Review Article Do Changes in Antimicrobial Resistance Necessitate Reconsideration of Surgical Antimicrobial Prophylaxis Strategies? Matthew E. Falagas, 1,2,3 Vangelis G. Alexiou, 1 George Peppas, 1,4 and Gregory C. Makris 1,5 Abstract Background: The potential need for re-evaluation of guidelines on surgical antimicrobial prophylaxis (AMP) in an era of advancing antimicrobial resistance is a matter of a considerable controversy. Method: Review of the pertinent literature. Results: Over the last decade, the prevalence of methicillin-resistant Staphylococcus aureus (MRSA) has increased significantly, as illustrated by several surveillance studies. The blending of community acquisition and long-term carriage may increase the probability of unrecognized MRSA carriers being admitted to the hospital. Thus, MRSA is considered a major epidemiological threat in most parts of the world, exerting pressure for recon- sideration of the guidelines for surgical AMP. The use of a glycopeptide as first-choice prophylaxis in major procedures such as cardiac surgery generally is not recommended but is not ruled out. Current recommenda- tions are based on trials performed almost a decade ago at the latest and do not reflect the contemporary epidemiology of resistance. A few recent studies suggested that vancomycin in combination with gentamicin and rifampicin reduces the incidence of surgical site infections significantly in high-risk patients. These devel- opments led some surgeons and infectious diseases clinicians to consider advanced antimicrobial coverage in surgical AMP. On the other hand, other clinicians are rightfully skeptical about extensive administration of glycopeptides or other agents beyond first- or second-generation cephalosporins because of the risk of further emergence and dissemination of antimicrobial resistance. Conclusion: Properly designed randomized trials are needed urgently to determine whether standard peri- operative AMP should be reconsidered in settings with changing etiology of surgical infections. S urgical site infections (SSIs) are among the most common nosocomial infections [1]. The incidence of SSIs is as high as 5% in patients undergoing clean extra-abdominal operations, whereas almost 20% of patients undergoing intra- abdominal operations develop SSIs [2]. Choosing the ap- propriate antimicrobial prophylaxis (AMP) is an important consideration for surgeons, particularly for major operations such as cardiac or prosthesis surgery having high rates of postoperative infections and longer hospitalization. Established knowledge tells us that the use of first- and second-generation cephalosporins is preferable, not only in delaying the emergence of antimicrobial resistance, but also with regard to costs and safety. However, in many settings, the epidemiological patterns of multi-drug-resistant (MDR) bacteria and the severity of infections caused by such patho- gens force surgeons to consider the use of more advanced antimicrobial drugs. In the surgical setting, the most impor- tant threat is posed by methicillin-resistant Staphylococcus aureus (MRSA), a common health care-associated pathogen [3], contributing to prolonged hospital stays and deaths [4,5]. The changing bacterial ecology necessitates frequent up- dating of preventive and therapeutic antimicrobial strategies. Nowadays, the clinical effectiveness of AMP with b-lactam drugs is questioned by many surgeons and infectious diseases experts. Should we consider more aggressive AMP strategies for some patients undergoing certain types of surgery or in specific settings with a higher incidence of infections caused by pathogens resistant to b-lactam antibiotics? We reviewed 1 Alfa Institute of Biomedical Sciences (AIBS), Athens, Greece. Departments of 2 Medicine and 4 Surgery, Henry Dunant Hospital, Athens, Greece. 3 Department of Medicine, Tufts University School of Medicine, Boston, Massachusetts. 5 Imperial College, Surgical Division, London, United Kingdom. SURGICAL INFECTIONS Volume 10, Number 6, 2009 ª Mary Ann Liebert, Inc. DOI: 10.1089=sur.2008.105 557