Yahya Almarhabi 1,2*
1 Center of Excellence in Trauma and Accidents, King Abdulaziz University, Jeddah 21589, Saudi Arabia
2 Department of Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah 21589, Saudi Arabia
* Correspondence: yalmarhabi@kau.edu.sa
Revised: April 29, 2025; Accepted: May 1, 2025; Published: May 2, 2025
Abstract
Surgical site infections (SSIs) remain a significant challenge in postoperative care. Inappropriate use of antibiotic can aggravate antimicrobial resistance leading to increased healthcare costs. While recent literature has demonstrated the efficacy of antibiotic stewardship efficacy in reducing unnecessary antibiotic exposure, inconsistencies in local practice gaps and adherence to guidelines persist, particularly in the Middle Eastern countries, including the Kingdom of Saudi Arabia (KSA). Realizing the need for context-specific evidence for assessing the impact of targeted antibiotic stewardship on surgical outcomes, this study aims to explore the influence of such implementation using 458 patients’ data from primary care hospital in Jeddah, Saudi Arabia. Employing a cross-sectional chart review, the study compared clinical outcomes and antibiotic usage in before (n=306) and after (n=152) program implementation. The analysis is supported by rigorous statistical analysis to assesses the differences in antibiotic duration, defined daily dose (DDD), hospital stay, readmission, and SSI rates. Key findings revealed significant reduction in antibiotic duration post-stewardship (mean 2.51 vs. 3.18 days, p=0.03), with no noticeable increase in SSIs or readmissions between both the groups. Further, it was also revealed that antibiotic stewardship implementation was effective in minimizing the antibiotic exposure without compromising the clinical outcomes or patient safety. Results highlighted the importance of adopting targeted stewardship interventions in optimizing surgical prophylaxis and patients’ well-being in similar healthcare settings.
Keywords: Surgical site infection; Antibiotic stewardship; Antimicrobial resistance; Prophylactic antibiotics; Healthcare quality
- Introduction
One of the most significant medical care breakthroughs in recent history is the emergence of antibiotics, which changed the practice of medicine from being predominantly a diagnostic to a therapeutic endeavor (Pollack & Srinivasan, 2014). Antibiotic stewardship in the preoperative surgical setting is a vital strategy aimed at optimizing the use of prophylactic antibiotics to prevent surgical site infections (SSIs). SSIs are among the most common complications following surgery, with an incidence ranging from 2% to 5% in various surgical procedures. Effective antibiotic stewardship not only enhances patient outcomes but also plays a crucial role in combating the growing threat of antibiotic resistance.
The preoperative phase is a critical period for implementing antibiotic prophylaxis. Antibiotic prophylaxis has been shown to significantly decrease the incidence of SSIs, which are a major cause of postoperative morbidity and mortality. Studies have demonstrated that the appropriate use of antibiotics can reduce the risk of SSIs by up to 80% in certain surgical procedures, such as total hip and knee replacements (Karlatti & Havannavar, 2016). Appropriate antibiotics for the preoperative phase are selected based on the type of surgery, patient allergies, and local antimicrobial resistance patterns. Commonly administered antibiotics included Cefazolin, Metronidazole and Cephalosporins. A single standard therapeutic dose is usually sufficient for prophylaxis. Additional doses may be needed during prolonged surgeries or with significant blood loss (Baseel et al., 2022). One Saudi Arabian study found significantly lower surgical site infection (SSI) rates in patients receiving preoperative antibiotics (1/157) compared to untreated patients (3/57), along with shorter hospital stays (Alsaeed et al., 2022). Similarly, a retrospective cohort study on colorectal surgery reported a significant reduction in hospital stay for patients receiving single-dose prophylaxis (14.0 days vs. 17.5 days for multiple-dose regimens) (Ventura Cerdá et al., 2007). A systematic review found that appropriate prophylactic antibiotic use can decrease SSI rates by 30-50% in elective surgeries (Sutherland et al., 2019). This reduction not only improves patient recovery but also minimizes healthcare costs associated with extended hospital stays and additional treatments. Moreover, antibiotic stewardship is essential for preserving the effectiveness of existing antibiotics. Optimized dosing strategies also contribute to faster normalization of clinical parameters, such as body temperature and inflammatory markers. A study on spinal surgery found that short-term antibiotic administration (2 days) resulted in quicker normalization of body temperature and C-reactive protein (CRP) levels compared to long-term administration (9 days) (Ohtori et al., 2008). The overuse and misuse of antibiotics contribute to the development of resistant bacterial strains, complicating treatment for future infections (McGowan, 2019; Lou et al. 2024; Lin et al. 2024; Li et al. 2025).
Despite its importance, implementing antibiotic stewardship in the preoperative setting presents several challenges. One major barrier is the variability in guidelines and practices across different surgical specialties and institutions. (Mehra, 2024) highlights that variability in intraoperative antibiotic dosing strategies may impact postoperative infection rates, potentially affecting patient recovery, length of hospital stays, and associated costs. Adherence to appropriate dosing guidelines is crucial for optimizing patient outcomes and resource utilization. Inconsistent adherence to evidence-based protocols can lead to either unnecessary antibiotic use or inadequate prophylaxis (Bratzler et al., 2005).
The lack of education and awareness among surgical staff significantly impacts the effectiveness of antibiotic prophylaxis in surgical settings. This deficiency can lead to improper adherence to guidelines, resulting in increased surgical site infections (SSIs), antimicrobial resistance, and higher healthcare costs. The effectiveness of Surgical Antimicrobial Prophylaxis (SAP) is contingent upon the correct selection, timing, dosage, and duration of antibiotic administration, all of which require a thorough understanding and adherence to established guidelines (Sutherland et al., 2019). Misuse of prophylactic antibiotics, such as inappropriate choice and prolonged duration, is common due to a lack of awareness and education among surgical staff (Ng & Chong, 2012). In Liberia, a study found that only 20.3% of cases adhered to the appropriate timing of SAP administration, highlighting a significant gap in compliance (Enriquez et al., 2022). A subsequent study conducted in Sudan revealed a concerning disparity in surgical knowledge and adherence to guidelines among surgeons. Only 12.5% exhibited adequate knowledge of appropriate SAP, while adherence to guidelines was notably low, with only 35.4% adhering to the prescribed timing for the initial dosage (Ahmed et al., 2019). In Ethiopia, despite a positive attitude towards SAP guidelines, poor practice was observed in 57.6% of medical staff, indicating that knowledge alone is insufficient without proper implementation (Tefera, 2019).
Cultural factors within surgical teams also play a significant role in the success of antibiotic stewardship initiatives. Fostering a collaborative environment where all team members prioritize appropriate antibiotic use requires strong leadership and effective communication. Resistance to change among surgical staff can impede the implementation of new protocols and practices (McGowan, 2019). This complexity necessitates tailored interventions that consider the unique cultural and contextual factors present in different healthcare settings. By understanding and addressing cultural and contextual factors, healthcare systems can develop more effective and sustainable antibiotic stewardship programs. This requires a commitment to interdisciplinary collaboration, continuous education, and the adaptation of interventions to local contexts. Additionally, the role of surgeons in antibiotic stewardship is crucial, as they are in a unique position to influence prescribing practices and advocate for evidence-based approaches (Leeds et al., 2017).
This study aims to explore the impact of antibiotic stewardship program within the surgical setting using data primary care hospital in Jeddah Saudi Arabia. The study intends to to assess whether implementing antibiotic stewardship will lead to a reduction in healthcare costs, including the dosage and duration of antibiotics, as well as the length of hospital stay and the frequency of re-admission, without compromising the incidence of surgical site infections (SSIs). Study findings will provide essential guidance to health practitioners and agencies for wide-scale deployment of antibiotic stewardship program in other jurisdictions.
- Methodology
- Study area and data collection
The present study employs a cross-sectional chart review methodology to investigate a cohort of 458 patients at a hospital in the Kingdom of Saudi Arabia (KSA) over a two-year period from 2021 to 2023. This approach allows for a comprehensive analysis of patient data, facilitating insights into various health outcomes and treatment efficacy within the specified timeframe. Prior to the initiation of the study, ethical approval was secured from the Hospital Committee, underscoring the commitment to uphold rigorous ethical standards throughout the research process. Furthermore, strict adherence to established ethical principles was maintained, particularly in relation to confidentiality and data protection, thereby ensuring the privacy of all individuals involved in the study.
Total 458 patients were enrolled in current study and further divided into two groups, Group A (n=306), pre antibiotic stewardship program group, and Group B (n=152), post antibiotic stewardship program group, The total Data collection involved extracting comprehensive demographic, clinical, and operative information from contemporary clinical records. This included details such as patients’ age and gender, BMI, weight, height, comorbidities, and specific information on antibiotic use, both preoperative and postoperative. The type and duration of antibiotics administered were noted, along with the Defined Drug Dosage (DDD). Additionally, the type of surgery performed, and the occurrence of surgical site infections (SSIs) were recorded. This detailed data was gathered to analyze factors influencing surgical outcomes and the effectiveness of antibiotic protocols.
- Statistical analysis
Statistical analyses were performed using SPSS version 25. Descriptive analysis was conducted by calculating frequencies and percentages for qualitative variables and Mean, Standard Deviation for quantitative variables. Association between groups and demographic variables and clinical features was evaluated by Chi-square test and Fisher exact test. The comparison of mean difference among Duration of Antibiotic and defined daily dose among both groups were compared by independent sample t test. P-value <0.05 was considered as significant.
3. Results
The demographic data presented in the table shows that the two groups, Group A (n=306), the pre-program group, and Group B (n=152), the post program group, were largely similar across various characteristics. The average age of the total sample was 43.90 years, with Group A having a mean age of 44.33 years and Group B slightly older at 45.06 years. Similarly, there is no significant difference in weight between the groups, with Group A averaging 76.19 kg and Group B 74.93 kg (p=0.468). The mean height is almost identical across both groups. The mean hospital stay in Group A was 1.83+1.41 and in group B was 1.72+1.09. There was no statistical difference in hospital stay among both groups (p=0.334).
In terms of gender, the males comprising 31.7% of the total sample and females 68.3%. Group A has 32.7% males and 67.3% females, while Group B has 29.6% males and 70.4% females. The BMI categories show a similar pattern, with approximately 40.6% of participants classified as obese. The age distribution further shows that the majority of participants fall within the 21-40 age group (46.3%), followed by the 41-60 age group (34.7%), with smaller proportions in other age ranges. Overall, the data suggest that Group A and Group B are comparable across all demographic variables, with no significant differences detected. (Table 1 & Figure 1)
Table 1: Demographics of Patients
| Variables | Group A (n=306) | Group B(n=152) | P-value |
| Age In Years | 44.33+14.68 | 45.06+15.03 | 0.242 |
| Weight (KG) | 76.19+17.7 | 74.93+17.3 | 0.468 |
| Hight (CM) | 161.39+10.19 | 161.32+10.40 | 0.942 |
| Hospital Stay (days) | 1.83+1.41 | 1.72+1.09 | 0.334 |
| Frequency (%) | |||
| Male | 100(32.7%) | 45(29.6%) | 0.505 |
| Female | 206(67.3%) | 107(70.4%) | |
| BMI | |||
| Underweight | 10(3.3) | 6(3.9) | 0.799 |
| Normal | 82(26.8) | 26(30.0) | |
| Overweight | 89(29.1) | 39(25.7) | |
| Obesity | 125(40.8) | 61(40.1%) | |
| Age | |||
| <20 | 9(2.9) | 5(3.3%) | 0.655 |
| 21-40 | 149(48.7) | 63(41.4) | |
| 41-60 | 103(33.7) | 56(36.8) | |
| 61-80 | 41(13.4) | 26(17.1) | |
| >81 | 4(1.3) | 2(1.3) | |
* Group A pre-program group, and Group B post-program group
Figure 1. Demographic of patients (Age, Weight, Male/Female, Height)
The table summarizes the clinical features of patients in Group A (n=306) and Group B (n=152), showing no significant differences between the groups across most variables. Regarding comorbidities, 75.3% of the overall sample had no comorbid conditions, with 76.8% in Group A and 72.4% in Group B (p=0.448), Hypertension was present in 7.6% of all patients, with similar proportions in Group A (7.8%) and Group B (7.2%). Diabetes mellitus was slightly more common in Group B (10.5%) compared to Group A (5.6%).
In terms of surgical types, the majority of patients (65.7%) underwent general surgery, with nearly identical rates in Group A (66.0%) and Group B (65.1%). Gynecological surgery was more frequent in Group B (25.0%) than in Group A (18.6%), (p=0.198). Orthopedic surgeries accounted for 12.2% of the total population, with Group A (13.4%) having a higher proportion than Group B (9.9%). Elective surgeries comprised 92.6% of all procedures, with comparable rates in Group A (91.8%) and Group B (94.1%) (p=0.387). Emergency surgeries were slightly more common in Group A (8.2%) than Group B (5.9%).
Readmission rates were low, with four patients (0.9%) in Group A experiencing readmission, while none were reported in Group B. However, the p-value of 0.157 indicates no significant difference. Regarding infections, 99.1% of patients had no postoperative infections, with a slightly higher infection rate in Group A (1.3%) compared to none in Group B (p=0.307). Surgical site infections (SSI) were rare, with only one case recorded in Group A and none in Group B. In summary, Group A and Group B show no significant differences in terms of comorbidities, types of surgery, surgical procedures, readmissions and infection rates, indicating that both groups showed same results. (Table 2)
Table 2: Clinical features of patients
| Comorbidities | Total | Group A (n=306) | Group B(n=152) | P-value |
| NO | 345(75.3) | 235(76.8%) | 110(72.4%) | 0.448 |
| Hypertension | 35(7.6) | 24(7.8%) | 11(7.2%) | |
| Diabetes mellitus | 33(7.2) | 17(5.6%) | 16(10.5%0 | |
| Hypertension, Diabetes mellitus & Dyslipidemia | 25(5.5) | 18(5.9) | 7(4.6) | |
| Hypertension & Diabetes | 16(3.5) | 10(3.3) | 6(3.9) | |
| Dyslipidemia | 4(0.9) | 2(0.7) | 2(1.3) | |
| Type of Surgery | ||||
| General Surgery | 301(65.7) | 202(66.0) | 99(65.1) | 0.198 |
| Gastrointestinal Surgery | 4(0.9) | 4(1.3) | 0(0.0) | |
| Orthopedic Surgery | 56(12.2) | 41(13.4%) | 15(9.9%) | |
| Gynecological surgery | 95(20.7) | 57(18.6%) | 38(25.0%) | |
| Head and Neck Surgery | 2(0.4) | 2(0.7%) | 0(0.0%) | |
| Surgical Procedure | ||||
| Elective | 424(92.6) | 281(91.8%) | 143(94.1%) | 0.387 |
| Emergency | 34(7.4) | 25(8.2%) | 9(5.9%) | |
| Readmission | ||||
| Yes | 4(99.1) | 4(1.3) | 0(0.0) | 0.157 |
| No | 454(0.9) | 302(98.7) | 152(100.0) | |
| Infection | ||||
| No | 454(99.1) | 302(98.6) | 152(100) | 0.307 |
| Yes | 4(0.87) | 4(1.30) | 0(0.0) | |
| Surgical Site Infection | ||||
| Non-SSI | 3(0.7) | 3(1.0) | 0(0.0) | NA |
| SSI | 1(0.2) | 1(0.3) | 0(0.0) | |
* Group A the extended antibiotic group, and Group B the single-dose group,
Table:3 Comparison of antibiotic use among groups
| Variables | Group A (n=306) | Group B(n=152) | P-value |
| Duration of Antibiotic (Day) | 3.18+3.11 | 2.51+3.0 | *0.03 |
| Defined Daily Dose (DDD) | 6.73+6.63 | 5.46+6.92 | 0.05 |
Results from Independent sample t test,
*P-value <0.05 considered as significant
Group A pre-program group, and Group B the post-program group
The table shows a comparison between Group A (n=306) and Group B (n=152) regarding the duration of antibiotic use and the defined daily dose (DDD). The average duration of antibiotic use was significantly longer in Group A, with a mean of 3.18 days, compared to 2.51 days in Group B. The p-value of 0.03 indicates that this difference is statistically significant, meaning that patients in Group A received antibiotic for a longer period than those in Group B.
As for the defined daily dose (DDD), Group A had a higher average (6.73 DDD) compared to Group B (5.46 DDD). There was insignificant difference among both groups (p < 0.05). .(Table 3). In conclusion, Group A had a significantly longer duration of antibiotic use, while the difference in antibiotic dosage was not statistically significant but showed a potential trend. We need to add that the SSI and all infection is not higher in group B compared to group A.
4. Discussion and Conclusions
This study evaluated the impact of a surgical antibiotic stewardship program on antibiotic use and clinical/surgical outcomes. The primary finding was a significant reduction in the duration of antibiotic administration in the post-intervention group (Group B), decreasing from a mean of 3.18 to 2.51 days (p = 0.03). This reduction aligns with stewardship goals to minimize unnecessary antibiotic exposure, thereby reducing the risk of antimicrobial resistance without compromising patient safety. Importantly, this reduction in duration did not result in increased postoperative infections. The infection rates, including surgical site infections (SSIs), remained statistically similar between Group A and Group B, with no recorded SSIs in the post-stewardship group. These findings support existing evidence that shorter antibiotic courses can be both safe and effective in preventing postoperative infections, particularly when prophylaxis is administered appropriately based on the type of surgery and patient profile.
Antibiotic usage varied across surgical disciplines. General and gynecological surgeries used more extended antibiotics, while gastrointestinal and orthopedic surgeries had more variable practices. This variation may reflect infection risk or procedure complexity, but it highlights the need for standardized protocols. Surgery type significantly influenced antibiotic use (p < 0.001), suggesting targeted interventions in specific domains.
The study has several limitations. It was conducted at a single center, potentially limiting external validity. The retrospective design may introduce selection and information bias, particularly related to documentation accuracy. The low frequency of postoperative infections, while clinically desirable, restricted the power to detect subtle differences between groups. Additionally, microbiological data and resistance patterns were not evaluated. Future research should incorporate prospective, multi-center designs, explore patient-centered outcomes, and assess microbial resistance trends to provide a more comprehensive evaluation of antibiotic stewardship interventions.
This study confirms the effectiveness of stewardship interventions in reducing antibiotic use duration and quantity. Previous studies have shown improved adherence, reduced hospital stays, and lower consumption without increased complications. This study adds evidence from a Saudi Arabian surgical population, reinforcing the global relevance and adaptability of stewardship principles.
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