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

Stephanie M. Cabral, Anthony D. Harris, Sara E. Cosgrove, Laurence S. Magder, Pranita D. Tamma, Katherine E. Goodman

Research output: Contribution to journalArticlepeer-review


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.

Original languageEnglish (US)
Pages (from-to)2106-2115
Number of pages10
JournalClinical Infectious Diseases
Issue number12
StatePublished - Jun 15 2023


  • acute kidney injury
  • antimicrobial stewardship
  • surgical prophylaxis
  • vancomycin

ASJC Scopus subject areas

  • Microbiology (medical)
  • Infectious Diseases


Dive into the research topics of 'Adherence to Antimicrobial Prophylaxis Guidelines for Elective Surgeries Across 825 US Hospitals, 2019-2020'. Together they form a unique fingerprint.

Cite this