and Dellinger, E.P. (2017) Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017. JAMA Surgery, 152, 784-791. https://doi.org/10.1001/jamasurg.2017.0904
[6]
Abdel Jalil, M.H., Abu Hammour, K., Alsous, M., Awad, W., Hadadden, R., Bakri, F. and Fram, K. (2017) Surgical Site Infections Following Caesarean Operations at a Jordanian Teaching Hospital: Frequency and Implicated Factors. Scientific Reports, 7, Article No. 12210. https://doi.org/10.1038/s41598-017-12431-2
[7]
Farid Mojtahedi, M., Sepidarkish, M., Almukhtar, M., Eslami, Y., Mohammadianamiri, F., Behzad Moghadam, K., et al. (2023) Global Incidence of Surgical Site Infections Following Caesarean Section: A Systematic Review and Meta-Analysis. Journal of Hospital Infection, 139, 82-92. https://doi.org/10.1016/j.jhin.2023.05.019
[8]
Gouvêa, M., de Oliveira Novaes, C., Pereira, D.M.T. and Iglesias, A.C. (2015) Adherence to Guidelines for Surgical Antibiotic Prophylaxis: A Review. The Brazilian Journal of Infectious Diseases, 19, 517-524. https://doi.org/10.1016/j.bjid.2015.06.004
[9]
Alahmadi, Y.M., Alharbi, R.H., Aljabri, A.K., Alofi, F.S., Alshaalani, O.A. and Alssdi, B.H. (2020) Adherence to the Guidelines for Surgical Antimicrobial Prophylaxis in a Saudi Tertiary Care Hospital. Journal of Taibah University Medical Sciences, 15, 136-141. https://doi.org/10.1016/j.jtumed.2020.01.005
[10]
Menz, B.D., Charani, E., Gordon, D.L., Leather, A.J., Moonesinghe, S.R. and Phillips, C.J. (2021) Surgical Antibiotic Prophylaxis in an Era of Antibiotic Resistance: Common Resistant Bacteria and Wider Considerations for Practice. Infection and Drug Resistance, 7, 5235-5252.
[11]
Kone, L.B., Torres, C., Banulescu, M., Maker, V.K. and Maker, A.V. (2022) Perioperative Broad-Spectrum Antibiotics Are Associated with Decreased Surgical Site Infections Compared to 1st-3rd Generation Cephalosporins after Open Pancreaticoduodenectomy in Patients with Jaundice or a Biliary Stent. Annals of Surgery, 275, 1175-1183. https://doi.org/10.1097/SLA.0000000000004216
[12]
Al Ramahi, J.W., Al-Abdouh, A., Hasan, N., Haddad, G., Al Baba, M., Al Aaraj, A., Fakhri, M., Shanab, L.A., Harara, B. and Barbarawi, M. (2019) Mortality and Length of Stay in Patients with Bloodstream Infections Due to Drug-Susceptible Versus Drug-Resistant Gram-Negative Bacteria. International Journal of Infectious Diseases and Therapy, 4, 33-39. https://doi.org/10.11648/j.ijidt.20190403.11
[13]
Kwaik, R.A., Jamal, W., Al Jammal, D., Al Radaidah, N. and Aqel, A.A. (2021) Susceptibility of the Multidrug-Resistant Nosocomial Pathogens Isolates in Jordan for the new Antimicrobial Agents. The International Arabic Journal of Antimicrobial Agents, 11, 1-8.
[14]
Haverkate, M.R., Derde, L.P.G., Brun-Buisson, C., Bonten, M.J.M. and Bootsma, M.C.J. (2014) Duration of Colonization with Antimicrobial-Resistant Bacteria after ICU Discharge. Intensive Care Medicine, 40, 564-571. https://doi.org/10.1007/s00134-014-3225-8
[15]
Centers for Disease Control and Prevention, National Healthcare Safety Network (2021) CDC /NHSN Definitions for Specific Types of Infections. https://www.cdc.gov/nhsn/pdfs/pscmanual/17pscnosinfdef_current.pdf
[16]
Centers for Disease Control and Prevention (2017) Surgical Site Infection Event (SSI). https://www.cdc.gov
[17]
van Buuren, S. and Groothuis-Oudshoorn, K. (2011) Mice: Multivariate Imputation by Chained Equations in R. Journal of Statistical Software, 45, 1-67. https://doi.org/10.18637/jss.v045.i03
[18]
Junaid, K.P., Kiran, T., Gupta, M., Kishore, K. and Siwatch, S. (2025) How Much Missing Data Is Too Much to Impute for Longitudinal Health Indicators? A Preliminary Guideline for the Choice of the Extent of Missing Proportion to Impute with Multiple Imputation by Chained Equations. Population Health Metrics, 23, Article No. 2. https://doi.org/10.1186/s12963-025-00364-2
[19]
Allegranzi, B., Bischoff, P., De Jonge, S., Kubilay, N.Z., Zayed, B., Gomes, S.M., Abbas, M., Atema, J.J., Gans, S., van Rijen, M. and Boermeester, M.A. (2016) New WHO Recommendations on Preoperative Measures for Surgical Site Infection Prevention: An Evidence-Based Global Perspective. The Lancet Infectious Diseases, 16, e276-e287. https://doi.org/10.1016/S1473-3099(16)30398-X
[20]
de Jonge, S.W., Boldingh, Q.J.J., Koch, A.H., Daniels, L., de Vries, E.N., Spijkerman, I.J.B., et al. (2021) Timing of Preoperative Antibiotic Prophylaxis and Surgical Site Infection: TAPAS, An Observational Cohort Study. Annals of Surgery, 274, e308-e314. https://doi.org/10.1097/sla.0000000000003634
[21]
De Jonge, S.W., Gans, S.L., Atema, J.J., Solomkin, J.S., Dellinger, P.E. and Boermeester, M.A. (2017) Timing of Preoperative Antibiotic Prophylaxis in 54,552 Patients and the Risk of Surgical Site Infection: A Systematic Review and Meta-Analysis. Medicine, 96, e6903. https://doi.org/10.1097/MD.0000000000006903
[22]
Sommerstein, R., Atkinson, A., Kuster, S.P., Thurneysen, M., Genoni, M., Troillet, N., et al. (2019) Antimicrobial Prophylaxis and the Prevention of Surgical Site Infection in Cardiac Surgery: An Analysis of 21 007 Patients in Switzerland. European Journal of Cardio-Thoracic Surgery, 56, 800-806. https://doi.org/10.1093/ejcts/ezz039
[23]
Branch-Elliman, W., O’Brien, W., Strymish, J., Itani, K., Wyatt, C. and Gupta, K. (2019) Association of Duration and Type of Surgical Prophylaxis with Antimicrobial-Associated Adverse Events. JAMA Surgery, 154, 590-598. https://doi.org/10.1001/jamasurg.2019.0569
[24]
Harbarth, S., Samore, M.H., Lichtenberg, D. and Carmeli, Y. (2000) Prolonged Antibiotic Prophylaxis after Cardiovascular Surgery and Its Effect on Surgical Site Infections and Anti-Microbial Resistance. Circulation, 101, 2916-2921. https://doi.org/10.1161/01.CIR.101.25.2916
[25]
Righi, E., Mutters, N.T., Guirao, X., del Toro, M.D., Eckmann, C., Friedrich, A.W., et al. (2023) ESCMID/EUCIC Clinical Practice Guidelines on Perioperative Antibiotic Prophylaxis in Patients Colonized by Multidrug-Resistant Gram-Negative Bacteria before Surgery. Clinical Microbiology and Infection, 29, 463-479. https://doi.org/10.1016/j.cmi.2022.12.012
[26]
Al Ramahi, J.W., Ajamieh, O.A., Marrar, N., Alalamat, L., Hasan, N., Jaber, A.E., Dodin, O. and Matar, A. (2020) The Rates of the Unnecessary Antimicrobial Use (UAU) and the Effect of the Infectious Disease Consultations: A Cross-Sectional Study. International Journal of Infectious Diseases and Therapy, 5, 56-63. https://doi.org/10.11648/j.ijidt.20200503.14
[27]
Spivak, E.S., Cosgrove, S.E. and Srinivasan, A. (2016) Measuring Appropriate Antimicrobial Use: Attempts at Opening the Black Box. Clinical Infectious Diseases, 63, 1-6. https://doi.org/10.1093/cid/ciw658
[28]
Cai, W., Wang, L., Wang, W. and Zhou, T. (2022) Systematic Review and Meta-Analysis of the Risk Factors of Surgical Site Infection in Patients with Colorectal Cancer. Translational Cancer Research, 11, 857-871. https://doi.org/10.21037/tcr-22-627
