There are limited U.S. 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.
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.
Across 825 hospitals and 521,091 inpatient elective surgeries, 308,760 (59%) were adherent to prophylaxis guidelines. In adjusted analysis, adherence varied significantly by U.S. census division (adjusted OR [aOR] range: 0.61-1.61) and was significantly lower in 2020 compared to 2019 (aOR 0.92, 95% CI: 0.91-0.94, p < 0.001). 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 to patients receiving cefazolin alone (aOR 1.19; 95% CI: 1.11-1.27, p < 0.001).
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.

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