Antibiotics in Anesthesiology

Antibiotics are powerful medications that fight bacterial infections by either killing bacteria or keeping them from reproducing.¹ Some well-known bacterial infections that can be treated with antibiotics include pneumonia, tuberculosis, sinusitis, urinary tract infections and sexually transmitted diseases.² They do not fight infections from viruses, such as colds or coughs, the flu, bronchitis and sore throats (except those caused by Group A streptococcus).¹ Despite historical views of antibiotics like penicillin as “wonder drugs,”³ their misuse and overuse can lead to antibiotic resistance, in which certain strains of bacteria no longer respond to antibiotics.⁴ Anesthesia providers frequently administer antibiotics to prevent postoperative infections.⁵ Thus, anesthesiology professionals must be knowledgeable about the importance of antibiotics in anesthesia care, the need for adequate training on antibiotics and the potential harms of antibiotic use.

Anesthesia providers are routinely involved in the provision, but not selection, of preoperative antibiotics.⁶ This is likely because the prevention of infections at surgical sites is highly dependent on the timing of antibiotic administration, and anesthesia providers are well-positioned to administer antibiotics at an appropriate time.⁶ Depending on the risk of infection for the procedure,⁷ the anesthesiology professional will administer prophylactic antibiotics during the immediate preoperative and intraoperative periods.⁵ By administering the antibiotic, the anesthesia provider can also take away burden from floor nurses, prevent delays to the operating room and reduce errors of omission by clarifying the antibiotic type with the surgeon.⁸ Antibiotic administration can be crucial for procedures with high infection rates, as surgical site infections increase the duration of hospital stay and total hospital expenses.⁷

The anesthesiology professional’s role includes determining the appropriate dosage of the antibiotic, which is a complicated endeavor.⁷ Decisions about antibiotic type and dosing are tailored to the surgical procedure and the individual patient based on age, size, renal function, allergies and more.^7,9 Several articles by different anesthesia providers address their discomfort with their level of training in antibiotic therapy.^5,7,9,10 A survey study by Warters et al. found that in general, anesthesiologists felt they had inadequate education in antibiotic therapy.⁶ According to Marymont et al., current anesthesiology residency programs do not impart the knowledge required to make the anesthesiologist responsible for appropriate dosing.⁹ This education gap can cause anesthesia providers to perform tasks and make complex decisions outside of their comfort zones.⁷

Antibiotics can also prevent a variety of harms that make antibiotic administration more complex or risky. For example, patients can have sensitivities or allergies to antibiotics.⁷ Thus, the anesthesia provider must be sure the patient has performed an antibiotic sensitivity test before the procedure.⁷ If testing has not occurred, the anesthesia provider can perform a scratch or puncture test before more definitive intradermal testing.⁷ Additionally, antibiotics can interact with anesthetic drugs in a variety of ways, with the most severe interactions resulting in organ toxicity.⁵ According to a paper by Kang, most antibiotics can cause neuromuscular blockade alone and can also potentiate blockade when combined with neuromuscular blockers.¹¹ The anesthesia provider must be aware of side effects associated with antibiotic therapy before administering antibiotic or anesthetic drugs.⁵

Another debate about anesthesia providers’ use of antibiotics stems from a potentially global problem: antibiotic resistance. Antibiotic resistance occurs when a bacterium has changed slightly to protect itself or neutralize a medication.⁴ Then, this bacterium is able to multiply and pass on its resistant properties, resulting in a bacterial population that is partially or completely resistant to antibiotic medication.⁴ According to the Centers for Disease Control and Prevention (CDC), up to one-third to one-half of antibiotic use in humans is unnecessary or inappropriate.⁴ This applies to anesthesiology as well, as various studies have shown that antibiotic prophylaxis is not indicated for procedures with low infection rate.⁷ In these cases, the risk of adverse medication reaction or antibiotic resistance is higher than the expected benefit of antimicrobial treatment.⁷ As the CDC moves forward with initiatives to prevent antibiotic resistance, anesthesia providers may have to alter their use of antibiotics.¹²

Antibiotics are commonly used to fight postoperative infections. Because of anesthesia providers’ role in medication administration, they are well-positioned to give antibiotic therapy. However, many anesthesiologists do not feel properly trained in the provision of antibiotics. Antibiotic therapy can be complicated and is associated with several interactions and side effects, including bacterial resistance. Leaders in the field should provide anesthesiology professionals with more training in antibiotic therapy⁷ and standardized protocols for antibiotic provision.^6,13

1. Antibiotics. MedlinePlus. Bethesda, MD: National Institutes of Health; April 18, 2019.
2. Felman A. Everything you need to know about infections. Medical News Today August 22, 2017.
3. Microbiology Society. The history of antibiotics. Antibiotics and antibiotic resistance 2020; https://microbiologysociety.org/members-outreach-resources/outreach-resources/antibiotics-unearthed/antibiotics-and-antibiotic-resistance/the-history-of-antibiotics.html.
4. Mayo Clinic. Antibiotics: Are you misusing them? Consumer Health: In-Depth January 18, 2018; https://www.mayoclinic.org/healthy-lifestyle/consumer-health/in-depth/antibiotics/art-20045720.
5. Cheng EY, Nimphius N, Hennen CR. Antibiotic therapy and the anesthesiologist. Journal of Clinical Anesthesia. 1995;7(5):425–439.
6. Warters RD, Szmuk P, Pivalizza EG, Gebhard RE, Katz J, Ezri T. The Role of Anesthesiologists in the Selection and Administration of Perioperative Antibiotics: A Survey of the American Association of Clinical Directors. Anesthesia & Analgesia. 2006;102(4):1177–1182.
7. Tewari A, Garg S, Kaul Tej K. Anesthesiologists and Perioperative Antibiotic Prophylaxis. Anesthesiology: The Journal of the American Society of Anesthesiologists. 2004;101(1):259.
8. Roth Jonathan V, M.D. More Reasons Why Anesthesiologists Should Administer Preoperative Antibiotics. Anesthesiology: The Journal of the American Society of Anesthesiologists. 2004;101(1):258–259.
9. Marymont J, Vender JS, Novak T, Katz J, Silk V. Antibiotics and the Anesthesiologist: Is There a “Consensus?”. Anesthesia & Analgesia. 2017;125(3):1080.
10. Warters RD, Szmuk P, Pivalizza Evan G, Gebhard R, Ezri T. Preoperative Antibiotic Prophylaxis: The Role of the Anesthesiologist. Anesthesiology: The Journal of the American Society of Anesthesiologists. 2003;99(2):515–516.
11. Kang J-M. Antibiotics and muscle relaxation. Korean Journal of Anesthesiology. 2013;64(2):103–104.
12. National Center for Emerging and Zoonotic Infectious Diseases (NCEZID) Division of Healthcare Quality Promotion (DHQP). What CDC is Doing: Antibiotic Resistance (AR) Solutions Initiative. Antibiotic / Antimicrobial Resistance (AR / AMR) November 4, 2019; https://www.cdc.gov/drugresistance/solutions-initiative/.
13. Mutlak H, Maurer O, Zacharowski K, Schön J, Jacob M, May M. An anesthesia perspective on surgical antibiotic prophylaxis: Results of a comprehensive infectiology survey study in German hospitals. American Journal of Infection Control. 2019;47(2):222–223.