EP113 - Rethinking Antibiotic use in Anorectal Surgery: Reducing Waste, Costs, and Infections through guideline adherence

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Purpose/Background: Surgical site infections after anorectal procedures are rare, making routine antibiotics prophylaxis unnecessary. Guidelines recommend prophylactic antibiotic only for patients with rectal abscesses with cellulitis, sepsis, or immunosuppression. Despite this, prophylactic antibiotics continue to be used outside of these criteria.

Methods/Interventions: A retrospective chart review was conducted at a safety-net hospital from January 2022 to March 2023. The study included patients who underwent procedures for fistulas, hemorrhoidal disease, abscess, and soft tissue lesion. Cases involving pilonidal disease, colonoscopies, flexible sigmoidoscopies, and major colorectal surgeries were excluded. Antibiotic costs were obtained from the institutional pharmacy, and waste was estimated by weighing materials used for administration.

Results/Outcomes: A total of 336 patients were identified. Of these, 26% (n=82) underwent seton placement, 20% (n=67) fistulotomy, 15% (n=51) hemorrhoidectomy, 13% (n=42) excision/fulguration of condyloma, 9% (n=31) incision and drainage of perirectal abscess, 8% (n=26) ligation of an intersphincteric fistula tract, 7% (n=22) biopsy of the anal canal/perianal mass, 2% (n=6) hemorrhoid ligation, 1% (n=5) sphincterotomy, 0.3% (n=1) advancement flap, 0.3% (n=1) fistula plug placement, and 0.3% (n=1) rectal ulcer biopsy. 

Of the entire cohort, 20% (n=66) had an indication for preoperative antibiotics, 14% (n=47) were immunosuppressed, and 6% (n=19) had systemic manifestations of infection. Antibiotics were administered to 12% (n=39) of patients, with 1% (n=4) receiving an additional intraoperative dose. Of these, 21% (n=8) had an indication, and 79% (n=31) did not. Among those receiving antibiotics with indication, 38% (n=3) had systemic manifestations of infection, and 63% (n=5) were immunosuppressed. 

Of the entire cohort, 30-day postoperative infection occurred in 1.2% (n=4). Of these, 2 patients had systemic manifestations of infection, 1 received antibiotics without indication, and 1 did not receive antibiotics. No infection occurred among immunosuppressed patients. 

Cefoxitin was used in 9% (n=29) of cases, followed by cefazolin 2% (n=8), ceftriaxone 0.9% (n=3), clindamycin 0.3% (n=1), and meropenem 0.3% (n=1). Adherence to guidelines could have saved $399.51 and prevented 5.6 pounds of waste over 15 months.

Conclusion/Discussion: A notable proportion of patients received antibiotics without appropriate indication, while many who met the criteria did not. Adherence to guidelines could prevent unnecessary treatments, reduce medical waste and improve patient outcomes. Enhancing interdisciplinary communication, particularly in emergency settings is essential for optimizing antibiotic stewardship. These findings highlight the need for more precise practices to improve patient care and resource efficiency.