Adherence to Antimicrobial Prophylaxis Guidelines for Elective Surgeries Across 825 US Hospitals, 2019-2020

Clin Infect Dis. 2023 Jun 16;76(12):2106-2115. doi: 10.1093/cid/ciad077.


Background: There are limited US data assessing adherence to surgical antimicrobial prophylaxis guidelines, particularly across a large, nationwide sample. Moreover, commonly prescribed inappropriate antimicrobial prophylaxis regimens remain unknown, hindering improvement initiatives.

Methods: We conducted a retrospective cohort study of adults who underwent elective craniotomy, hip replacement, knee replacement, spinal procedure, or hernia repair in 2019-2020 at hospitals in the PINC AI (Premier) Healthcare Database. We evaluated adherence of prophylaxis regimens, with respect to antimicrobial agents endorsed in the American Society of Health-System Pharmacist guidelines, accounting for patient antibiotic allergy and methicillin-resistant Staphylococcus aureus colonization status. We used multivariable logistic regression with random effects by hospital to evaluate associations between patient, procedural, and hospital characteristics and guideline adherence.

Results: Across 825 hospitals and 521 091 inpatient elective surgeries, 308 760 (59%) were adherent to prophylaxis guidelines. In adjusted analysis, adherence varied significantly by US Census division (adjusted OR [aOR] range: .61-1.61) and was significantly lower in 2020 compared with 2019 (aOR: .92; 95% CI: .91-.94; P < .001). The most common reason for nonadherence was unnecessary vancomycin use. In a post hoc analysis, controlling for patient age, comorbidities, other nephrotoxic agent use, and patient and procedure characteristics, patients receiving cefazolin plus vancomycin had 19% higher odds of acute kidney injury (AKI) compared with patients receiving cefazolin alone (aOR: 1.19; 95% CI: 1.11-1.27; P < .001).

Conclusions: Adherence to antimicrobial prophylaxis guidelines remains suboptimal, largely driven by unnecessary vancomycin use, which may increase the risk of AKI. Adherence decreased in the first year of the COVID-19 pandemic.

Keywords: acute kidney injury; antimicrobial stewardship; surgical prophylaxis; vancomycin.

Publication types

  • Research Support, U.S. Gov't, P.H.S.
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Acute Kidney Injury* / drug therapy
  • Adult
  • Anti-Bacterial Agents / therapeutic use
  • Anti-Infective Agents* / therapeutic use
  • Antibiotic Prophylaxis / methods
  • COVID-19*
  • Cefazolin / therapeutic use
  • Guideline Adherence
  • Hospitals
  • Humans
  • Methicillin-Resistant Staphylococcus aureus*
  • Pandemics
  • Retrospective Studies
  • Surgical Wound Infection / drug therapy
  • Surgical Wound Infection / epidemiology
  • Surgical Wound Infection / prevention & control
  • Vancomycin / therapeutic use


  • Anti-Bacterial Agents
  • Cefazolin
  • Vancomycin
  • Anti-Infective Agents