INTRODUCTION
Surgical Site Infections (SSIs) have consistently been one of the major contributors of Hospital Acquired Infections (HAI) . Every year, up to one-third of patients undergoing surgery suffer from SSIs and at least some of these are potentially preventable by a combination of good clinical practices and appropriate pharmaco-prophylaxis.

In India, Surgical antimicrobial prophylaxis (SAP) is one of the most impactful, yet misused interventions in peri-operative care. The rationale of SAP is to use narrow-spectrum antibiotics timed to achieve tissue bactericidal concentrations at the time of incision, repeated only if surgery is prolonged or associated with excessive bleeding. Deviation from these principles contributes to the catastrophic, downstream antimicrobial resistance (AMR) we are facing worldwide, especially in India. An estimated 4.71 million deaths globally were associated with bacterial AMR in 2019, of which 1.27 Million were directly attributable to it.1 Inappropriate antibiotic use drives a vicious circle of events causing more SSIs, requiring broader antibiotic coverage thereby leading further to AMR.

CHOICE OF IDEAL ANTI-MICROBIAL AND ADMINISTRATION
The anti-microbial must be (1) active against pathogens likely to contaminate the surgical site (skin flora), (2) given in an appropriate dosage and timing ensuring adequate serum and tissue concentrations during the period of potential contamination, (3) safe, and (4) administered for the shortest effective period to minimize adverse effects, AMR and cost.2 Ideally, the chosen narrow-spectrum antibiotic should not be in common therapeutic use to ensure continued efficacy. The administration of antibiotics should be seen as a component of a perioperative stewardship bundle incorporating a clear indication, rationale for choice of drug, planning its delivery and redosage as required for duration of surgery or blood loss, timed discontinuation and auditing for feedback. Single pre-op dose within 60 minutes before incision is appropriate for most procedures. Postoperative prophylaxis should not routinely continue beyond 24 hours.

THE INDIAN CONTEXT
The dual challenge in India lies in the rising rates of AMR coupled with high burden of SSI, as in other Low and Middle Income Countries (LMICs). The ICMR (in line with other international guidelines for SAP) recommends the use of single dose cefazolin as the antibiotic of choice for most surgeries, not to be continued beyond the duration of surgery.3 However, continuing the prophylactic drug for longer is common. In a multi-center rural study, 79.8% of the cases were prescribed anti-microbials beyond the indicated timeline.4 Many surgeons may have the misguided concern that the “milieu” in over-burdened public sector hospitals may not be as clean as those in resource-rich countries, and therefore continue to prolong antibiotics following surgery.5 Several studies have attested that prolonging antibiotics beyond 24 hours has not shown to reduce the risk of SSIs, but instead contributes to AMR and C. difficile infections.2 This was validated in a public sector tertiary care hospital in Delhi,  where a quality improvement study showed that adherence to a single anti-microbial dose of SAP increased from 2.1% to 67.7% over 6 months without any concomitant increase in SSI rate.6 Extension to 48 hours is frequently debated in Cardiac surgery and joint replacement with conflicting evidence but still practiced more from fear of the devastating consequences of infections therein. However it is important to stress that resource limitation cannot be used as a rationale for longer prophylaxis. In fact, unnecessary prolonged antibiotics consume scarce pharmacy resources, increase adverse effects and select resistance, while diverting attention from higher-value SSI prevention measures.

The recent spurt of accreditation activities by hospitals and insurance regulatory bodies in India, has probably had a positive-ripple effect on increasing appropriate use. However continued monitoring and audits by infection control teams would be required to show continued compliance. S. aureus and E. coli have been common in post-operative infections, but the continuing rise of gram negative MDR organisms from post-operative patients in India is a cause for concern.5 Hierarchical dynamics and fear of blame in Surgical fields in India, often lead to junior surgeons to mimic senior colleagues instead of following prevailing hospital guidelines. Guidelines alone will not change prescribing behaviour; senior-surgeon ownership, audit-and-feedback, standardised order sets and visible accountability are required.7

HOW DO WE SOLVE THIS? (PLAYING WITH FIRE WHILE WALKING ON THIN ICE)

The cornerstone of SSI prevention should be standard infection control practices eg incorporation of the 7S Bundle of SSI Prevention (Safe operating room; Screen for risk factors and MRSA/MSSA; Showers with chlorhexidine; Skin prep with alcohol based antiseptics; Sutures with antimicrobial; Solution to irrigate with chlorhexidine; Skin adhesive or antimicrobial dressings to protect incision) 8.

. The misinformed belief that this can be compensated by broad/extended spectrum antibiotics for longer than necessary durations has proven to be detrimental by increasing AMR. Protracting antimicrobial prophylaxis until the removal of all indwelling drains, catheters and intra-vascular lines has been demonstrated to be unnecessary in multiple studies.2 The metabolic stress response to surgery may result in mild pyrexia or leukocytosis without any actual “infection”. This early post-operative occurrence can prompt prolongation of the prophylactic antibiotic in a confused therapeutic manoeuvre. Postoperative fever/leukocytosis should NOT automatically trigger continuation of SAP. If sepsis is clearly suspected, the diagnosis of infection should be attempted with requisite cultures. It is preferable, at this stage, to switch to a therapeutic course of an appropriate antibiotic and if an anastomotic leak is demonstrated – it requires source control combined with therapeutic antibiotics rather than continued prophylaxis. Antibiotics cannot seal the perforation! Source control must be primary and paramount, along with the therapeutic antibiotics.

Those who are allergic to Beta-lactam antibiotics, clindamycin and vancomycin have been recommended for prophylaxis, but are associated with a higher risk of SSIs and worse outcomes.9 The label of penicillin allergy can be erroneous and a good history should be sought or records checked, whether it was a true severe immediate hypersensitivity or a vague documentation of a possible (minor?) event. Besides, the allergy is rarely synonymous with cross-reactivity with cephalosporins. Pre-operative skin testing could be a viable option to increase cefazolin utilization in such cases (by de-labelling allergy) without a corresponding increase in adverse events.10 Reserving specified antibiotics for prophylaxis, and avoiding their use therapeutically should be an important component of antibiotic stewardship. Cefazolin has been recommended most widely, but there could be regional differences in AMR and drug availability. 

Existing resistance patterns must be monitored to ensure that such use is sensible. In this regard, the National Accreditation Board for Hospitals (NABH) recommends a similar policy to monitor local antibiograms. This may explain why Cefuroxime is a frequent alternative (and included in ICMR guidelines as an alternative to Cefazolin) as second generation cephalosporins came later to India and have not been used as much, as a therapeutic drug. Integrating technology with the institutional antibiotic policy at the point of prescribing, can help in guiding surgeons in making the right decision.

The common causes of non-compliance include deviation of antibiotic selection from the recommended antibiotic policy of the hospital, or the prescription of the antimicrobial beyond the recommended duration. Well-intentioned surgeons while caring for the tangible patient in front of them resort to irrational antibiotic use, which is the hammer driving the nail into the (seemingly intangible) coffin of  antimicrobial resistance. The negative feedback loop of inappropriate antibiotic use causes more drug-resistant SSIs, thereby requiring broader spectrum of antibiotics. 

In minimal access surgery, the routine use of SAP in low-risk cases should be individualised and prophylaxis should be indicated based on procedure, patient and risk stratification. A meta-analysis of 18 trials concluded that SAP in low-risk laparoscopic cholecystectomies proved no benefit.11 Surgeons in public hospitals serving lower income groups of society and perceived less hygienic milieu may have the feeling that the guidelines have been designed for elitist public hospitals, without substantiating evidence. Cross institutional visits and studying actual data might help in dispelling such notions.

CONCLUSIONS

Rational SAP is a low-cost, high-impact lever to reduce SSIs and arrest the rising AMR in India. The key lies in diligent implementation of available guidelines, audits and making surgical groups a larger part in the antimicrobial stewardship. SSI rates may reflect infection control practices of the settings where the surgeries are performed, but the high antimicrobial resistance rates within these patient groups reflect an overwhelming need for surgical antimicrobial stewardship. SAP should not be viewed as an isolated antibiotic intervention. It is one component of a perioperative safety system in which infection prevention, appropriate prophylaxis, antimicrobial stewardship, source control and surveillance are interconnected.

ACKNOWLEDGEMENT
None

CONFLICTS OF INTEREST
The authors declare no conflict of interest.

SOURCE OF FUNDING
None

ETHICS STATEMENT INCLUDING PATIENT CONSENT
Not applicable

AUTHOR’S CONTRIBUTION
Both authors contributed to the literature review, writing the draft and editing the draft to finalise it.

AI DECLARATION
No AI tool was used to generate research data, perform data analysis, interpret findings, formulate scientific conclusions, or make editorial decisions. All AI-assisted content was critically reviewed, verified, and revised by the authors. The authors take full responsibility for the accuracy, originality, integrity, and final content of the manuscript. 

REFERENCES

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3. Indian Council for Medical Research Treatment guidelines for antimicrobial use in common syndromes 2nd edition. Published 2019. Last accessed 1st September, 2026.  https://www.icmr.gov.in/icmrobject/custom_data/pdf/resource-guidelines/Treatment_Guidelines_2019_Final.pdf 

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