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Antibiotics
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Antimicrobial Stewardship in Surgical Infection
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Antimicrobial Stewardship in Surgical Infection

A special issue of Antibiotics (ISSN 2079-6382). This special issue belongs to the section "Antibiotics Use and Antimicrobial Stewardship".

Deadline for manuscript submissions: 20 September 2026 | Viewed by 6753

Special Issue Editor

Dr. Nuno Rocha-Pereira

E-Mail Website
Guest Editor
1. Infection and Antimicrobial Resistance Control and Prevention Unit, Hospital Epidemiology Centre, Unidade Local de Saúde São João, Porto, Portugal
2. Department of Medicine, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
Interests: antimicrobial stewardship; antimicrobial resistance; treatment of MDR/XDR gram-negative bacteria

Special Issue Information

Dear Colleagues,

Surgical site infections remain among some of the most frequent healthcare-associated infections worldwide. Their management presents unique challenges, from the complexity of source control to the growing threat of multidrug-resistant organisms. As such, antimicrobial stewardship (AMS) has become increasingly critical in the surgical setting—not only to ensure effective treatment but also to preserve the long-term utility of life-saving antimicrobials.

This Special Issue invites contributions that explore AMS strategies tailored to surgical infections, including perioperative prophylaxis, diagnostic optimization, and interdisciplinary stewardship efforts. Emphasis will be placed on practical approaches, implementation in varied healthcare contexts, and measurable outcomes in both infection control and antimicrobial use.

Submissions may include original research, systematic reviews, meta-analyses, quality improvement, and implementation science work.

Through this collection, we aim to advance dialogue, share innovations, and support clinicians in aligning antimicrobial decision-making with the evolving realities of surgical care.

Dr. Nuno Rocha-Pereira
Guest Editor

Manuscript Submission Information

Manuscripts should be submitted online at www.mdpi.com by registering and logging in to this website. Once you are registered, click here to go to the submission form. Manuscripts can be submitted until the deadline. All submissions that pass pre-check are peer-reviewed. Accepted papers will be published continuously in the journal (as soon as accepted) and will be listed together on the special issue website. Research articles, review articles as well as short communications are invited. For planned papers, a title and short abstract (about 250 words) can be sent to the Editorial Office for assessment.

Submitted manuscripts should not have been published previously, nor be under consideration for publication elsewhere (except conference proceedings papers). All manuscripts are thoroughly refereed through a single-blind peer-review process. A guide for authors and other relevant information for submission of manuscripts is available on the Instructions for Authors page. Antibiotics is an international peer-reviewed open access monthly journal published by MDPI.

Please visit the Instructions for Authors page before submitting a manuscript. The Article Processing Charge (APC) for publication in this open access journal is 2900 CHF (Swiss Francs). Submitted papers should be well formatted and use good English. Authors may use MDPI's English editing service prior to publication or during author revisions.

Keywords

  • antimicrobial stewardship
  • surgical infection
  • surgical site infection
  • antimicrobial resistance
  • diagnostic stewardship

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Published Papers (6 papers)

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Research

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21 pages, 1442 KB  
Article
Open-Label Prospective Randomized Comparative Study of the Efficacy and Safety of Gentamicin in Comparison to Other Antibiotics in the Management of Acute Appendicitis in Surgically Treated Patients
by Nika Obolnar, Žan Čebron, Gregor Norčič, Darko Černe, Aleš Jerin, Urška Čegovnik Primožič, Gaj Vidmar, Tadeja Pintar Kaliterna and Bojana Beović
Antibiotics 2026, 15(4), 395; https://doi.org/10.3390/antibiotics15040395 - 13 Apr 2026
Viewed by 730
Abstract
Background: Antimicrobial resistance coupled with the lack of new antibiotics calls for the responsible use of antibiotics, including old antimicrobials. Aminoglycosides are effective against bacteria in acute appendicitis, a common intra-abdominal infection. Their use has been discouraged recently, but their place in therapy [...] Read more.
Background: Antimicrobial resistance coupled with the lack of new antibiotics calls for the responsible use of antibiotics, including old antimicrobials. Aminoglycosides are effective against bacteria in acute appendicitis, a common intra-abdominal infection. Their use has been discouraged recently, but their place in therapy is based on studies performed in the era of lower resistance rates, and with multiple dosing regimens. Methods: In a prospective randomized open-label study, we compared the efficacy and safety of gentamicin in one daily dose and metronidazole (GTM+MZ) to ertapenem (ETP) and to cefuroxime with metronidazole (CXM+MZ) in adult patients surgically treated for acute appendicitis. Efficacy was assessed via the duration of antibiotic treatment and hospital stay, c-reactive protein (CRP) dynamics, and post-operative complications. Nephrotoxicity was assessed with urine biomarkers. Statistical analysis comprised mixed-model analysis of variance (ANOVA) with the missing-data-imputation method and linear mixed model (LMM). Results: One hundred-and-sixty-six patients were included in this study. There were no significant differences among the three groups in the durations of treatment and lengths of stay (p = 0.093, p = 0.222). CRP level was the lowest (p = 0.003) in the ETP group. There were five complications during hospitalization, with two of them classified as infectious. Both occurred in the GTM+MZ group; however, the difference was not statistically significant (p = 0.330). No difference was found in complications in the month following the operation (p = 0.763). Biomarkers indicating kidney injury showed the same trend in all three groups. Conclusions: Our results suggest the use of once-daily dose of gentamicin following an appendectomy for acute appendicitis. Gentamicin may be used to decrease selective pressure of other antimicrobials. Full article
(This article belongs to the Special Issue Antimicrobial Stewardship in Surgical Infection)
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15 pages, 856 KB  
Article
Early Discontinuation of Prophylactic Antibiotics Is Not Associated with Increased Surgical Site Infection Risk in Spine Surgery: A Nationwide Cohort Study
by Sangjun Park, Jun-Seok Lee, Young-Hoon Kim, Sang-Il Kim, Youngjin Kim, Sukil Kim and Hyung-Youl Park
Antibiotics 2026, 15(3), 272; https://doi.org/10.3390/antibiotics15030272 - 6 Mar 2026
Viewed by 868
Abstract
Background/Objectives: Surgical site infection (SSI) remains a significant complication following spine surgery, yet the optimal duration of prophylactic antibiotic administration remains debated. We investigated the association between prophylactic antibiotic duration and SSI rates following spine surgery using a nationwide claims database. Methods [...] Read more.
Background/Objectives: Surgical site infection (SSI) remains a significant complication following spine surgery, yet the optimal duration of prophylactic antibiotic administration remains debated. We investigated the association between prophylactic antibiotic duration and SSI rates following spine surgery using a nationwide claims database. Methods: This retrospective cohort study analyzed data from the Health Insurance Review and Assessment Service quality assessment database across four assessment waves (2014–2020, sixth to ninth). Adult patients (aged ≥19 years) undergoing elective spine surgery (decompression, instrumented fusion, vertebroplasty, or kyphoplasty) were categorized into two groups based on prophylactic antibiotic duration: <24 h or ≥24 h. Surgery type was the primary surgical categorization, while surgery site (cervical, thoracic, lumbar) was assessed separately in supplemental analyses. Primary outcomes included SSI, non-surgical-site infections, and total postoperative infections within 3 months. Multivariable logistic regression was performed to identify independent predictors of infection. Results: Of 82,840 patients included, 19,988 (24.1%) discontinued prophylactic antibiotics within 24 h and 62,852 (75.9%) continued antibiotics for ≥24 h. The <24 h group demonstrated significantly lower SSI rates compared to the ≥24 h group (0.16% vs. 1.47%, p < 0.05). After adjustment for confounders, prolonged antibiotic prophylaxis (≥24 h) was associated with increased odds of SSI (adjusted odds ratio [aOR] = 10.73, 95% CI = 7.30–15.79), non-surgical-site infections (aOR = 16.06, 95% CI = 13.11–19.67), and total postoperative infections (aOR = 17.82, 95% CI = 14.83–21.42). Conclusions: In this nationwide cohort, early discontinuation of prophylactic antibiotics within 24 h was not associated with increased SSI risk. Prolonged antibiotic prophylaxis beyond 24 h was associated with higher SSI rates, although confounding by indication likely contributed to this finding. These results are consistent with current guideline recommendations for limiting prophylactic antibiotic duration to 24 h or less in routine spine surgery, while recognizing that individualized approaches may be warranted in some high-risk patients. Full article
(This article belongs to the Special Issue Antimicrobial Stewardship in Surgical Infection)
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14 pages, 632 KB  
Article
Should Preoperative Biliary Decontamination Be Considered to Minimize Morbidity and Mortality Following Pancreatoduodenectomy?
by Natalia Olszewska, Tomasz Guzel, Agnieszka Milner, Piotr Paluszkiewicz, Edyta Podsiadły and Maciej Słodkowski
Antibiotics 2026, 15(2), 134; https://doi.org/10.3390/antibiotics15020134 - 29 Jan 2026
Cited by 1 | Viewed by 704
Abstract
Background: Pancreatoduodenectomy (PD) remains the fundamental treatment for periampullary malignancies but is associated with considerable morbidity (20–50%) and mortality (2–7%). Bacteriobilia contributes to unfavourable postoperative outcomes. Current antibiotic prophylaxis recommendations endorse first-generation cephalosporins, which often fail to adequately target pathogens most frequently isolated [...] Read more.
Background: Pancreatoduodenectomy (PD) remains the fundamental treatment for periampullary malignancies but is associated with considerable morbidity (20–50%) and mortality (2–7%). Bacteriobilia contributes to unfavourable postoperative outcomes. Current antibiotic prophylaxis recommendations endorse first-generation cephalosporins, which often fail to adequately target pathogens most frequently isolated from bile. To date, no specific guidelines for preoperative targeted antibiotic therapy have been established, although tailoring such strategies to the bile microbiome may improve surgical outcomes. This study aimed to characterize bile microbiology in patients undergoing PD for pancreatic ductal adenocarcinoma (PDAC), evaluating potential antibiotherapy regimens that provide effective coverage against the most frequently isolated pathogens. Methods: A retrospective cohort analysis of 725 patients surgically treated for pancreatic tumours at a high-volume pancreatic surgery center between 2017 and 2022 was performed. To minimize heterogeneity, study was restricted to 138 patients who underwent PD with histopathological confirmed PDAC. Intraoperative bile cultures were assessed. Results: Patients with bacteriobilia likewise experienced worse outcomes: higher 5-year mortality (OR 3.01, p = 0.007), greater overall postoperative pancreatic fistula (POPF) occurrence (OR 2.54, p = 0.044) and wound infections (OR 2.90, p = 0.038). Among bile microbiome the highest susceptibility rates were observed for combination of amoxicillin/clavulanic acid with gentamicin, while the lowest were noted for cephalosporin–metronidazole regimen (93.6% vs. 30.2%, respectively). Conclusions: Bacteriobilia contributes to postoperative complications and serves as a predictor of poorer survival after PD. Standard perioperative antibiotic prophylaxis in PD is insufficient. Based on our findings, perioperative antibiotic therapy with amoxicillin/clavulanic acid and gentamicin combination appears to provide superior coverage and may improve postoperative morbidity and overall survival following PD. Full article
(This article belongs to the Special Issue Antimicrobial Stewardship in Surgical Infection)
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13 pages, 1117 KB  
Article
Implementing a Standard Operating Procedure Is Associated with Improved Vancomycin Target Attainment in Bone and Joint Infections: A Pre-Post Study
by Moritz Diers, Juliane Beschauner, Maria Felsberg, Laura Isabell Kossack, Alexander Zeh, Karl-Stefan Delank, Natalia Gutteck and Felix Werneburg
Antibiotics 2025, 14(11), 1087; https://doi.org/10.3390/antibiotics14111087 - 28 Oct 2025
Cited by 1 | Viewed by 1006
Abstract
Background: Intravenous vancomycin is a mainstay for prosthetic joint infections, osteomyelitis, and implant-associated infections, yet real-world dosing frequently misses PK/PD targets. We assessed whether a ward-embedded standard operating procedure (SOP) improves target attainment and dosing efficiency. Methods: Single-centre, non-randomized pre-post study [...] Read more.
Background: Intravenous vancomycin is a mainstay for prosthetic joint infections, osteomyelitis, and implant-associated infections, yet real-world dosing frequently misses PK/PD targets. We assessed whether a ward-embedded standard operating procedure (SOP) improves target attainment and dosing efficiency. Methods: Single-centre, non-randomized pre-post study in an orthopedic service. SOP mandated weight-adapted loading dose, renal function-adjusted maintenance dosing, a 15–20 mg/L trough target, and scheduled TDM. Adults receiving ≥72 h IV vancomycin were included; major renal failure and incomplete TDM were excluded. Pre-SOP data were retrospective; post-SOP data were prospective (03/2024–06/2025). Primary outcome: proportion of troughs within 15–20 mg/L (first and repeated). Repeated measures were modeled with GEE. Time to first in-range trough used Kaplan–Meier (indexed by measurement number). Results: We included 154 patients (pre-SOP n = 58; post-SOP n = 96); baseline characteristics were broadly similar. Use of a weight-based loading dose rose from 31.0% pre-SOP to 100% post-SOP (p < 0.001). At the first trough, 17.2% vs. 26.0% were within 15–20 mg/L (p = 0.238). Across 847 troughs (pre = 319; post = 528), the in-range proportion increased from 28.2% to 41.7%, with subtherapeutic values declining from 38.2% to 26.3% and supratherapeutic values remaining nearly similar (33.5% → 32.0%). Time to first in-range trough shortened from a median of 4 to 2 measurements (log-rank p < 0.001). Post-SOP measurements had higher odds of being in range (aOR 1.68, 95% CI 1.29–2.20; p < 0.001), with marginal predicted probabilities of 33.4% (pre) vs. 47.8% (post). Dose adjustments per patient decreased from a mean 4.0 to 2.48 (p < 0.001). Conclusions: A pragmatic, orthopedic ward–embedded SOP for intravenous vancomycin improved pharmacologic precision: more measurements within target, fewer subtherapeutic exposures, faster target attainment, and fewer dose changes. These data support protocol-first implementation as an immediately actionable step toward more consistent vancomycin exposure in orthopedic care. Future work should integrate AUC-guided, model-informed precision dosing and evaluate clinical endpoints and generalizability across centres. Full article
(This article belongs to the Special Issue Antimicrobial Stewardship in Surgical Infection)
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17 pages, 1453 KB  
Article
Peri-Operative Antimicrobial Prophylaxis Modulates CD4+ Lymphocyte Immunophenotype Ex Vivo in High-Risk Patients Undergoing Major Elective Surgery—A Preliminary Observational Study
by Susi Paketci, Jack Williams, Walter Pisciotta, Richard Loye, Alessia V. Waller, Rahila Haque, David Brealey, Mervyn Singer, John Whittle, Ramani Moonesinghe, Nishkantha Arulkumaran, Timothy Arthur Chandos Snow and the University College London Hospitals Critical Care Research Team
Antibiotics 2025, 14(10), 1026; https://doi.org/10.3390/antibiotics14101026 - 14 Oct 2025
Viewed by 975
Abstract
Background: Post-operative infections are a significant cause of morbidity in patients undergoing major elective surgery. Peri-operative antibiotics are used to reduce the risk of infection. Several antibiotics modulate the host immune response. Objectives: Our objective was to determine the ex vivo [...] Read more.
Background: Post-operative infections are a significant cause of morbidity in patients undergoing major elective surgery. Peri-operative antibiotics are used to reduce the risk of infection. Several antibiotics modulate the host immune response. Objectives: Our objective was to determine the ex vivo immunomodulatory properties of commonly used antibiotics (amoxicillin, cefuroxime, metronidazole, or combined cefuroxime–metronidazole) on monocyte and lymphocyte phenotypes in patients undergoing major elective surgery. Methods: We performed a prospective cohort study of patients aged ≥18 years admitted to the post-anaesthetic care unit following major elective non-cardiac surgery. Peripheral blood mononuclear cells isolated immediately after surgery were incubated with antibiotics with or without a monocyte (heat-killed E. coli) or lymphocyte (CD3/CD28 beads) stimulus ex vivo. Immune cell phenotype was characterised using flow cytometry. Results: Twenty-eight patients were included. All antibiotics tested were associated with a reduction in T-cell viability, and changes to monocytes were minimal. Among CD4+ and CD8+ lymphocytes, cefuroxime increased IFN-γ (at low and high doses) and increased CD4+ lymphocyte IL-2 and IL-2R at higher doses. Among CD4+ lymphocytes, at both doses, cefuroxime increased %Th1 population, with a parallel decrease in %Th2, %Th17, IL-17A, FOX-P3, and T-bet. Among the Th1 sub-population, changes were seen at higher cefuroxime doses, including increased viability and PD-1, and a decrease in FAS, IFN-γ and CD28, and IL-7R expression. Conclusions: The choice of antibiotics directly impacts immune function following major surgery, with cefuroxime associated with ex vivo immunomodulatory effects on CD4+ lymphocytes. The functional implications on the development of subsequent post-operative infectious complications and long-term cancer-free survival require further investigation. Full article
(This article belongs to the Special Issue Antimicrobial Stewardship in Surgical Infection)
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Review

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18 pages, 2564 KB  
Review
Antibiotic Prophylaxis in Patients Undergoing Oncologic Head and Neck Surgery with Free Flap Reconstruction: Still a Matter of Debate
by Femke Goormans, Auke van Mierlo, Isabel Spriet, Gaétan Van de Vyvere, Bart Knockaert and Robin Willaert
Antibiotics 2025, 14(11), 1160; https://doi.org/10.3390/antibiotics14111160 - 15 Nov 2025
Viewed by 1878
Abstract
Background/Objectives: Surgical site infection (SSI) significantly impacts patient outcomes in oncologic head and neck surgery with free flap reconstruction. Perioperative antibiotic prophylaxis (PAP) is widely accepted to prevent SSI. Despite decades of research, infection rates often exceed 40%, and controversies remain regarding [...] Read more.
Background/Objectives: Surgical site infection (SSI) significantly impacts patient outcomes in oncologic head and neck surgery with free flap reconstruction. Perioperative antibiotic prophylaxis (PAP) is widely accepted to prevent SSI. Despite decades of research, infection rates often exceed 40%, and controversies remain regarding antibiotic type and duration. While the literature on general head and neck surgery is abundant, it does not fully address the unique challenges of oncologic patients undergoing complex free flap reconstruction in the head and neck region. This review assesses the evidence for PAP in this population and examines concerns related to antimicrobial resistance (AMR). Methods: We conducted a review of clinical trials, systematic reviews, and relevant literature on PAP in oncologic head and neck surgery with free flap reconstruction. Key aspects included antibiotic type, timing, duration, and impact on SSI rates and patient outcomes. General head and neck surgery literature was considered when procedure-specific data were lacking. Results: PAP reduces SSI rates, but clinical practice varies regarding antibiotic choice and duration. Short-term prophylaxis may suffice for some procedures, whereas prolonged regimens are often used despite limited additional benefit. A multidisciplinary approach considering procedure-specific risks and patient factors improves outcomes. The risk of AMR underscores the need for standardized, evidence-based protocols. Significant gaps remain, particularly concerning optimal PAP regimens for free flap reconstruction. Conclusions: PAP is essential for SSI prevention in head and neck oncologic surgery with free flap reconstruction, yet current practices are heterogeneous. Standardized, procedure-specific protocols are needed to optimize prophylaxis, reduce SSI rates, and limit AMR, ultimately improving patient care and outcomes. Full article
(This article belongs to the Special Issue Antimicrobial Stewardship in Surgical Infection)
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