Perioperative surgical antibiotic prophylaxis (SAP)

Much investigated measure

How and when can SAP prevent SSI

"SAP refers to the prevention of infectious complications by administering an effective antimicrobial agent prior to exposure to contamination during surgery."1

"Successful SAP requires delivery of the antimicrobial agent in effective concentrations to the operative site before contamination occurs."1

"The benefit of the routine use of SAP prior to non-clean and implant surgery to prevent SSI has long been recognized."1


GuidelineRecommendationCategory (if mentioned)
CDC2“Administer preoperative antimicrobial agents only when indicated based on published clinical practice guidelines and timed such that a bactericidal concentration of the agents is established in the serum and tissues when the incision is made.”Category IB; strong recommendation; accepted practice
“No further refinement of timing can be made for preoperative antimicrobial agents based on clinical outcomes.”No recommendation; unresolved issue
“Administer the appropriate parenteral prophylactic antimicrobial agents before skin incision in all cesarean section procedures.”

Category IA; strong recommendation; high-quality evidence

“The literature search did not identify randomized controlled trials that evaluated the benefits and harms of weight-adjusted parenteral antimicrobial prophylaxis dosing and its effect on the risk of SSI. Other organizations have made recommendations based on observational and pharmacokinetic data, and a summary of these recommendations can be found in the Other Guidelines section of the narrative summary for this question.”No recommendation; unresolved issue
“The search did not identify sufficient randomized controlled trial evidence to evaluate the benefits and harms of intraoperative redosing of parenteral prophylactic antimicrobial agents for the prevention of SSI. Other organizations have made recommendations based on observational and pharmacokinetic data, and a summary of these recommendations can be found in the Other Guidelines section of the narrative summary for this question.”No recommendation; unresolved issue
“In clean and clean-contaminated procedures, do not administer additional prophylactic antimicrobial agent doses after the surgical incision is closed in the operating room, even in the presence of a drain.”Category IA; strong recommendation; high-quality evidence
WHO1“The panel recommends the administration of SAP prior to the surgical incision when indicated (depending on the type of operation).”Strong recommendation; low quality of evidence
“The panel recommends the administration of SAP within 120 minutes before incision, while considering the half-life of the antibiotic.”Strong recommendation; moderate quality evidence
“The panel suggests that preoperative oral antibiotics combined with mechanical bowel preparation (MBP) should be used to reduce the risk of SSI in adult patients undergoing elective colorectal surgery.”Conditional recommendation; moderate quality evidence

“Give antibiotic prophylaxis to patients before:

  • clean surgery involving the placement of a prosthesis or implant
  • clean-contaminated surgery
  • contaminated surgery.”
“Do not use antibiotic prophylaxis routinely for clean non-prosthetic uncomplicated surgery.”-
“Use the local antibiotic formulary and always take into account the potential adverse effects when choosing specific antibiotics for prophylaxis.”-
“Consider giving a single dose of antibiotic prophylaxis intravenously on starting anaesthesia. However, give prophylaxis earlier for operations in which a tourniquet is used.”-
“Before giving antibiotic prophylaxis, take into account the timing and pharmacokinetics (for example, the serum half-life) and necessary infusion time of the antibiotic. Give a repeat dose of antibiotic prophylaxis when the operation is longer than the half-life of the antibiotic given.”-
“Give antibiotic treatment (in addition to prophylaxis) to patients having surgery on a dirty or infected wound.”-
“Inform patients before the operation, whenever possible, if they will need antibiotic prophylaxis, and afterwards if they have been given antibiotics during their operation.”-
KRINKO4The Commission recommends that the indication for systematic antibiotic prophylaxis should be specific to the procedure.Category IA
Multiple doses should only be administered during surgery for very long operations.Category IA
Avoid prolonged administration of antibiotics after the end of surgery.Category IA


Denise Leistenschneider, Senior Clinical Consultant
"The prophylactic administration of antibiotics is and remains an aspect to be weighed up carefully due to the possible development of antimicrobial resistance – all the more reason to consider new approaches such as antimicrobial irrigation"

Extract of recommendations​

What to consider in advance

  • Is antibiotic treatment indicated for the type of operation?1–4

  • What is the pharmacokinetics/half-life of the antibiotic?1,3

  • What are the possible side effects?3

When to use antibiotic prophylaxis3

  • "clean surgery involving the placement of a prothesis or implant”

  • “clean-contaminated surgery”

  • “contaminated surgery”

When not to use antibiotic prophylaxis3

  • “for clean non-prosthetic uncomplicated surgery”

How to use antibiotic prophylaxis

  • Give a single dose of antibiotic prophylaxis before starting anaesthesia3

  • Administer antibiotic prophylaxis timely before the incision, so that a bactericidal concentration is established in the tissue1,2 (within 120 minutes before incision1)

  • Give a repeat dose only in case of longer opartions3,4

Influence of SAP on the risk of SSI4

Significant influences are particularly detectable in the case of:

  • high to very high initial infection rates

  • high risk patientsort

  • hopaedic interventions with permanent implants

  • treatment of long bone fractures

  • breast surgery

Indications for SAP4

Indications for SAP that are considered safe include:

  • risk of intraoperative contamination with subsequent SSI due to high pathogen exposure in the operating area (usually in the presence of the wound classifications clean-contaminated, contaminated and dirty).
  • in the case of clean operations, presence of an additional risk factor such as emergency surgery, osteosynthesis, spinal cord surgery, open reduction and internal fixation of fractures, high-risk surgery, surgery on large joints, insertion of vascular and joint implants, heart valves and other alloplastic materials and replacement of existing implants such as endoprostheses, artificial heart valves, etc. - treatment of open fractures.
  • for clean operations with a risk of infection due to the patient's own risks and as a result of significant morbidity, e.g. operations on immunocompromised patients, patients with severe underlying illnesses, patients with a high ASA score, pre-radiation, hypothermia.
All content and recommendations listed are to be regarded as extracts from the original literature and do not claim to be exhaustive.
Click to see full list References:
  1. WHO (2018) Global guidelines for the prevention of surgical site infection. World Health Organization 2018.
  2. Berrios-Torres SI, et al. (2017) Centers of Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017. JAMA Surg 152(8): 784–791.
  3. NICE (2020) Surgical site infections: prevention and treatment. NICE guidelines. Published: 11 April 2019. Last updated:19 August 2020.
  4. KRINKO (2018) Prävention postoperativer Wundinfektionen. Empfehlungen der Kommission für Krankenhaushygiene und Infektionsprävention (KRINKO) beim Robert Koch-Institut. Bundesgesundheitsbl 61: 448–473.

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