Surgical Antibiotic Prophylaxis in an Era of Antibiotic Resistance: Common Resistant Bacteria and Wider Considerations for Practice

Figures & data

Table 1 Examples of Bacteria Implicated in Surgical Site Infection Categorised by Surgical Procedure

Procedure	Example of Bacteria Associated with Surgical Site Infection*	Examples of Possible Antibiotic Resistance Encountered
Cardiothoracic surgery	Staphylococcus epidermidis, Staphylococcus aureus, Streptococcus spp., Corynebacterium spp., Enterobacterales**	MRSA, ESBL producers
Gastrointestinal surgery	Enterococcus spp., Gram-positive cocci (Streptococcus spp.), Enterobacterales**, anaerobes	VRE, ESBL producers, CRE
Gynaecological surgery	Staphylococcus aureus, Group B Streptococcus, Enterococcus spp., Enterobacterales**	MRSA, VRE, ESBL producers
Head, oral and neck surgery	Staphylococcus aureus, Enterobacterales**, Pseudomonas aeruginosa, anaerobes	MRSA, ESBL producers
Neurosurgical surgery	Staphylococcus aureus, Staphylococcus epidermidis, Streptococcus spp., Corynebacterium spp., Enterobacterales**, Pseudomonas aeruginosa, anaerobes	MRSA, ESBL producers
Orthopaedic surgery	Staphylococcus epidermidis, Staphylococcus aureus, Streptococcus spp., Enterobacterales**, Pseudomonas aeruginosa, anaerobes	MRSA, ESBL producers
Urological surgery	Gram-negative bacilli, Enterococcus spp., Enterobacterales**	VRE, ESBL producers, FR-GNB, CRE
Vascular surgery	Staphylococcus epidermidis, Staphylococcus aureus, Enterococcus spp., Enterobacterales**, Pseudomonas aeruginosa	MRSA, VRE, ESBL producers

Notes: Table 1 shows examples of bacteria and antibiotic resistance encountered in surgical site infection by surgical procedure. *Table is not exhaustive of all possible organisms and bacterial resistance associated with surgical site infection, resistance may vary across different institutions, always follow site-specific resistance patterns and protocols where available. **Common examples of Enterobacterales in surgical site infections include: Enterobacter spp., Escherichia coli, Klebsiella pneumoniae.

Abbreviations: MRSA, methicillin-resistant Staphylococcus aureus; ESBL producers, extended-spectrum β-lactamase-producing bacteria; VRE, vancomycin-resistant Enterococcus; CRE, carbapenem-resistant Enterobacterales; FR-GNB, fluoroquinolone-resistant Gram-negative bacteria.

Table 2 Common Agents in Surgical Antibiotic Prophylaxis and Possible Alternatives for Consideration

Antibiotic	Antibiotic Class	Bacterial Coverage	Role in Surgical Antibiotic Prophylaxis
Common agents used in surgical antibiotic prophylaxis
Cefazolin	β-lactam	Gram-positive ++	Gram-positive and limited Gram-negative cover. Common for many surgical procedures
		Gram-negative +
		Anaerobes +
Clindamycin	Lincosamide	Gram-positive ++	Gram-positive cover, typically reserved for patients with immediate hypersensitivity to β-lactam antibiotics
		Gram-negative -
		Anaerobes ++
Gentamicin	Aminoglycoside	Gram-positive -	Gram-negative cover, commonly used in urological and gastrointestinal surgery
		Gram-negative +++
		Anaerobes -
Vancomycin	Glycopeptide	Gram-positive +++	Gram-positive cover, typically reserved for patients with immediate hypersensitivity to β-lactam antibiotics or patients with MRSA
		Gram-negative -
		Anaerobes ++
Alternative agents for consideration as surgical antibiotic prophylaxis in antibiotic resistance*
Meropenem/Ertapenem	Carbapenem	Gram-positive ++	Consider for ESBL producers and sensitivity to carbapenems. Avoid in suspected immediate hypersensitivity to β-lactams
		Gram-negative +++
		Anaerobes ++
Fosfomycin	Oxazolidinone	Gram-positive +	Consider for transrectal prostate biopsy in patients complicated with or suspected fluoroquinolone resistant bacteria (mostly E. coli)
		Gram-negative ++
		Anaerobes -
Daptomycin	Cyclic lipopeptide	Gram-positive +++	Consider for VRE. Could also be considered for MRSA where vancomycin or teicoplanin contraindicated
		Gram-negative -
		Anaerobes +
Linezolid	Oxazolidinone	Gram-positive +++	Consider for VRE. Could also be considered for MRSA where vancomycin or teicoplanin contraindicated
		Gram-negative -
		Anaerobes +
Tigecycline	Glycylcycline	Gram-positive ++	Consider for cover of VRE and MRSA where vancomycin, daptomycin and/or linezolid are contraindicated. Avoid in suspected hypersensitivity to tetracyclines
		Gram-negative ++
		Anaerobes ++

Notes: Table 2 shows examples of common agents used in surgical antibiotic prophylaxis and examples of alternatives that could be considered in resistant bacteria based on their underlying spectrum of activity. Definitions, +++Indicates high degree of antibiotic activity, ++Indicates moderate degree of antibiotic activity, +Indicates low degree of antibiotic activity, -Indicates minimal to no antibiotic activity, *There is limited evidence comparing the efficacy of surgical antibiotic prophylaxis with alternative agents for resistant bacteria, unnecessary use may potentiate resistance and judicious selection is recommended in conjunction with infectious diseases/medical microbiology guidance.

Abbreviations: MRSA, methicillin-resistant S. aureus; ESBL producers, extended-spectrum β-lactamase-producing bacteria; VRE, vancomycin-resistant Enterococcus.

Figure 1 Stages affecting risk of surgical site infection with antibiotic-resistant bacteria.

Notes: Obesity: body mass index ≥35kg/m², requiring fluid resuscitation: requirement of blood transfusion and/or intravenous fluids due to excessive blood loss (exceeding 1500mL).

Abbreviation: AR, antibiotic resistance.

Figure 2 Proposed flow chart for surgical antibiotic prophylaxis in the era of antibiotic resistance.

Notes: A proposed algorithm for screening patients with antibiotic resistance and considerations for surgical antibiotic prophylaxis. *Consult medical microbiology/infectious diseases for appropriate management options for carbapenem-resistant Enterobacterales (CRE), **Fosfomycin may be appropriate for transrectal prostate biopsy.

Abbreviations: AR, antibiotic resistance; ESBL producers, extended-spectrum β-lactamase-producing bacteria; FR-GNB, fluoroquinolone-resistant Gram-negative bacteria; VRE, vancomycin-resistant Enterococcus; MRSA, methicillin-resistant Staphylococcus aureus; SAP, surgical antibiotic prophylaxis.