Surgical Infection & Antimicrobials — Prophylaxis, cIAI, Source Control, NSTI, C. difficile, Stewardship

The infected laparotomy undoes the operation — so learn antimicrobials as timing at the start and discipline at the end: prophylaxis in the tissues before the knife with nothing after closure, brief broad cover for intra-abdominal infection once the source is controlled, debridement within hours for necrotizing infection under broad empiric cover, the C. difficile ladder climbed to transplant before colectomy, and every dose between chosen by stewardship and local resistance data.^{[3][22][45][56][58][63]}

A 58-year-old man has a Hartmann's procedure for Hinchey III diverticulitis with faecal peritonitis: hypotensive, lactate rising, on broad-spectrum cover. The examiner will ask when his antibiotics should have started and when they must stop, whether his source control can wait until morning, what his bundle compliance buys, how short his postop course can be, and what you do when his perineal wound necrotises on day 3 or his diarrhoea turns out to be C. difficile on day 9. This page teaches each answer with every number taken from the paper named beside it.^{[22][25][41][45][56]}

SSI Burden & Guideline Architecture — preventable yet unmoved

Surgical-site infection complicates up to 10-20% of operations with considerable strain on healthcare resources — and is probably the most preventable of the healthcare-associated infections.^[4][5] About half of SSIs are deemed preventable using evidence-based strategies, which is the CDC-2017 headline number and the reason prophylaxis discipline matters.^[3] The WHO built the global frame: 13 preoperative recommendations from systematic reviews plus expert consensus, then 16 intraoperative and postoperative ones, assembled because no international guidelines existed and national ones disagreed.^[1][2] Yet level-I guidelines from NICE in the UK and the SCIP programme in the USA have not measurably moved SSI rates — compliance, not knowledge, is the gap, and heterogeneous bundle composition limits every pooled conclusion.^[5]

Prophylaxis — Timing, Choice, Stop

Time prophylaxis to the incision three compatible ways: start within 30 minutes of the incision, give IV prophylaxis 30-60 minutes before incision time, and meet the WHO window of 60-120 minutes before the knife — all three rules serve one pharmacology, bactericidal concentrations in serum and tissues when the incision is made.^[6][8][9] At induction of anaesthesia, about 30 minutes before incision, is the practical anchor most teams use.^[7] Choose the drug against the procedure's pathogens: the agent must be effective against the organisms that cause infection after that given operation, which is why the first-generation cephalosporin cefazolin became a prophylactic drug of choice in many guidelines.^[7] Keep courses short on purpose: prophylaxis should be brief to decrease toxicity, antimicrobial resistance, and excess cost — and should not exceed 24 hours for the majority of procedures.^[8][6] A single preoperative dose suffices for most operations, with no proven benefit from multiple-dose regimens over single-dose ones.^[7][6] Compliance is the viva's weak point: in the Liberian audit only 20.3% of cases met SAP timing, and among Class I general-surgery cases just 12.5% were guideline-compliant — indication plus timing are the two gates to audit first.^[9]

Then stop. For clean and clean-contaminated procedures, no further antimicrobial doses after the surgical incision is closed in the operating room — even with a drain in place.^[3] Continuing prophylaxis postoperatively is not safety but selection pressure, and prescribing audits find prophylaxis for SSI prevention suboptimal despite universal acceptance — for want of protocols, knowledge, communication, logistics, and audit.^[66]

Bundles & Organ-Space SSI — the Repaired Half

In colorectal surgery, bundles cut overall SSI by 44% (risk ratio 0.57), superficial by 44%, deep by 33%, and organ-space by 37% — across 35 studies and 54,221 patients, but with only three randomised trials.^[12] The parallel synthesis agrees: 40% overall reduction with 44% superficial and 34% organ-space cuts — and names the elements that track the deepest cuts, sterile closure trays, bowel preparation with oral antibiotics, and pre-closure glove changes.^[10] Expect about eleven interventions per bundle spanning pre-, intra-, and postoperative phases; phase-grouping and compliance beat adding elements.^[11] For the examiner's mechanism question: bowel preparation combined with oral antibiotics, plus preoperative chlorhexidine showers, correlate with the highest organ-space reductions — while separate trays with glove-gown change track the superficial ones.^[12]

Rank bowel preparation honestly from the 10-trial, 5,107-patient network meta-analysis: IV antibiotics plus oral antibiotics rank first and mechanical preparation plus IV plus oral rank second, cutting incisional SSI by more than half — with no difference between strategies for anastomotic leak.^[13] The triclosan footnote belongs here briefly, with closure detail fenced to wound-healing: in colorectal surgery the pooled SSI rate ran 6.90% coated versus 9.11% uncoated (odds ratio 0.62, confidence interval crossing unity), with benefit confined to monocentric trials and reversed in multicentre ones.^[14]

cIAI — Guidelines & Empiric Principles

Name the lineage. The SIS/IDSA expert panel replaced the 2002/2003 guidance with evidence-based recommendations for patients with, or at risk of, intra-abdominal infection — adding children, all-age appendicitis, and neonatal necrotising enterocolitis where management differs.^[15] The 2024 IDSA update contributes 21 GRADE recommendations spanning risk assessment, diagnostic imaging, and microbiological evaluation in adults, children, and pregnant people.^[16] The SIS 2024 update covers agent selection, timing, route, duration, de-escalation, source-control timing, specific pathogens and disease processes, and hospital stewardship programmes.^[17] The WSES 2013 guidelines stand as the emergency-surgery counterpart — written because complicated intra-abdominal mortality remains exceedingly high despite better diagnosis, surgery, and drugs.^[18] Behind all of them sits the grading method: recommendations most commonly follow randomised comparative trials, with observational reports and expert opinion in lesser roles.^[20] The two traditions met early: the 2010 SIS-IDSA guidance and the WSES Bologna consensus now read as complementary literature, not rivals.^[21]

Prescribe empiric therapy by one rule: broad enough to cover all likely organisms, because inappropriate initial therapy worsens patient outcomes and develops bacterial resistance.^[28] Base the choice on community versus hospital acquisition, local resistance, and the patient's characteristics and comorbidities — then adjust or de-escalate as soon as microbiology returns.^[31] The Prague warning justifies the breadth: among 592 cIAI patients, E. coli resistance to amoxicillin-clavulanate rose 28.7% to 37.5%, to piperacillin-tazobactam 25% to 32%, and to third-generation cephalosporins 2.3% to 5.6% between 2014 and 2017.^[30] The newer agents answer defined gaps: ceftolozane-tazobactam stays highly active against multidrug-resistant P. aeruginosa including carbapenem-resistant isolates, and both it and ceftazidime-avibactam sit inside current WSES guidance.^[30] Run the whole programme through stewardship: optimising prescriptions improves effectiveness and safety while minimising C. difficile and resistance selection — the Italian council's 23 antimicrobial recommendations exist for exactly that trade.^[29] The AGORA alliance of 79 countries says the same at planetary scale: timely effective source control with appropriate antimicrobials, and prescribing behaviour as the intervention.^[28] In theatre, add the WSES intraoperative position: wound protectors and antibacterial sutures seem effective in intra-abdominal infection, normothermia should be pursued with available resources, and pharmacokinetic-pharmacodynamic knowledge should decide intraoperative redosing.^[19]

cIAI Duration — the Short Course

After definitive source control, stop early. EAST pooled 16 short-versus-long studies — short averaging 4 days (range a single dose to 10 days) against long averaging 8 days (range over a day to 28) — and found no differences in mortality (odds ratio 0.90), SSI (0.88), persistent or recurrent abscess (0.76), unplanned interventions, length of stay, or readmissions.^[22] The recommendation follows the data: four or fewer days versus eight or more in adults with definitive source control — explicitly at very low evidence quality, which is itself worth stating in the viva.^[22] The GAIS survival guide generalises the principle: short-duration therapy dosed by pharmacokinetics and pharmacodynamics inside a stewardship frame, with fluids and vasopressors for the critically ill alongside — not instead of — antibiotics.^[23] Appendicitis converges on the same answer from two societies: SAGES conditionally favours short-term postoperative antibiotics for complicated appendicitis, and WSES-2025 limits postop therapy to short 2-3-day courses in complicated disease.^[35][36]

Source Control — Timing Principles & Failure

Intra-abdominal infection is deadly precisely because one item on its treatment list belongs to surgeons alone: urgent diagnosis, fluids, antibiotics with labs pending, haemodynamic measurement — and source control, which makes abdominal sepsis a unique treatment challenge.^[25] Delayed or inadequate source control independently predicts poor outcomes, and recognising failure is often difficult or impossible — so the timing, adequacy, and procedure debates are genuine, not rhetorical.^[25] Intra-abdominal infections are the second most common sepsis-related death with hospital mortality of 23-38%, and source control means reducing microbial load by every available route: resection of the focus, percutaneous drainage and toilette, decompression, debridement, device removal, with anatomy restored.^[24] In peritonitis specifically, late diagnosis and delayed care dramatically raise mortality — delayed source control and late anti-infective therapy are of critical importance, with organ-failure signs outweighing biological surrogates at the bedside.^[37]

Choose on-demand over planned relaparotomy when the system allows it: the randomised trial preferred relaparotomy on demand irrespective of peritonitis severity — but only with round-the-clock monitoring, imaging, and decision-making guaranteed.^[38] Admit the honest controversy: surgical intervention is essential yet the time-point of source control remains controversially discussed — rapid diagnosis undisputed, timetable contested.^[39] Frame the disease in Sepsis-3 language for the intensivist examiner: life-threatening organ dysfunction from a dysregulated host response, with the 2016 campaign update demanding rapid diagnosis and standardised therapy.^[26] Reserve damage control — deferred anastomosis with temporary closure reaching near-90% fascial-closure rates — as a paradigm shift still awaiting controlled proof of benefit.^[27]

Sepsis Bundles in Surgical Patients — Start Fast, Stay Honest

Sepsis-3 replaced SIRS-based diagnosis with SOFA-based prognosis, and surgeons own two bundle items nobody else can deliver: adequate source control and carbapenem-resistance awareness with rapid MDRO diagnostics and multidisciplinary alerting.^[40] The STOP-IT trial challenged the long-course paradigm while procalcitonin now individualises stopping — start bundled, finish personalised.^[40] The Hour-1 bundle standardises the opening moves around rapid diagnostics and therapeutics; early effective antimicrobials remain strongly outcome-linked, though stewardship tension is real — and the strict one-hour completion evidence stays heterogeneous with variable real-world compliance.^[41]

Then teach the two surgical-bundle trials as a matched pair. In South Africa, 677 surgical-sepsis patients (53% intra-abdominal) managed 56% 3-hour-bundle compliance with no mortality difference — 15% compliant versus 10% non-compliant deaths — so compliance alone did not explain outcomes in that setting.^[42] In Thailand, 401 surgical patients gained median survival after one-hour-bundle implementation, with three clock thresholds predicting death: fluids delayed beyond 2 hours, pressors beyond 2 hours, and empirical antibiotics beyond 5 hours.^[43] Around theatre, the anaesthetist's hour-1 framework covers recognition, ultrasound-guided haemodynamics, and handover between operating room and intensive care — resuscitation detail itself fenced to the shock and fluids topics.^[44]

NSTI — Recognition & Diagnosis

Necrotising soft-tissue infections are heterogeneous in microbiology, risk factors, and anatomy, present nonspecifically with frequent diagnostic delay — and the diagnosis stays clinical: explore on high suspicion and accept a negative-exploration rate.^[45] Incidence has risen while morbidity and mortality stay high; poor awareness delays first debridement and amplifies severity — so alertness and early referral to specialised centres are themselves therapy.^[46] Expect variability despite guidelines: antibiotic choice and duration, debridement timing, and adjuvant use all vary between centres.^[47] Quantify the tools without over-trusting them: fever is 46.0% sensitive and 77.0% specific, haemorrhagic bullae 25.2% and 95.8%, hypotension 21.0% and 97.7% — no single physical sign rules NSTI out.^[49] CT (88.5% sensitive, 93.3% specific) beats plain radiography (48.9%, 94.0%), while LRINEC at 6 (68.2%/84.8%) and at 8 (40.8%/94.9%) is too insensitive to exclude disease.^[49] Use LRINEC for its designed job — distinguishing cellulitis that responds to medical management from NSTI that needs operative debridement plus antimicrobials — since imaging otherwise adds little.^[50] Rates run 0.86 to 32.64 per 100,000 person-years with climate and seasonal influence, across polymicrobial, GAS, S. aureus, Gram-negative, and post-trauma fungal types — with intraoperative tissue culture as the diagnostic gold standard.^[51] The WSES/SIS-E Bertinoro consensus gathers the whole team — general and emergency surgeons, intensivists, infectious-disease specialists — around exactly these infections.^[55]

NSTI — Treatment: Debride Early, Cover Broadly

Debride early and keep going back: ideally within 6 hours of presentation, certainly within 12 — mortality 14% early versus 25.8% late — with re-debridement every 12-24 hours until improvement with no remaining necrotic tissue.^[45][54] The mainstay is early complete surgical debridement combined with antimicrobial therapy, close monitoring, and physiologic support — surgery plus drugs, never drugs alone.^[50] Start immediate empirical broad-spectrum antibiotics covering Gram-positive, Gram-negative, anaerobes, and S. pyogenes when indicated; tailor on tissue cultures; continue at least until debridement is complete with clinical improvement.^[45][53] Select the empiric regimen by infection site, healthcare versus community origin, ESBL and MRSA risk, and shock signs — with beta-lactam-allergy alternatives prepared and special plans for immunocompromised hosts.^[53] After complex-abscess drainage, adjuvant antimicrobials gain support alongside alternative agents per the SIS 2020 update.^[48] For Fournier's gangrene specifically, skin-sparing debridement proves feasible with better primary closure and lower cost, layered with targeted antibiotics, antimicrobial solutions, and negative-pressure wound care.^[52] Refuse routine adjuncts: data are insufficient for routine hyperbaric oxygen or intravenous immunoglobulin, their effects stay controversial — though both might have a role in selected patients, which is a trial question, not a prescription.^[45][50][51]

C. difficile in Surgical Patients — the Ladder

Scope the disease first: the commonest nosocomial diarrhoea, shaped by hypervirulent 027-ribotype outbreaks, toxin A/B colitis from mild diarrhoea to fulminant megacolon and perforation — with antibiotics, advanced age, hospitalisation, and proton-pump inhibitors as the risk set.^[57] ESCMID's 2021 ladder is the prescription to memorise: metronidazole is no longer recommended when fidaxomicin or vancomycin are available; fidaxomicin is preferred for initial disease and first recurrence when feasible; faecal transplant or bezlotoxumab join standard antibiotics from the second recurrence — graded by GRADE across cure, recurrence, sustained cure, and mortality endpoints.^[56] Newer options keep arriving with higher-level evidence — fidaxomicin, transplant, monoclonal antibodies — chosen by severity, comorbidity, recurrence risk, and cost.^[62]

For severe and fulminant disease the stakes invert: colectomy or diverting loop ileostomy with lavage carries post-surgical mortality approaching 30%, while faecal transplantation cures 70-90% with less death and fewer colectomies — favour transplant, especially in the elderly comorbid patient who cannot survive resection.^[58] Know the special populations at viva depth: immunocompromised incidence runs 6-33% in haemato-oncology and up to 23% in lung transplant with 7.1-8.3 per 1,000 patient-years in HIV, and recurrence reaches 40% — driven by antimicrobials, immune suppression, healthcare exposure, and colonisation.^[59] In inflammatory bowel disease specifically, fidaxomicin held recurrence to 10% at 8 weeks with 82% sustained response at 12 weeks.^[60] At the bedside of pseudomembranous colitis — pain, diarrhoea, fever, leucocytosis with yellow-white plaques — stool testing plus empiric antibiotics start on suspicion, endoscopy with biopsy follows when tests are negative but symptoms escalate, and surgeons enter for perforation, gangrenous colon, or severe disease.^[61]

Stewardship & Prescribing — the Machinery

Start from the uncomfortable denominator: massive ICU antibiotic consumption drives resistance dissemination — yet up to half of empirically treated ICU patients have no confirmed infection, while de-escalation and shortening are underused in documented sepsis.^[63] Build the machinery every hospital needs: an infectious-diseases-led multidisciplinary team running prospective audit with handshake feedback, formulary restriction with preauthorisation, education, de-escalation promotion, rapid diagnostics, and infection prevention.^[64] In abdominal surgery the payoff is concrete: prophylaxis significantly cuts postoperative infections while multidrug-resistant bacteria complicate therapy — so local susceptibility patterns must choose the empiric regimen.^[65] Most prescribing errors cluster on selection and duration — low thresholds, delayed starts, ignored local resistance, wrong dose-route-drug, missing de-escalation — with surgical prophylaxis suboptimal despite acceptance, for want of protocols, knowledge, communication, logistics, and audit.^[66]

Resistance & Targeted Prophylaxis — Know Your Enemy

Set the baseline: SSI complicates about 5% of operations, S. aureus from the patient's own skin is the commonest isolate, and resistant organisms are the growing concern — with MRSA, polymicrobial flora, and fungi reshaping postoperative microbiology across 4,002 general-surgical patients.^[68][71] For multidrug-resistant Gram-positive carriers, ESCMID recommends screening S. aureus before high-risk surgery, decolonisation with intranasal mupirocin with or without chlorhexidine bathing (recommended before cardiothoracic and orthopaedic surgery, suggested elsewhere), and adding vancomycin to standard prophylaxis for MRSA carriers in cardiothoracic, orthopaedic, and neurosurgery — with combined decolonisation plus targeted prophylaxis suggested, and no VRE recommendation for lack of data.^[67] The African meta-analyses justify local antibiograms over imported protocols: S. aureus in 29% of wound/SSTI/SSI samples with MRSA above 40%, and anti-pseudomonal carbapenem resistance at or above 20% in P. aeruginosa and A. baumannii.^[69] Endemic healthcare-associated infection sits at a median 15% prevalence, with contaminated wounds (odds ratio 1.75), urinary and vascular catheters, and ventilation among the risk factors — and E. coli the commonest isolate.^[70] Remember where resistance is born: 65% of resistant Gram-negative surgical-ICU infections strike while receiving antibiotics, including the sensitive form of the later-resistant pathogen in 42% — prior antibiotic exposure is the history that predicts the next organism.^[72]

Disease-Specific Antibiotics & the Leak–MDR Interface

Perforated peptic ulcer condenses the whole topic into one GRADE sentence: prompt recognition, resuscitation when required, appropriate antibiotic therapy, and timely surgical or radiological treatment.^[32] Appendicitis spans the WSES generations: the 2020 Jerusalem update organises diagnosis, nonoperative management with antibiotics, laparoscopy and technique, intraoperative scoring, and perioperative antibiotic therapy — with nonoperative-plus-antibiotics and perioperative cover as the antimicrobial core.^[33] In the elderly the disease differs — higher mortality, perforation, diagnostic difficulty, delay, complications, and cancer risk — but the four statement domains (diagnosis, nonoperative, operative, antibiotic therapy) transfer intact.^[34] SAGES conditionally favours operating (delayed beyond 12 hours or immediate), suction with or without lavage, no routine drains, short-term postoperative antibiotics for complicated disease, and interval appendectomy after initially nonoperative complicated cases.^[35] WSES-2025 sharpens the numbers: scores plus imaging cut negative appendectomy, nonoperative antibiotics stay safe and effective in selected uncomplicated cases, operation waits safely within 24 hours, laparoscopy remains standard, postop antibiotics stop at 2-3 days in complicated disease, and nonoperative complicated abscesses need follow-up for neoplasms.^[36]

At the anastomotic-leak interface, state the honest evidence position first: no general-surgery-applicable leak-antibiotics-duration trial survived triage — the split repair for that angle returned empty, and this topic claims no duration it cannot source. What the literature does support is the MDR consequence: among 6,767 colorectal-cancer operations, 190 leaks (2.8%) with 143 cultured, 46 (32.2%) grew multidrug-resistant bacteria — predicted by antibiotics beyond 5 days before leak diagnosis and by diabetes, with adequate initial empiric cover achieved in only 35% of MDR cases versus 75% otherwise, plus longer antibiotic courses and hospital stays.^[74] The lesson is de-escalation's mirror image: cover adequately at once, then stop early — because each extra pre-diagnosis antibiotic day buys the resistance that defeats the empiric regimen. Leak biology itself is fenced to wound-healing.^[74]

Postoperative Fever & Honest Scope Limits

Postprocedure fevers vary in timing, duration, and severity; they are not all infectious — yet all require thorough investigation excluding life-threatening causes, which is the emergency-provider principle to carry onto the ward.^[73] Two scope limits close the topic honestly, and the examiner respects stated limits over invented coverage. First, no general-surgery-applicable post-laparotomy pneumonia or urinary-tract-infection prevention trial survived triage — the pneumonia/UTI angle returned cardiac, transplant, dialysis, obstetric, and textbook records, none transferable to the laparotomy patient — so this topic teaches fever principles only and fences pneumonia/UTI prevention elsewhere.^[73] Second, as above, no anastomotic-leak antibiotics-duration trial exists in transferable form.^[74] What survives both limits is the antimicrobial core this topic does own: time prophylaxis to the incision and stop at closure, treat cIAI briefly after source control, debride NSTI within hours under broad cover, climb the C. difficile ladder to transplant before colectomy, and let stewardship with local resistance data choose every dose between.^{[3][22][45][56][63][67]}

Exam Synthesis & Fence Map — what this topic owns

This topic owns seven things and fences everything else: prophylaxis choice, timing, and duration at class level; empiric selection, duration, and de-escalation for cIAI, NSTI, and surgical C. difficile; cIAI management with source-control timing principles; NSTI recognition and management; C. difficile in surgical patients; stewardship and resistance strategy; and organ-space SSI prevention at antimicrobial level.^{[3][17][22][25][45][56][63]} Wound-level closure, sutures, NPWT, and leak biology belong to wound-healing; source-control execution to surgical-sepsis; resuscitation bundles with fluids to postoperative-sepsis and fluids-electrolytes; pressors, MAP, and lactate to shock-surgical; ventilation to ards-surgical; KDIGO and dialysis timing to acute-kidney-injury-surgical; feeding to icu-nutrition-surgical; blood products to massive-transfusion and damage-control-resuscitation; SOFA trajectories to multiorgan-dysfunction; compartment management to abdominal-compartment-syndrome; gap and lactate logic to acid-base-balance.^{[14][19][26][72]} The one-paragraph antimicrobial story for the viva: half of SSIs are preventable yet rates stand still for want of compliance; cefazolin within the hour with redosing on blood loss and nothing after closure; colorectal bundles halve SSI with bowel prep plus oral antibiotics driving the organ-space cut; cIAI treated briefly after source control per EAST with de-escalation on cultures; NSTI debrided within hours under broad cover with no routine adjuncts; C. difficile climbed from fidaxomicin to transplant before colectomy; and every empiric choice filtered through stewardship and the local antibiogram.^{[3][6][12][13][22][31][45][54][56][58][67]}

Exam Pearls — the one-liners that score

• WHO: 13 preop + 16 intra/postop recommendations; CDC-2017: half of SSIs preventable, stop prophylaxis at closure even with a drain.^[1][2][3]
• SSI hits up to 10-20% of operations yet stays the most preventable infection; guidelines plus bundles have not moved rates — audit compliance first.^[4][5]
• Cefazolin within 30 minutes (30-60 IV window, WHO 60-120), single dose suffices, never beyond 24 hours — Liberia managed 20.3% compliance.^[6][7][8][9]
• Colorectal bundles cut SSI 44% overall (RR 0.57) with 37% organ-space; IV plus oral antibiotics rank first, halving incisional SSI with no leak difference.^[12][13]
• cIAI lineage: SIS/IDSA 2010, WSES 2013, SIS 2024, IDSA 2024 (21 GRADE recs) — empiric breadth first, de-escalation on cultures, AGORA's 79-country agreement.^{[15][16][17][18][28]}
• EAST: 4 days equals 8 days (mortality OR 0.90, SSI 0.88, abscess 0.76) — recommend four or fewer days after definitive source control.^[22]
• Delayed or inadequate source control independently predicts poor outcomes; on-demand relaparotomy won the RCT but demands 24-hour systems.^[25][38]
• Hour-1 bundle standardises the start; SA surgical sepsis showed no mortality gain at 56% compliance while Thai implementation lengthened survival — fluids and pressors past 2 hours and antibiotics past 5 hours kill.^[41][42][43]
• NSTI: clinical diagnosis, CT 88.5/93.3 beats film, LRINEC cannot exclude — debride within 6-12 hours (14% vs 25.8% mortality) with re-looks every 12-24 hours under broad cover, no routine HBOT or IVIG.^[45][49][54]
• C. difficile: fidaxomicin preferred, transplant or bezlotoxumab from second recurrence; severe disease — transplant cures 70-90% against ~30% surgical mortality.^[56][58]
• Stewardship: half of ICU empiric courses lack confirmed infection — audit with handshake feedback, restrict formularies, de-escalate, use rapid diagnostics.^[63][64]
• Resistance: SSI ~5% with skin-derived S. aureus; decolonise carriers with mupirocin with or without chlorhexidine and add vancomycin for MRSA carriers; Africa MRSA above 40% — trust local data.^[67][68][69]
• Leaks grow MDR in 32.2% with only 35% adequate initial cover when antibiotics ran beyond 5 days pre-diagnosis — cover adequately at once, then stop early.^[74]
• Postop fever is not always infection but always demands life-threat workup; pneumonia/UTI prevention and leak-duration trials are honestly absent here.^[73][74]

References74ShowHide

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