# Compliance with antimicrobial stewardship guidelines in surgery: an observational, multidisciplinary, cohort study

Salomé Goncalves, Neyla Mohammedi, François Antonini, Alexandre Bleibtreu, Marwan Bouras, François Depret, Pierre Fillatre, Marc Garnier, Rémy Gauzit, Djamel Mokart, et al.

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Salomé Goncalves, Neyla Mohammedi, François Antonini, Alexandre Bleibtreu, Marwan Bouras, et al. Compliance with antimicrobial stewardship guidelines in surgery: an observational, multidisciplinary, cohort study. World Journal of Emergency Surgery, 2025, 20 (1), pp.63. 10.1186/s13017-025-00636-0. hal-05171470

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# Compliance with antimicrobial stewardship guidelines in surgery: an observational, multidisciplinary, cohort study

Salomé Goncalves¹, Neyla Mohammedi¹, François Antonini¹,², Alexandre Bleibtreu³, Marwan Bouras⁴, François Depret⁵,⁶,⁷,⁸,⁹, Pierre Fillatre¹⁰,¹¹, Marc Garnier¹², Rémy Gauzit¹³, Djamel Mokart¹⁴, Véronique Mondain¹⁵, Laurent Muller¹⁶, Bruno Pastene¹, Mathilde Puges¹⁷, Philippe Amabile¹⁸, Cyrille Bastide¹⁹, Stéphane V. Berdah²⁰, Xavier B. D'Journo²¹, Xavier Flecher²²,²³, Pierre-Hugues Roche²⁴, Gabriel Birgand²⁵, Carole Eldin²⁶,²⁷ and Marc Leone¹,²⁸,²⁹*

**Abstract**

**Purpose** Antimicrobial stewardship aims to improve clinical outcomes while reducing the unintended effects of antimicrobial use. The use of antibiotics in surgical wards, except for surgical antibiotic prophylaxis, has been poorly documented. Our goal was to assess the rate of compliance with the guidelines of antibiotic prescriptions in surgical wards.

**Method** In a single academic center, a retrospective analysis was conducted over a two-month period to assess the rate of compliance with four criteria reflecting good practice in terms of antimicrobial stewardship: (1) decision of treatment initiation in line with the guidelines, (2) adequate spectrum of antibiotics in terms of patient characteristics; (3) duration of antibiotic treatment in compliance with the guidelines, and (4) whether re-adaptation of treatment was required. Positive responses to these four criteria indicated a 100% compliance rate. A pair of experts assessed the clinical vignettes to decide the compliance of each criterion. The secondary aims were to assess whether a 100% compliance rate was associated with positive outcomes.

**Results** Among the 1,339 single stays in surgical wards, 232 patients (17%) received antibiotics during the study period. The rate of compliance with all four criteria was 33%. In addition, 149 (64%) patients complied with indication and spectrum, and 91 (39%) patients complied with indication, spectrum, and duration. Compliance with the antimicrobial treatment was associated with improved outcomes.

**Conclusion** Of the patients hospitalized in the surgical wards, antimicrobial stewardship guidelines were complied with in 33% patients. Full compliance with the guidelines was associated with improved outcomes.

**Keywords** Antibiotics, Surgery, Compliance, Guidelines

Full list of author information is available at the end of the article

<footnote>*Correspondence:
Marc Leone
Marc.Leone@ap-hm.fr</footnote>
## Introduction

The primary goal of antimicrobial stewardship (AMS) is to improve clinical outcomes while reducing the unintended effects of antimicrobial use. Other goals include decreasing selection pressure on pathogens and improving resource consumption [1]. In routine, AMS involves systematic assessment and collaborative initiatives to optimize the use of antimicrobial agents in terms of their indication, re-evaluation, and duration of administration [2]. Noncompliance with AMS guidelines has been associated with poor outcomes, notably prolonged duration of hospitalization and increased mortality [3-5].

Although more antibiotics are prescribed for surgical than medical patients, insufficient AMS efforts have been made in surgical specialties [6-8]. Many patients at risk of infection are hospitalized in surgical wards, 52% of whom are administered antimicrobial agents [9], while surgeons are generally focused on surgical site infection prevention and surgical antibiotic prophylaxis [10]. Thus, improving antimicrobial handling and infection control in surgical wards is an increasing need [11]. AMS, which is a critical component in the training of infectious disease (ID) and intensive care residents, is not prominent in the educational programs of surgeons [12].

Our primary goal in this study was to assess the rate of appropriate prescription of antimicrobial agents in the surgical wards of a university hospital in terms of their indication, spectrum, duration, and need for readaptation. The secondary goal was to determine the variables associated with an adequate prescription and its impact on the becoming of patients.

## Methods

### Study design

An observational, noninterventional, retrospective study was conducted in six surgical wards (orthopedic, thoracic, digestive, urologic, vascular, and neurology surgical) of a university hospital (Nord Hospital, Assistance Publique Hôpitaux Universitaires de Marseille) in Marseille, France. The study received approval from our ethics committee (CERAR IRB 00010254-2023-059) and was registered by our institution (APHM) under the number 2019-01 PADS23-123. The patients were informed about the study, and a non-opposition consent to participate was obtained from each patient. The inclusion period in the six wards ranged from March 1st to April 31st.

Adult patients hospitalized in surgical wards during the study period were included if they received a curative antibiotic treatment (excluding surgical antibiotic prophylaxis). Patients hospitalized in surgical wards for medical reasons, patients below 18 years of age, and pregnant women were excluded from the study.

### Primary objective: assessment of compliance rate

The primary objective was to determine the rate of patients hospitalized in surgical wards who were prescribed antibiotics in compliance with the following four criteria: (1) decision of treatment initiation in line with the AMS guidelines [1, 13, 14]; (2) adequate spectrum of antibiotics with regards to the patient characteristics and infection site; (3) duration of antibiotic treatment in compliance with the guidelines [1, 13, 14]; and (4) evaluation of whether antibiotic adaptation was required. Positive responses to all four criteria indicated 100% compliance rate.

To assess these criteria, an adjudication committee of 10 national experts—five ID physicians and five anesthesiologists—was formed. The experts were selected according to their ID knowledge in the field of perioperative medicine based on their participation in international studies or guidelines production. Each expert reviewed around 50 clinical vignettes summarizing a clinical case and had to determine whether each criterion was met. These clinical vignettes were developed by two investigators (SG and NM) using the data extracted from electronic medical files.

Then, five pairs of experts (one ID and one anesthesiologist) were constituted, who discussed all clinical vignettes. Finally, in the case of persistent disagreement, the principal investigators (CE and ML) resolved the case. To avoid any conflicts of interest, none of the 10 experts was from our institution. An institutional leaflet for antibiotic choice is available online (http://www.montintranet/medical/guide-des-antibiotiques).

### Secondary objective: assessment of variables associated with appropriate prescription

The secondary objectives were to identify variables associated with an adequate prescription, defined by a 100% compliance rate. We also assessed the unintended effects of the antibiotics administered during the study. To assess the effect of a compliant prescription of antibiotics, we used the following composite criteria of poor outcomes: (1) all causes 28-day mortality (from the first day of curative antimicrobial treatment), (2) persistent hospitalization at day 28, and (3) unplanned admission to an intensive care unit (ICU) during the 28 days after study inclusion. The occurrence of one of these three criteria was considered a poor outcome. Other criteria for secondary outcomes were 28-day mortality; one-year mortality; duration of hospital stay; unplanned ICU admission; multidrug resistance (MDR) bacteria acquisition; and side effects of antimicrobial agents, including *Clostridioides difficile* infection, allergic reaction, hematopoietic disorders, acute renal failure defined by KDIGO criteria [15], digestive disorders (clinical or biological), and catheter-related bloodstream infections [16].
## Data collection

Data were collected from the electronic medical files using the reports of surgeons, anesthesiologists, nurses, and ICU and ID consultants. They comprised demographics (age, gender, and body mass index), medical history, American Society Assessment score, and comorbidities (allergy, hypertension, chronic cardiac failure, chronic renal failure, diabetes, immunosuppression, infection in the last year, risk factors for MDR pathogen carriage, and treatment by non-anti-inflammatory

<table><caption>**Table 1** Patient characteristics (n = 232)</caption><thead><tr><th>Characteristics</th><th>Value</th></tr></thead><tbody><tr><td>Age, years (mean) [Q1-Q3]</td><td>60 [45-77]</td></tr><tr><td>ASA Score, n (%)</td><td></td></tr><tr><td>ASA 1</td><td>25 (11)</td></tr><tr><td>ASA 2</td><td>97 (42)</td></tr><tr><td>ASA 3</td><td>86 (37)</td></tr><tr><td>ASA 4</td><td>10 (4)</td></tr><tr><td>Male sex, n (%)</td><td>144 (62)</td></tr><tr><td>BMI (mean) [Q1; Q3]</td><td>26 [22-30]</td></tr><tr><td>Hypertension, n (%)</td><td>96 (41)</td></tr><tr><td>Diabetes, n (%)</td><td>52 (22)</td></tr><tr><td>Smoking, n (%)</td><td>63 (27)</td></tr><tr><td>Coronary artery disease, n (%)</td><td>31 (13)</td></tr><tr><td>Emergency admission, n (%)</td><td>101 (44)</td></tr><tr><td>Life in healthcare institution, n (%)</td><td>16 (7)</td></tr><tr><td>Immunosuppression, n (%)</td><td>12 (0.05)</td></tr><tr><td>On NSAIDs, n (%)</td><td>40 (17)</td></tr><tr><td>Suspected allergy, n (%)</td><td></td></tr><tr><td>To antibiotics</td><td>12 (5)</td></tr><tr><td>To beta-lactams</td><td>7 (3)</td></tr><tr><td>Type of surgical ward, n (%)</td><td></td></tr><tr><td>Vascular surgery</td><td>17 (7)</td></tr><tr><td>Digestive surgery</td><td>55 (23)</td></tr><tr><td>Thoracic surgery</td><td>20 (9)</td></tr><tr><td>Urologic surgery</td><td>61 (26)</td></tr><tr><td>Orthopedic surgery</td><td>58 (25)</td></tr><tr><td>Neurosurgery</td><td>22 (10)</td></tr><tr><td>Length of stay, days (mean) [Q1-Q3]</td><td></td></tr><tr><td>In surgery</td><td>11 [4-12]</td></tr><tr><td>In hospital</td><td>13 [4-14]</td></tr><tr><td>Hospitalized &lt; 90 days, n (%)</td><td>77 (33)</td></tr><tr><td>Antibiotic therapy in the past 12 months, n (%)</td><td>60 (26)</td></tr><tr><td>ICU stay before surgery, n (%)</td><td>11 (5)</td></tr><tr><td>MDR carriage</td><td></td></tr><tr><td>Tested, n (%)</td><td>11 (5)</td></tr><tr><td>ESBL, n (%)</td><td>1 (&lt; 0.05)</td></tr><tr><td>Type of surgery, n (%)</td><td></td></tr><tr><td>Low risk</td><td>123 (53)</td></tr><tr><td>Intermediate/high risk</td><td>71 (30)</td></tr><tr><td>No surgery</td><td>39 (17)</td></tr><tr><td>Surgical re-operation, n (%)</td><td>19 (9)</td></tr></tbody></table>

ASA: American Society of Anesthesiology; BMI: body mass index; ESBL: extended spectrum beta-lactamase; ICU: intensive care unit; MDR: multidrug resistant; NSAID: non-steroidal anti-inflammatory drugs

steroid agents). The following variables were also collected from the electronic medical files: clinical and biological variables, imaging in relation to any infective episode, blood and tissue sample analysis (availability, results), type of surgery (risk level), features of antibiotic prescription (agent, dose, route of administration, duration, and a written justification in the electronic medical file), readaptation of antibiotics if performed (interruption, escalation, de-escalation, dose, route, and duration), and ID/ICU consultation for infection [early (<72 h) or late (>72 h)].

In the case of recurrent episodes or rehospitalizations, only the first episode of the first hospital stay was considered for the analysis.

## Statistical analysis

Considering an alpha risk of 5%, the required number of subjects for the primary outcome was 246 according to an expected inappropriate prescription rate of 20% [17, 18].

Data were analyzed using R software (version 4.1.2). Continuous variables were expressed as means [interquartile ranges]. Comparisons between groups were made using the Mann-Whitney test. Categorical variables are displayed as absolute values and percentage. Proportions were compared using Fisher's exact test. A univariable analysis was performed to identify factors associated with a "poor outcome," followed by a multivariable analysis using logistic regression. Relevant variables with a significance of less than 0.2 were included in the model. A bidirectional stepwise variable selection according to Akaike's information criterion was used to refine the model. The results of the multivariate analyses were expressed as odds ratios (OR) with 95% confidence interval (95% CI). A statistical significance level of *p* < 0.05 was used for all analyses.

## Results

### Population and pathogen description

During the study period, 1,512 stays in surgical wards were screened, including 173 recurrent stays (n = 1339). Finally, 232 (17%) patients received antibiotics and were included in the analysis (Suppl. Figure 1). The characteristics of the patients are shown in Table 1. They were 60 [45-77] years old, and 62% of the patients were male. One hundred and seventy-seven (76%) patients received surgical antibiotic prophylaxis in the operating room before study inclusion (Table 2). The main sources of infection were urine (n = 63, 27%), surgical site (n = 52, 22%), and digestive tract (n = 48, 21%) (Suppl Table 1). Clinical signs—fever or shivers—were mentioned in 190 (82%) electronic medical files. The all causes 28-day mortality rate was 4.7%.
<table><caption>**Table 2** Prescription of antibiotics</caption><thead><tr><th>Characteristics, n (%)</th><th>Value</th></tr></thead><tbody><tr><td>Monotherapy</td><td>125 (54)</td></tr><tr><td>Combined therapy</td><td>108 (46)</td></tr><tr><td>Empirical therapy</td><td>206 (88)</td></tr><tr><td>Adjusted after a first administration</td><td>112 (49)</td></tr><tr><td>Reevaluation</td><td>165 (71)</td></tr><tr><td>Prescription by surgeon</td><td>206 (88)</td></tr><tr><td>Intravenous</td><td>171 (73)</td></tr><tr><td>Discontinuation justified in the electronic medical file</td><td>72 (30)</td></tr><tr><td>Duration of antibiotic therapy, days (mean) [Q1-Q3]</td><td>8 [3-9]</td></tr><tr><td>Prophylactic antibiotics in the operating room</td><td>177 (76)</td></tr><tr><td>External consultant, n (%)</td><td></td></tr><tr><td>Total</td><td>93 (40)</td></tr><tr><td>Infectious disease specialist</td><td>74 (32)</td></tr><tr><td>Intensivist</td><td>18 (8)</td></tr><tr><td>External consultant after 72 h or no opinion</td><td>162 (70)</td></tr><tr><td>Antimicrobial agents used for antibiotic prophylaxis, n (%)</td><td></td></tr><tr><td>Cefazolin</td><td>48 (21)</td></tr><tr><td>Piperacillin-Tazobactam</td><td>40 (17)</td></tr><tr><td>Daptomycin</td><td>31 (13)</td></tr><tr><td>Metronidazole</td><td>30 (13)</td></tr><tr><td>Ceftriaxone</td><td>28 (12)</td></tr><tr><td>Cefoxitin</td><td>12 (5)</td></tr><tr><td>Linezolid</td><td>9 (4)</td></tr><tr><td>Ciprofloxacin</td><td>4 (2)</td></tr><tr><td>Molecules for antibiotic therapy, n (%)</td><td></td></tr><tr><td>Piperacillin-Tazobactam</td><td>76 (33)</td></tr><tr><td>Ceftriaxone</td><td>48 (20)</td></tr><tr><td>Daptomycin</td><td>40 (17)</td></tr><tr><td>Amoxicillin-Clavulanic Acid</td><td>38 (16)</td></tr><tr><td>Metronidazole</td><td>35 (15)</td></tr><tr><td>Amoxicillin</td><td>7 (3)</td></tr><tr><td>Ciprofloxacin</td><td>23 (9)</td></tr><tr><td>Trimethoprim-Sulfamethoxazole</td><td>11 (5)</td></tr><tr><td>Linezolid</td><td>9 (4)</td></tr><tr><td>Meropenem</td><td>9 (4)</td></tr><tr><td>Cefotaxime</td><td>8 (3)</td></tr><tr><td>Amikacin</td><td>7 (3)</td></tr><tr><td>Ertapenem</td><td>5 (2)</td></tr></tbody></table>

Samples, which were mainly blood (n = 72, 39%) and urine (n = 82, 44%), were collected before the initiation of antibiotics in 144 (62%) patients and per-operatively in 89 (39%) patients. When samples were available (n = 185, 80%), we identified Gram-positive bacteria in 86 (46%) patients. Among these, we found methicillin-susceptible *Staphylococcus aureus* in 23 (12%) patients and coagulase-negative *Staphylococcus* in 20 (11%) patients (Suppl Table 1). Gram-negative bacteria were identified in 78 (42%) patients—where Enterobacteriaceae was found in 62 (34%) patients, 13 (7%) of whom produced extended-spectrum beta-lactamases. It is worth noting that the use of surgical antibiotic prophylaxis was not associated with the production of extended-spectrum beta-lactamases

(p = 0.423). Twelve (6%) patients with *Pseudomonas aeruginosa* and three (2%) with *Stenotrophomonas melophilia* were identified. Samples were sterile in 57 (30%) patients (Suppl Table 1).

Antibiotic treatment was prescribed by surgeons in 206 (88%) patients. The route was intravenous in 171 (73%) patients (Table 2), and three antibiotics were used preferentially: piperacillin-tazobactam (n = 76, 33%), ceftriaxone (n = 48, 20%), and daptomycin (n = 40, 17%). A single antibiotic was used in 125 (54%) patients. Empirical antibiotics were used in 206 (88%) patients. An external consultant, an ID specialist (n = 74, 80%) or ICU physician (n = 18, 20%), was called for 93 (40%) patients (Table 2).

Complications related to antibiotics, notably digestive disorders (n = 12, 60%) and acute kidney injury (n = 3, 15%), occurred in 20 (8.5%) patients (Suppl Table 2).

## Primary endpoint

The indication for antibiotic treatment was complied with in 210 (91%) cases; 149 (64%) cases complied with both indication and spectrum, and 91 (39%) cases complied with indication, spectrum, and duration (Fig. 1). Finally, the rate of compliance with the four criteria was 33%.

Among the 232 clinical vignettes, an agreement was found in 216 (93%) expert pairs. Among these, 82 (35%) required intra-pair reconciliation, which was sufficient for 66 cases. A round by the principal investigators (CE, ML) was required for 16 clinical vignettes. Of these disagreements, six were related to duration, four to spectrum, four to adaptation, and two to indication.

Of the patients treated with surgical antibiotic prophylaxis, 61 (34%) followed the four criteria, compared to 15 (27%) of those not treated with a surgical antibiotic prophylaxis (p = 0.22).

In a post hoc analysis, we examined the impact of patient severity on compliance by identifying various subgroups: ASA 3–4 patients, patients undergoing emergency admission, ICU patients, and patients requiring therapeutic escalation. No subgroup exhibited an association with compliance to the four criteria.

## Secondary endpoints

### Determinants of prescription

In the univariable analysis, no association was found between the call to an external consultant and an adequate prescription, regardless of whether the consultation was requested early or late.

The patients with clinical signs of infection were more likely to receive an adequate prescription (OR 4.6 (1.7–12.2), p = 0.001). Similarly, an association was found between the need for surgical reintervention and an adequate prescription (OR 2.0 (1.1–3.5), p = 0.03) (Table 3).
<figure><img src="image_3.png" /><figcaption>**Fig. 1** Rate of compliance according to the four criteria. The rate of compliance with indication, spectrum, duration and readaptation was represented by each bar</figcaption></figure>

These findings were confirmed using a multivariable analysis (Table 3).

## Outcome

When a sample had been collected before initiating antibiotics, we found an association with an improved outcome (OR 0.4 (0.2–0.9), *p* = 0.02). Likewise, an association was found between our composite criteria of poor outcomes and the lack of written justification of the antimicrobial agent interruption in the electronic medical file (OR 0.20 (0.04–0.70), *p* = 0.007). There was a significant association between ICU admission before transfer to surgical wards and poor outcomes (OR 7.2 (2–25), *p* < 0.001) (Table 3). In the multivariable analysis, the compliance of the antimicrobial treatment was associated with improved outcomes (OR 0.3 (0.1–0.9), *p* = 0.03) (Fig. 2).

## Discussion

Among the patients hospitalized in the six surgical wards, 17% were prescribed a curative antibiotic outside the use of surgical antibiotic prophylaxis. The rate of compliance with all four criteria, which reflected full compliance with the AMS guidelines, was 33%. Note that the indication for initiating an antimicrobial agent treatment was adequate in 91% cases, while the duration and readaptation were less compliant with the recommended practices [14, 19–21]. Interestingly, a compliant antimicrobial prescription was associated with improved outcomes defined by survival, hospital discharge, or lack of ICU admission at day 28.

Our results are in line with those obtained by previous observational studies [17, 18, 22], although few differences can be discussed. For example, only 17% of patients hospitalized in the surgical wards received a curative

antimicrobial treatment, which was lower than that described in previous studies. In a point prevalence study including 3,964 patients in 38 French hospitals, 32% of the patients received an antimicrobial treatment [23]. The rate of antibiotic prescription for hospitalized patients has been found to be above 60% in several point prevalence studies [24]. Other differences could be related to inclusion criteria, choice of compliance criteria, and type of antibiotic treatment. For instance, including surgical antibiotic prophylaxis in our analysis was associated with an improved rate of compliance. Previous studies have emphasized that surgeons pay considerable attention to the appropriateness of surgical antibiotic prophylaxis [25]. Finally, the patient severity did not seem to be associated with the level of compliance.

In terms of the duration of the antibiotic treatment, our findings were in line with previous literature reporting prolonged duration of antibiotic treatment in surgical settings [22]. Interventions can help reduce treatment duration. In a prospective interventional cohort study, the introduction of a national stewardship program was associated with a significant decrease in the percentage of prolonged treatments [26]. However, Charani et al. showed that, in medical wards, antibiotic prescription is collectivist, based on evidence, while surgeons tend to consider it as a nonsurgical intervention delegated to a junior physician or an external consultant [10]. This results in complex and individualistic decision-making. In routine, involving ID specialists may represent a solution, but their availability is a limitation in real life.

Our study highlighted an association between compliance with antibiotic treatment in surgical wards and patient outcomes. Being compliant with AMS guidelines has been associated with improved outcomes in other settings [3–5]. In some previous studies, implementing
<table><caption>**Table 3** Univariate and multivariate analysis</caption><thead><tr><th>Variable</th><th>Odds Ratio</th><th>p</th><th>95% CI</th></tr></thead><tbody><tr><td colspan="4"><strong>Univariate results on combined criteria for the primary outcome</strong></td></tr><tr><td>External consultant</td><td>1.2</td><td>0.6</td><td>[0.7-2.0]</td></tr><tr><td>ICU before surgical ward</td><td>0.7</td><td>0.7</td><td>[0.2-2.9]</td></tr><tr><td>Clinical signs</td><td>4.6</td><td>0.001</td><td>[1.7-12.2]</td></tr><tr><td>Surgical re-operation</td><td>2</td><td>0.03</td><td>[1.1-3.5]</td></tr><tr><td>Emergency admission</td><td>0.8</td><td>0.3</td><td>[0.4-1.3]</td></tr><tr><td colspan="4"><strong>Multivariate results for the primary outcome</strong></td></tr><tr><td>Variable</td><td>Odds Ratio</td><td>p</td><td>95% CI</td></tr><tr><td>Surgical reoperation</td><td>2.5</td><td>0.01</td><td>[1.2-5.0]</td></tr><tr><td>Clinical signs</td><td>4</td><td>0.009</td><td>[1.5-13]</td></tr><tr><td>Sample before initiating antibiotic therapy</td><td>0.4</td><td>0.01</td><td>[0.2-0.8]</td></tr><tr><td colspan="4"><strong>Univariate results on combined criteria for poor outcome</strong></td></tr><tr><td></td><td>Odds Ratio</td><td>p</td><td>95% CI</td></tr><tr><td>Oral administration</td><td>0.1</td><td>&lt;0.001</td><td>[0.02-0.39]</td></tr><tr><td>External consultant</td><td>2.2</td><td>0.06</td><td></td></tr><tr><td>External consultant before 72 h</td><td>2</td><td>0.12</td><td></td></tr><tr><td>External consultant after 72 h or no consultant</td><td>0.5</td><td>0.1</td><td></td></tr><tr><td>Emergency admission</td><td>1.4</td><td>0.4</td><td></td></tr><tr><td>ICU before surgical ward</td><td>7.2</td><td>&lt;0.001</td><td>[2.0-25]</td></tr><tr><td>Surgical re-operation</td><td>0.6</td><td>0.3</td><td>[0.2-1.6]</td></tr><tr><td>Sample before antibiotic therapy</td><td>0.4</td><td>0.02</td><td>[0.2-0.9]</td></tr><tr><td>Justified antibiotic discontinuation</td><td>0.2</td><td>0.007</td><td>[0.04-0.7]</td></tr><tr><td>Adequate prescription</td><td>0.3</td><td>0.03</td><td></td></tr><tr><td colspan="4"><strong>Multivariate results combined criteria for poor outcome</strong></td></tr><tr><td></td><td>Odds Ratio</td><td>p</td><td>95% CI</td></tr><tr><td>Adequate prescription</td><td>0.3</td><td>0.03</td><td>[0.08-0.8]</td></tr><tr><td>Sample before antibiotic therapy</td><td>0.4</td><td>&lt;0.05</td><td>[0.2-0.98]</td></tr><tr><td>ICU before surgical ward</td><td>5.7</td><td>0.02</td><td>[1.3-25]</td></tr><tr><td>ASA &gt; 2</td><td>2.2</td><td>0.08</td><td>[0.9-5.4]</td></tr></tbody></table>

ASA: American Society Anesthesiology; CU: confidence interval; ICU: intensive care unit

an AMS program was associated with reduced exposure to antibiotics [27], lesser use of broad-spectrum antibiotics [28], shorter duration of hospital stay, and decreased costs [29]. Improving the adherence to AMS rules relies on a bundle of interventions including multidisciplinary teamwork, education and training, improved communication, development of protocols and decision tools, performing audit and feedback.

Our study has several strengths. First, although conducted in a single center, different surgical wards were assessed simultaneously. As the study was retrospective, the surgeons did not change their practice for the study, avoiding observer bias [30]. Second, our design included senior physician pairs with expertise in ID and peri-operative medicine, who are not involved in decision-making in our institution. A second analysis of the

clinical vignettes was performed in cases of disagreement between the pairs. This guarantees a high level of consistency in the responses of experts.

Certain limitations of this study also need to be acknowledged. The retrospective design represents a limitation but reflects real life. The expert pairs who assessed the clinical vignettes could have different interpretations of the guidelines, but only 16 out of the 232 vignettes did not reach a consensus in the pairs. The study was performed in a single institution, which limits the generalization of the results, although they were in line with previous studies [4, 5, 22]. Our study did not detail surgical antibiotic prophylaxis. However, one should note the surgical antibiotic prophylaxis is a critical step in the management of surgical patients. Here we found no associations between the use of a surgical antibiotic prophylaxis and the compliance to good rules for a curative antimicrobial treatment. Another limitation is the cause of death on day 28. Indeed, we did not collect this variable. Therefore, we can only describe an association, not causation, because the cause of death may differ from lack of compliance. Finally, the sample size was not exactly as expected.

In conclusion, among the four criteria reflecting AMS in surgical wards, the compliance rates ranged from 91% for indication alone to 33% for all four criteria. Using a composite endpoint reflecting outcomes, our results suggested an association between compliance with adequate prescription of antibiotics and improved outcomes. These findings, which need to be confirmed in multicenter studies, invite the implementation of AMS in surgical wards.
<figure><img src="image_4.png" /><figcaption>**Fig. 2** Factors associated with the composite criteria for outcome. An odds ratio below 1 was associated with improved outcomes</figcaption></figure>

**Supplementary Information**

The online version contains supplementary material available at https://doi.org/10.1186/s13017-025-00636-0.

Supplementary Material 1

Supplementary Material 2

Supplementary Material 3

**Acknowledgements**

Not applicable.

**Author contributions**

SG, NM, CE and ML conceived the studyFA and NM conducted the analysisSG and NM collected the dataSG, NM and ML drafted the initial manuscriptAB, BP, MB, FD, DM, VM, MP, RG, MG, and LM assessed the data and reviewed the final manuscriptPA, CB, PHR, XBD, and SVB participated to the collection of data and reviewed the final manuscriptGB reviewed the content of the initial manuscriptAll authors reviewed the manuscript.

**Funding**

The study did not receive any funding.

**Data availability**

The corresponding author can send data on reasonable request.

**Declarations**

**Ethic statement**

The study received approval from our ethics committee (CERAR IRB 00010254-2023-059) and was registered by our institution (APHM) under the number 2019-01 PADS23-123. The patients were informed about the study, and a non-opposition consent was obtained from each patient.

**Competing interests**

The authors declare no competing interests.

**Author details**

¹Department of Anesthesiology and Intensive Care Unit, Nord Hospital, Assistance Publique Hôpitaux Universitaires de Marseille, Marseille 13015, France

²Data scientist Department, Department of Medical Informatics, CHU Timone, Marseille 13005, France

³Infectious Disease Unit, La Pitié-Salpétrière University Hospital, AP-HP University of Paris, Paris 75013, France

⁴CHU Nantes, Department of Anesthesiology and Intensive Care Unit, Nantes University, Nantes 44000, France

⁵Department of Anesthesiology and Critical Care and Burn Unit, Assistance Publique - Hôpitaux de Paris (AP-HP), Groupe Hospitalier St Louis-Lariboisière, Paris, France

⁶University Paris Cite, Paris, France

⁷Institut National de la Santé et de la Recherche Médicale (INSERM), INSERM UMR-S 942 Mascot, Lariboisière Hospital, Paris, France

⁸INI-CRCT Network, Nancy, France

⁹FHU PROMICE, Paris, France

¹⁰Intensive Care Unit, Centre Hospitalier Yves Le Foll, Saint Brieuc, France

¹¹INSERM, Rennes CIC 1414, France
¹²Département d'Anesthésie-Réanimation et Médecine Périopératoire, CHU de Clermont-Ferrand, Clermont-Ferrand 63000, France

¹³Infectiologie Transversale, Réanimation Ollier, CHU Cochin, Paris, France

¹⁴Department of Anesthesiology and Critical Care, Paoli-Calmettes Institute, Marseille 13009, France

¹⁵Service des Maladies Infectieuses et Tropicales, Centre Hospitalo-Universitaire de Nice, Hôpital Archet 1, Nice 06202, France

¹⁶Division of Anesthesia, Critical Care, Pain and Emergency Medicine, UR-UM103 IMAGINE, University of Montpellier, Nimes University Hospital, Nimes, France

¹⁷Infectious and Tropical Diseases Department, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France

¹⁸Department of Vascular Surgery, Nord Hospital, Assistance Publique Hôpitaux Universitaires de Marseille, Aix Marseille University, Marseille, France

¹⁹Department of Urology, Nord Hospital, Assistance Publique Hôpitaux Universitaires de Marseille, Aix Marseille University, Marseille, France

²⁰Department of General Surgery, Nord Hospital, Assistance Publique Hôpitaux, Universitaires de Marseille, Aix-Marseille University, Marseille 13015, France

²¹Department of Thoracic Surgery, Diseases of the Esophagus and Lung Transplantation, Assistance Publique-Hôpitaux de Marseille and Aix-Marseille University, Hôpital Nord, Marseille 13015, France

²²Aix-Marseille University, Assistance publique des hôpitaux de Marseille, Institut du mouvement et de l'appareil locomoteur, Marseille 13015, France

²³AP-HM Hôpital Nord, Marseille 13015, France

²⁴Department of Neurology, Nord Hospital, Assistance Publique Hôpitaux Universitaires de Marseille, Aix Marseille University, Marseille 13015, France

²⁵CPIas, Centre Hospitalo-Universitaire de Nantes, Nantes, France

²⁶Comité de Lutte contre les Infections Nosocomiales (CLIN), Hôpital Nord, Marseille 13015, France

²⁷Unité des Virus Émergents (UVE: Aix-Marseille Univ, Università di Corsica, IRBA), IRD 190, Inserm 1207, Marseille, France

²⁸Aix Marseille University, Marseille, France

²⁹Service d'anesthésie et de réanimation, Chemin des Bourrely, Hôpital Nord, Marseille 13015, France

Received: 18 February 2025 / Accepted: 12 July 2025

Published online: 19 July 2025

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