Penicillin allergy is a significant burden on patient, prescribing and hospital outcomes. There has been increasing interest in the incorporation of penicillin allergy testing (i.e. delabelling) into antimicrobial stewardship (AMS) programmes to reduce the burden of penicillin allergy labels and improve prescribing. In particular, there has been a focus on point-of-care penicillin allergy assessment and direct oral challenge for low-risk phenotypes. The National Antibiotic Allergy Network has provided a guide to assist AMS clinicians with the incorporation of penicillin allergy programmes, in particular direct oral challenge, into Australian hospitals.

Purpose of reviewThis review aims to discuss the current state of surgical antimicrobial prophylaxis (SAP) evidence for surgical site infection prevention. Despite decades of research, knowledge gaps persist in identifying optimal SAP regimens.Recent findingsRecent randomised controlled trials highlight ongoing heterogeneity in study design. Key new findings support the use of oral preoperative SAP for colorectal surgery and advise against the use of SAP for transperineal prostate biopsy. There is growing evidence for culture-based SAP over empiric use for transrectal prostate biopsy.Contentious issues remain regarding topical antimicrobials for cardiac procedures involving sternotomy, the necessity of SAP for wire lumpectomy and laparoscopic cholecystectomy for both mild or moderate acute cholecystitis. Procedures where SAP is not indicated, yet research is still being conducted on this topic include dental implants and clean orthopaedic procedures.SummaryResearch efforts continue with numerous trials published and registered to determine optimal SAP regimens. However, many efforts are suboptimal due to poor statistical design and redundant questions already answered by existing literature. To improve practice and influence surgeons prescribing behaviour future RCTs should be well powered, with large sample sizes across multiple sites, focusing on clinically relevant questions.

Background: Cefazolin is the most commonly recommended antimicrobial for surgical antimicrobial prophylaxis (SAP). However, the Australian Surgical National Antimicrobial Prescribing Survey revealed a wide range of antimicrobials prescribed for SAP. Inappropriate use of broad-spectrum antimicrobials is associated with increased patient harm and is a posited driver for antimicrobial resistance. Objectives: To describe patient, hospital and surgical factors that are associated with appropriateness of the top five prescribed antimicrobials/antimicrobial classes for procedural SAP. Methods: All procedures audited from 18 April 2016 to 15 April 2019 in the Surgical National Antimicrobial Prescribing Survey were included in the analysis. Estimated marginal means analyses accounted for a range of variables and calculated a rate of adjusted appropriateness (AA). Subanalyses of the top five audited antimicrobials/antimicrobial classes identified associations between variables and appropriateness. Results: A total of 12 419 surgical episodes with 14 150 prescribed initial procedural doses were included for analysis. When procedural SAP was prescribed, appropriateness was low (57.7%). Allergy status, surgical procedure group and the presence of prosthetic material were positively associated with cefazolin and aminoglycoside appropriateness (P < 0.05). There were no significant positive associations with glycopeptides and third/fourth-generation cephalosporins. The use of broad-spectrum antimicrobials was the most common reason for inappropriate choice (67.9% of metronidazole to 83.3% of third/fourth-generation cephalosporin prescriptions). Conclusions: Various factors influence appropriateness of procedural SAP choice. Identification of these factors provides targets for antimicrobial stewardship interventions, e.g. procedures where surgeons are regularly prescribing broad-spectrum SAP. These can be tailored to address local hospital prescribing practices.

Importance:Surgical antimicrobial prophylaxis (SAP) is a common indication for antibiotic use in hospitals and is associated with high rates of inappropriateness. Objective:To describe the SAP prescribing practices and assess hospital, surgical, and patient factors associated with appropriate SAP prescribing. Design, Setting, and Participants:Multicenter, national, quality improvement study with retrospective analysis of data collected from Australian hospitals via Surgical National Antimicrobial Prescribing Survey audits from January 1, 2016, to June 30, 2018. Data were analyzed using multivariable logistic regression. Crude estimates of appropriateness were adjusted for factors included in the model by calculating estimated marginal means and presented as adjusted-appropriateness with 95% confidence intervals. Main Outcomes and Measures:Adjusted appropriateness and factors associated with inappropriate prescriptions. Results:A total of 9351 surgical episodes and 15 395 prescriptions (10 740 procedural and 4655 postprocedural) were analyzed. Crude appropriateness of total prescriptions was 48.7% (7492 prescriptions). The adjusted appropriateness of each surgical procedure group was low for procedural SAP, ranging from 33.7% (95% CI, 26.3%-41.2%) for dentoalveolar surgery to 68.9% (95% CI, 63.2%-74.5%) for neurosurgery. The adjusted appropriateness of postprocedural prescriptions was also low, ranging from 21.5% (95% CI, 13.4%-29.7%) for breast surgery to 58.7% (95% CI, 47.9%-69.4%) for ophthalmological procedures. The most common reason for inappropriate procedural SAP was incorrect timing (44.9%), while duration greater than 24 hours was the most common reason for inappropriate postprocedural SAP (54.3%). Conclusions and Relevance:High rates of inappropriate procedural and postprocedural antimicrobial use were demonstrated across all surgical specialties. Reasons for inappropriateness, such as timing and duration, varied according to the type of SAP and surgical specialty. These findings highlight the need for improvement in SAP prescribing and suggest potential targeted areas for action.

Surgical antimicrobial prophylaxis is the most common indication for antimicrobial use in Australian hospitals. However, it is associated with high rates of inappropriate use. Effective use of antimicrobials to prevent infection is essential to reduce risks associated with surgical procedures. Efforts need to be made to maximise the quality of surgical antimicrobial prophylaxis prescribing. Procedural prophylaxis (before or during surgery) is not indicated for all surgeries, especially minor procedures. Post-procedural prophylaxis, including the use of topical antimicrobials, is rarely indicated yet frequently prescribed. The Therapeutic Guidelines: Antibiotic is a key reference for all Australian prescribers. GPs can have a significant role in optimising surgical antimicrobial prophylaxis and reducing the burden of inappropriate antimicrobial use.