Guideline-concordant antibiotic prophylaxis on surgical site infection rates following colorectal surgery: real-world data from Thailand

Prapakorn Tanyakul; Varut Lohsiriwat; Pichapat Ngarmskunroongrote; Naddanai Kaewjaidee

doi:10.3393/ac.2025.00913.0130

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Original Article Complications Guideline-concordant antibiotic prophylaxis on surgical site infection rates following colorectal surgery: real-world data from Thailand: Prapakorn Tanyakul, Varut Lohsiriwat, Pichapat Ngarmskunroongrote, Naddanai Kaewjaidee; Annals of Coloproctology 2026;42(2):208-215.
DOI: https://doi.org/10.3393/ac.2025.00913.0130
Published online: April 17, 2026

Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand

Correspondence to: Varut Lohsiriwat, MD, PhD Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wang Lung Rd, Bangkok 10700, Thailand Email: varut.loh@mahidol.ac.th

• Received: July 28, 2025 • Revised: October 23, 2025 • Accepted: November 2, 2025

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Abstract
INTRODUCTION
METHODS
RESULTS
DISCUSSION
ARTICLE INFORMATION
REFERENCES

Abstract

Purpose
Antibiotic prophylaxis (AP) is a key component in preventing surgical site infections (SSIs). The existing gap between clinical guidelines and real-world practice may influence SSI rates. This study aimed to compare SSI rates between patients receiving guideline-concordant AP based on the 2020 Thailand guideline (group A) and those receiving broader-spectrum and/or prolonged prophylaxis (group B).
Methods
We reviewed a database of adult patients who underwent elective colorectal resection between January 2022 and April 2024 at the largest university hospital in Thailand. SSIs were diagnosed using the US Centers for Disease Control and Prevention’s criteria. SSI rates between the 2 groups were compared, and factors associated with SSIs were determined.
Results
This study included 1,584 patients, with an average age of 66 years, and 822 (51.9%) were male. The most common operation was anterior resection (n=470, 29.7%). A total of 1,030 patients (65.0%) underwent open surgery, and 228 patients (14.4%) had stoma formation. There were 405 patients (25.6%) in group A. Overall, SSIs occurred in 104 patients (6.6%): 69 incisional SSIs (4.4%) and 35 organ/space SSIs (2.2%). There was no significant difference in SSI rates between groups (group A vs. group B: 4.7% [95% confidence interval (CI), 2.9%–7.2%] vs. 7.2% [95% CI, 5.8%–8.8%]; P=0.078). Multivariate analysis identified 3 independent predictors of SSIs: hypoalbuminemia (odds ratio [OR], 2.53; 95% CI, 1.54–4.16; P<0.001), obesity (OR, 1.89; 95% CI, 1.08–3.32; P=0.026), and intraoperative blood loss greater than 400 mL (OR, 1.83; 95% CI, 1.06–3.16; P=0.031).
Conclusion
There was no significant difference in SSI rates following colorectal surgery between patients receiving guideline-concordant AP and those receiving broader-spectrum and/or prolonged prophylaxis.
Keywords: Surgical wound infection; Antibiotic prophylaxis; Colorectal surgery; Guideline; Risk factors

INTRODUCTION

Surgical site infections (SSIs) are among the most significant complications following colorectal surgery and contribute substantially to prolonged hospitalization, increased healthcare costs, and poorer functional outcomes [1, 2]. According to the US Centers for Disease Control and Prevention (CDC), SSIs account for 22% of all healthcare-associated infections, and 15% are associated with colorectal procedures [3]. The reported incidence rates of SSIs following colorectal surgery reach up to 30% [4]. Furthermore, patients with SSIs have been reported to lose 0.5 to 0.6 disability-adjusted life years [5]. For these reasons, reducing SSIs after colorectal surgery has been recognized as a priority.

Antibiotic prophylaxis (AP) has been established as a major component in SSI prevention. Numerous studies have demonstrated its efficacy in reducing infection rates [6–8], particularly in colorectal surgery, where AP reduces the risk of SSIs by 13% to 39% [9]. In recent years, several organizations have published new or updated guidelines for SSI prevention, including the CDC [6], the World Health Organization (WHO) [7], the American College of Surgeons (ACS) and the Surgical Infection Society (SIS) [8], the UK National Institute for Health and Care Excellence (NICE) [10], and the Asia Pacific Society of Infection Control (APSIC) [11]. All these guidelines reaffirm the effectiveness of a single preoperative dose of AP tailored to the pathogens most likely to cause infection in that procedure. A recent international cohort study involving 5.8 million operations from 17 SSI surveillance networks worldwide demonstrated a sustained decline in SSI rates over surveillance periods, partly attributable to proper AP use [12]. In Thailand, the Surgical Infection Society of Thailand (SIST) guideline published in 2020 recommends AP with either cefazolin or cefuroxime combined with metronidazole for major colorectal procedures [13].

However, considerable variation persists in clinical practice regarding both the selection and duration of AP. A common deviation from guidelines involves the use of broader-spectrum antibiotics and/or extending AP beyond 24 hours postoperatively. A nationwide study in Thailand in 2018 revealed that the predominant AP regimen for elective colorectal surgery was ceftriaxone combined with metronidazole, representing broader-spectrum coverage. Moreover, only 10% of patients discontinued antibiotics within 24 hours after surgery, while almost 30% received antibiotics for more than 7 days postoperatively [14]. Meanwhile, the use of broader-spectrum and/or prolonged AP can increase the risk of Clostridium difficile colitis, promote antimicrobial resistance, and raise healthcare costs [15–17].

The primary objectives of this study were to determine the rate of AP use that was concordant with the national guideline (the 2020 Thailand SIST recommendation) in elective colorectal surgery, and to compare the rates of SSIs between patients receiving guideline-concordant AP and those receiving broader-spectrum and/or prolonged AP. The secondary objectives were to determine factors associated with SSIs and to analyze AP-related costs between the guideline-concordant group and its counterpart.

METHODS

Ethics statement

This study was approved by the Institutional Review Board of the Faculty of Medicine Siriraj Hospital, Mahidol University (No. Si 364/2024). Informed consent was waived due to the use of deidentified data and the retrospective nature of the study.

Study design and patients

This was a retrospective analysis of data drawn from an institutional database of adult patients (aged 18 years and older) who underwent elective colorectal resection between January 2022 and April 2024 at the Department of Surgery, Faculty of Medicine Siriraj Hospital. The exclusion criteria consisted of patients with preexisting infection, those receiving therapeutic antibiotics for any infection, such as urinary tract infection or pneumonia, emergency colorectal procedures, and anal surgery.

Data collection

Data were collected using a case record form comprising 5 parts. The first part recorded patients’ characteristics including age, sex, body mass index (BMI), American Society of Anesthesiologists (ASA) physical status, preoperative hematocrit, preoperative albumin, underlying diseases, a history of intra-abdominal surgery, and a history of abdominal or pelvic radiation. The second part recorded operative data, including the type of operation, surgical approach, operative time, intraoperative blood loss, and stoma formation. The third part recorded AP, including the antimicrobial agents used and the duration of administration. The fourth part recorded SSI data, classified as either incisional or organ/space SSIs within 30 days of postoperative surveillance. Notably, the diagnosis of SSIs was standardized based on CDC criteria [18]. The fifth part focused on AP-related costs, which included 3 components: antimicrobial agent costs, infusion set costs (฿65 or approximately US $2 per set), and intravenous administration costs (฿32 or approximately US $1 per time). These costs were based on our hospital’s pricing data [19]. However, the cost analysis did not include expenses related to hospital stay because AP usually ceased within the period of hospitalization determined by each patient’s postoperative recovery.

Patient grouping

Patients were divided into 2 groups based on adherence to AP recommended by the 2020 Thailand SIST guideline [13]. Group A (guideline-concordant AP) received either cefazolin or cefuroxime combined with metronidazole, with prophylaxis discontinued within 24 hours after the operation. Group B (nonconcordant AP) received either broader-spectrum antibiotics (usually ceftriaxone or other third-generation cephalosporins together with metronidazole) and/or a duration of AP extending beyond 24 hours postoperatively.

The guideline specifies that weight-based intravenous AP should be administered within 60 minutes before surgical incision and should be re-dosed intraoperatively if blood loss exceeds 1,500 mL or if the operation time exceeds 2 half-lives of the AP drugs (redosing interval of 4 hours for cefuroxime or cefazolin). It is also worth noting that mechanical bowel preparation was used only for left-sided colonic and rectal operations and did not include oral antibiotics.

Sample size calculation

The sample size was calculated to compare SSI rates between the 2 groups. Based on a previous study in Thailand, the incidence of SSIs following colorectal surgery was 5.5% (95% confidence interval [CI], 3.82%–7.64%) [20]. Because group B typically involved broader-spectrum and/or prolonged AP use, we hypothesized that the SSI rate would be at the lower bound (3.82%) compared to the upper bound (7.64%) in group A. A recent survey in our hospital suggested that the ratio between group A and group B was approximately 1:3 [14]. Using these assumptions with a 95% CI (α=0.05) and 80% power (β=0.20), the required sample size was 360 patients for group A and 1,080 patients for group B, totaling 1,440 patients. After accounting for a potential 10% loss to follow-up, the final target sample size was 1,584 patients.

To avoid selection bias, we retrospectively reviewed the database of targeted surgical patients in chronological order beginning in April 2024 until reaching 1,584 cases. This research was conducted after obtaining approval from our Institutional Review Board, which is accredited by the Association for the Accreditation of Human Research Protection Programs (AAHRPP), ensuring adherence to ethical standards.

Statistical analysis

Statistical analyses were performed using PASW SPSS ver. 18.0 (SPSS Inc). Continuous variables were expressed as mean±standard deviation or median (interquartile range [IQR]) and were compared using the Student t-test or Mann-Whitney U-test. One-way analysis of variance was used to compare means among groups. Categorical variables were expressed as number (percentage) and compared using Pearson chi-square test or Fisher exact test. Factors associated with the development of SSIs were analyzed using a multivariate logistic regression method. Of note, variables yielding P-values of <0.2 in univariate analysis were subsequently included in the multivariate analysis [21]. A P-value of <0.05 was considered statistically significant.

RESULTS

Patient characteristics and surgical variables

During the 28-month study period, 2,100 major colorectal resections were performed. After excluding emergency colorectal procedures (n=385) and patients receiving therapeutic antibiotics for any infection (n=131), a total of 1,584 patients were eligible for analysis. The cohort was divided into group A, representing AP guideline concordance (n=405, 25.6%), and group B, representing non-AP guideline concordance (n=1,179, 74.4%). Details of nonconcordant AP included broader-spectrum AP (n=628, 39.6%), prolonged AP (n=74, 4.7%), and broader-spectrum AP with prolonged usage (n=477, 30.1%).

The study population had a mean age of 66±13 years (range, 18–102 years), with a male predominance (n=822, 51.9%). The most common operation was anterior resection (n=470, 29.7%), followed by right hemicolectomy (n=395, 24.9%) and sigmoidectomy (n=288, 18.2%). A total of 1,030 patients (65.0%) underwent open surgery, and 228 patients (14.4%) required stoma formation. There were no significant differences in baseline demographics or most surgical variables between the 2 groups, except that group B was more likely to include patients undergoing laparoscopy, multivisceral resection, or procedures in individuals with a history of intra-abdominal surgery or abdominopelvic irradiation, as well as those without the use of a wound protector (Table 1).

SSI rates and their sequelae

Overall, SSIs developed in 104 patients (6.6%), with rates of 4.7% (95% CI, 2.85%–7.23%) in group A and 7.2% (95% CI, 5.80%–8.84%) in group B (P=0.078). After excluding organ/space SSIs (n=35), incisional SSIs were observed in 69 patients (4.4%), with rates of 3.2% (95% CI, 1.72%–5.43%) in group A and 4.8% (95% CI, 3.61%–6.12%) in group B (P=0.190).

Patients who developed SSIs had significantly longer hospital stays, with a median of 9.5 days (IQR, 6.8–15.3 days) and a mean of 14.2±1.6 days. In contrast, patients without SSIs had a median hospital stay of 5 days (IQR, 4–6 days) and a mean of 5.6±0.1 days. Both differences were statistically significant (P<0.001).

Risk factors associated with SSIs

Univariate analysis identified 6 potential factors associated with SSIs: high BMI, low serum albumin, multivisceral resection, open surgery, volume of intraoperative blood loss, and the utilization of a wound protector (Table 2). However, after adjusting for potential confounders in multivariate analysis, only 3 factors remained independent predictors of SSI development: hypoalbuminemia (serum albumin <3.5 g/dL; odds ratio [OR], 2.53; 95% CI, 1.54–4.16; P<0.001), obesity (BMI ≥25 kg/m²; OR, 1.89; 95% CI, 1.08–3.32; P=0.026), and intraoperative blood loss >400 mL (OR, 1.83; 95% CI, 1.06–3.16; P=0.031) (Table 3). Notably, the use of broader-spectrum and/or prolonged AP had no discernible effect on SSI incidence.

Expense of AP

The average cost of AP was significantly lower in group A (US $14.3; 95% CI, 13.8–14.8) than in group B (US $17.3; 95% CI, 16.9–17.7; P<0.001). The mean total AP-related cost was also significantly lower in group A (US $30.1; 95% CI, 29.8–30.4) compared with group B (US $51.7; 95% CI, 51.1–52.3; P<0.001).

DISCUSSION

This observational study from the largest university hospital in Thailand demonstrated that only 25.6% of patients undergoing elective colorectal surgery received appropriate AP based on the nationwide Thailand guideline for SSI prevention. In this study, inappropriate AP involving the use of broader-spectrum AP and/or prolonged AP did not reduce the incidence of SSIs. In fact, patients receiving nonconcordant AP tended to experience higher SSI rates and significantly increased AP-related costs. Furthermore, this study identified 3 meaningful risk factors associated with increased SSI risk: hypoalbuminemia, obesity [22], and intraoperative blood loss exceeding 400 mL.

It should be emphasized that only approximately one-quarter of cases in this cohort received AP aligned with the latest national guideline in Thailand. Although this rate from a major teaching hospital was higher than the average 10% adherence reported in antimicrobial use surveillance data from 183 hospitals across the country [14], it remains suboptimal, particularly when compared with adherence rates in developed nations. For example, 2 large multicenter studies from France and Australia reported approximately 60% adherence to national guidelines for several intra-abdominal operations, including colorectal surgery [23, 24].

It is possible that the low compliance rate with AP guidelines across Thailand may be partly attributed to the limited implementation of structured antimicrobial stewardship (AMS), especially in non-university hospitals. When AMS programs are well organized, they can promote the rational use of AP, reduce SSI rates, and improve economic outcomes [25]. Indeed, a recent systematic review from low- and middle-income countries showed that antimicrobial prophylaxis programs effectively improved guideline adherence, decreased antibiotic consumption, and reduced prophylaxis-related costs [26]. However, the review did not include any data from Thailand, reflecting the incomplete nationwide development of AMS.

This cohort study confirmed that inappropriate AP, usually broader-spectrum and/or prolonged AP, did not reduce SSI incidence. A large systematic review and meta-analysis including 79,058 patients across multiple surgical specialties similarly found that extended AP duration did not reduce SSIs compared with standard duration [27]. Likewise, the WHO’s comprehensive analysis of multiple randomized controlled trials comparing prolonged AP with shorter durations (less than 24 hours) in colorectal surgery found no significant difference in SSI rates [28]. Furthermore, inappropriate AP not only failed to reduce SSIs but also significantly increased prophylaxis costs, as our findings demonstrated nearly double the AP-related expense in the nonconcordant group.

Beyond unnecessary healthcare costs, broader-spectrum and/or prolonged AP may increase the long-term risks of C. difficile infection (CDI) and antimicrobial resistance (AMR), which impose severe burdens on healthcare systems and patients. For instance, a study from Thailand reported an alarmingly high prevalence (37%) of extended-spectrum β-lactamase (ESBL)–producing Enterobacteriaceae among asymptomatic individuals [29]. Prolonged use of third-generation cephalosporins has been identified as a major risk factor for ESBL acquisition [30]. Extended AP beyond 24 hours also exposes patients to serious complications, including postoperative acute kidney injury and a duration-dependent doubling of CDI risk [31]. These complications have substantial implications not only for patient outcomes but also for healthcare costs, with CDI-attributable expenses in the United States estimated at $6.3 billion annually [31]. Data from Thailand published in 2012 reported that AMR-related infections resulted in 3.8 million additional hospital days, nearly 40,000 deaths, and $180 million in antibiotic expenditures [16].

It is noteworthy that patients undergoing laparotomy had a higher rate of guideline-concordant AP than those undergoing laparoscopy. This observation may relate to surgeon-specific preferences for AP regimens depending on the surgical approach. Additionally, this study identified 3 risk factors independently associated with increased SSIs: hypoalbuminemia, obesity, and intraoperative blood loss exceeding 400 mL. These findings are consistent with several recent systematic reviews that identified these factors as independent SSI predictors following abdominal surgery [32, 33]. Although group B patients tended to have higher baseline risk profiles (previous intra-abdominal surgery and/or radiation) and more complex procedures (multivisceral resection), these factors were not associated with the SSI rate in our multivariable analysis. Likewise, broader-spectrum or prolonged AP did not reduce the SSI rate. These findings may suggest that optimizing intrinsic patient factors (such as correcting hypoalbuminemia or addressing obesity) and improving operative technique (such as minimizing blood loss) are more important for SSI reduction than altering AP regimens, even in high-risk patients.

Although our study utilized real-world data with standardized SSI definitions and complete 30-day follow-up, several limitations should be considered. First, as a single-center study focused exclusively on colorectal surgery, our findings may not be generalizable to other procedures, particularly those requiring different AP strategies such as pancreatoduodenectomy for pancreatic cancer [34]. Second, the retrospective design limited insight into the clinical reasoning behind nonconcordant AP. Broader-spectrum or prolonged AP may be used in response to surgical complexity or perceived risk rather than indiscriminate overuse [34]. This underscores the need for structured antibiotic stewardship, such as requiring attending approval for deviations from standard AP. Misuse of AP may also stem from junior clinicians who often initiate antibiotic decisions; therefore, stewardship education and decision-support tools should be integrated into surgical workflows. Third, although we evaluated direct AP-related costs, we did not assess downstream consequences such as AMR and CDI, which may affect patients’ and community bacterial flora. Last, several potential SSI risk factors (such as active smoking, steroid use, and intraoperative spillage) were not systematically collected in our database and therefore were not included in the analysis.

In conclusion, our study highlights that guideline-concordant AP in colorectal surgery remains suboptimal in routine practice. Broader-spectrum and/or prolonged AP did not reduce SSI rates but substantially increased AP-related costs. Our findings also underscore that SSIs are largely influenced by intrinsic patient factors (hypoalbuminemia and obesity) and an operative factor (excessive intraoperative blood loss). These results emphasize the importance of optimizing AP practices by improving guideline adherence and addressing patient-specific risk factors to enhance surgical outcomes.

ARTICLE INFORMATION

Conflict of interest

No potential conflict of interest relevant to this article was reported.

Funding

None.

Author contributions

Conceptualization: VL; Data curation: PN, NK, PT; Formal analysis: VL, PT; Methodology: VL; Investigation: PN, NK, PT; Writing–original draft: PN, NK, PT; Writing–review & editing: VL. All authors read and approved the final manuscript.

Table 1.

Patient demographics and surgical variables (n=1,584)

Characteristic	Group A (n=405)	Group B (n=1,179)	P-value
Patient demographic
Age (yr)	66.6±12.4	65.5±13.2	0.151
Sex			0.893
Male	209 (51.6)	613 (52.0)
Female	196 (48.4)	566 (48.0)
Body mass index (kg/m²)	23.1±4.1	23.0±3.9	0.872
ASA physical status ≥III	115 (28.4)	358 (30.4)	0.455
Preoperative hematocrit (%)	35.7±5.0	36.0±5.3	0.368
Preoperative albumin (g/dL)	3.9±0.4	3.9±1.3	0.876
Diabetes mellitus	100 (24.7)	283 (24.0)	0.780
Hypertension	212 (52.3)	648 (55.0)	0.362
Coronary artery disease	29 (7.2)	97 (8.2)	0.494
History of intra-abdominal surgery	98 (24.2)	348 (29.5)	0.040^*
History of abdominal or pelvic radiation	39 (9.6)	163 (13.8)	0.029^*
Surgical variable
Type of surgery
Right hemicolectomy	89 (22.0)	306 (26.0)	0.110
Left hemicolectomy	39 (9.6)	124 (10.5)	0.612
Sigmoidectomy	89 (22.0)	199 (16.9)	0.022^*
Hartmann procedure	25 (6.2)	64 (5.4)	0.575
Anterior resection	127 (31.4)	343 (29.1)	0.389
Abdominoperineal resection	23 (5.7)	95 (8.1)	0.116
Other	13 (3.2)	48 (4.1)	0.437
Surgery with stoma formation	54 (13.3)	174 (14.8)	0.481
Multivisceral resection	33 (8.1)	151 (12.8)	0.012^*
Laparotomy	337 (83.2)	693 (58.8)	<0.001^*
Operative time (min)	200 (165–250)	200 (145–272.5)	0.970
Intraoperative blood loss (mL)	100 (50–250)	100 (50–300)	0.908
No usage of wound protector	34 (8.4)	306 (26.0)	<0.001^*
Intraoperative hypothermia	210 (51.9)	549 (46.6)	0.066

Values are presented as mean±standard deviation, number (%), or median (interquartile range). Group A, patients receiving guideline-concordant antibiotic prophylaxis. Group B, patients receiving nonconcordant antibiotic prophylaxis (broader-spectrum and/or prolonged prophylaxis).

ASA, American Society of Anesthesiologists; SSI, surgical site infection.

^*P<0.05.

Table 2.

Patient characteristics and surgical variables according to the presence or absence of SSIs (n=1,584)

Variable	SSI		P-value
Variable	No (n=1,480)	Yes (n=104)	P-value
Patient demographic
Age (yr)	65.8±12.8	65.6±14.7	0.879
Sex			0.103
Male	760 (51.4)	62 (59.6)
Female	720 (48.6)	42 (40.4)
Body mass index (kg/m²)	23.0±3.9	23.4±4.0	0.010^*
ASA physical status ≥III	440 (29.7)	33 (31.7)	0.666
Preoperative hematocrit (%)	35.9±5.2	35.2±5.6	0.187
Preoperative albumin (g/dL)	4.0±1.1	3.6±0.7	<0.001^*
Diabetes mellitus	367 (24.8)	16 (15.4)	0.030^*
Hypertension	817 (55.2)	43 (41.3)	0.006^*
Coronary artery disease	117 (7.9)	9 (8.7)	0.785
History of intra-abdominal surgery	416 (28.1)	30 (28.8)	0.871
History of abdominal or pelvic radiation	186 (12.6)	16 (15.4)	0.405
Surgical variable
Type of surgery
Right hemicolectomy	371 (25.1)	24 (23.1)	0.650
Left hemicolectomy	150 (10.1)	13 (12.5)	0.443
Sigmoidectomy	270 (18.2)	18 (17.3)	0.811
Hartmann procedure	84 (5.7)	5 (4.8)	0.710
Anterior resection	439 (29.7)	31 (29.8)	0.975
Abdominoperineal resection	108 (7.3)	10 (9.6)	0.384
Other	58 (3.9)	3 (2.9)	0.596
Surgery with stoma formation	210 (14.2)	18 (17.3)	0.381
Multivisceral resection	163 (11.0)	21 (20.2)	0.005^*
Laparotomy	951 (64.3)	79 (76.0)	0.016^*
Operative time (min)	200 (150–270)	215 (165–300)	0.052
Intraoperative blood loss (mL)	100 (50–285)	200 (68–463)	0.005^*
No usage of wound protector	309 (20.9)	31 (29.8)	0.032^*
Intraoperative hypothermia	705 (47.6)	54 (51.9)	0.397
Broader-spectrum and/or prolonged AP	1,094 (73.9)	85 (81.7)	0.078

Values are presented as mean±standard deviation, number (%), or median (interquartile range).

SSI, surgical site infection; ASA, American Society of Anesthesiologists; AP, antibiotic prophylaxis.

^*P<0.05.

Table 3.

Potential patient- and surgical-related variables associated with the SSI rate (n=1,584)

Variable	No. of patients (%)	No. of SSIs (%)	Univariate analysis		Multivariate analysis
Variable	No. of patients (%)	No. of SSIs (%)	OR (95% CI)	P-value	OR (95% CI)	P-value
Sex
Female	762 (48.1)	42/762 (5.5)	1 (Reference)		1 (Reference)
Male	822 (51.9)	62/822 (7.5)	1.40 (0.93–2.10)	0.103	1.39 (0.90–2.14)	0.141
Body mass index
<25 kg/m²	1,146 (72.3)	58/1,146 (5.1)	1 (Reference)		1 (Reference)
≥25 kg/m²	438 (27.7)	46/438 (10.5)	2.20 (1.47–3.30)	<0.001^*	1.89 (1.08–3.32)	0.026^*
Albumin level
Normal	1,364 (86.1)	74/1,364 (5.4)	1 (Reference)		1 (Reference)
Hypoalbuminemia	220 (13.9)	30/220 (13.6)	2.75 (1.75–4.32)	<0.001^*	2.53 (1.54–4.16)	<0.001^*
Surgical approach
Non-laparotomy	554 (35.0)	25/554 (4.5)	1 (Reference)		1 (Reference)
Laparotomy	1,030 (65.0)	79/1,030 (7.7)	1.76 (1.11–2.79)	0.016^*	1.42 (0.85–2.36)	0.209
Operative time
≤4 hr	1,105 (69.8)	64/1,105 (5.8)	1 (Reference)		1 (Reference)
>4 hr	479 (30.2)	40/479 (8.4)	1.48 (0.98–2.23)	0.059	1.02 (0.60–1.69)	0.895
Multivisceral resection
No	1,400 (88.4)	83/1,400 (5.9)	1 (Reference)		1 (Reference)
Yes	184 (11.6)	21/184 (11.4)	2.04 (1.23–3.39)	0.005^*	1.43 (0.81–2.56)	0.124
Blood loss
≤400 mL	1,343 (84.8)	74/1,343 (5.5)	1 (Reference)		1 (Reference)
>400 mL	241 (15.2)	30/241 (12.4)	2.44 (1.56–3.82)	<0.001^*	1.83 (1.06–3.16)	0.031^*
Wound protector use
Yes	1,244 (78.5)	73/1,244 (5.9)	1 (Reference)		1 (Reference)
No	340 (21.5)	31/340 (9.1)	1.61 (1.04–2.50)	0.032^*	1.16 (0.71–1.89)	0.495
Antibiotic prophylaxis
Guideline-concordant AP	405 (25.6)	19/405 (4.7)	1 (Reference)		1 (Reference)
Broad-spectrum/prolonged AP	1,179 (74.4)	85/1,179 (7.2)	1.58 (0.95–2.63)	0.077	1.36 (0.78–2.35)	0.274

Notably, the overall SSI rate was 6.6% (104 of 1,584 patients).

SSI, surgical site infection; OR, odds ratio; CI, confidence interval; AP, antibiotic prophylaxis.

^*P<0.05.

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Guideline-concordant antibiotic prophylaxis on surgical site infection rates following colorectal surgery: real-world data from Thailand

Ann Coloproctol. 2026;42(2):208-215. Published online April 17, 2026

DOI: https://doi.org/10.3393/ac.2025.00913.0130

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Guideline-concordant antibiotic prophylaxis on surgical site infection rates following colorectal surgery: real-world data from Thailand

Characteristic	Group A (n=405)	Group B (n=1,179)	P-value
Patient demographic
Age (yr)	66.6±12.4	65.5±13.2	0.151
Sex			0.893
Male	209 (51.6)	613 (52.0)
Female	196 (48.4)	566 (48.0)
Body mass index (kg/m²)	23.1±4.1	23.0±3.9	0.872
ASA physical status ≥III	115 (28.4)	358 (30.4)	0.455
Preoperative hematocrit (%)	35.7±5.0	36.0±5.3	0.368
Preoperative albumin (g/dL)	3.9±0.4	3.9±1.3	0.876
Diabetes mellitus	100 (24.7)	283 (24.0)	0.780
Hypertension	212 (52.3)	648 (55.0)	0.362
Coronary artery disease	29 (7.2)	97 (8.2)	0.494
History of intra-abdominal surgery	98 (24.2)	348 (29.5)	0.040^*
History of abdominal or pelvic radiation	39 (9.6)	163 (13.8)	0.029^*
Surgical variable
Type of surgery
Right hemicolectomy	89 (22.0)	306 (26.0)	0.110
Left hemicolectomy	39 (9.6)	124 (10.5)	0.612
Sigmoidectomy	89 (22.0)	199 (16.9)	0.022^*
Hartmann procedure	25 (6.2)	64 (5.4)	0.575
Anterior resection	127 (31.4)	343 (29.1)	0.389
Abdominoperineal resection	23 (5.7)	95 (8.1)	0.116
Other	13 (3.2)	48 (4.1)	0.437
Surgery with stoma formation	54 (13.3)	174 (14.8)	0.481
Multivisceral resection	33 (8.1)	151 (12.8)	0.012^*
Laparotomy	337 (83.2)	693 (58.8)	<0.001^*
Operative time (min)	200 (165–250)	200 (145–272.5)	0.970
Intraoperative blood loss (mL)	100 (50–250)	100 (50–300)	0.908
No usage of wound protector	34 (8.4)	306 (26.0)	<0.001^*
Intraoperative hypothermia	210 (51.9)	549 (46.6)	0.066

Variable	SSI		P-value
Variable	No (n=1,480)	Yes (n=104)	P-value
Patient demographic
Age (yr)	65.8±12.8	65.6±14.7	0.879
Sex			0.103
Male	760 (51.4)	62 (59.6)
Female	720 (48.6)	42 (40.4)
Body mass index (kg/m²)	23.0±3.9	23.4±4.0	0.010^*
ASA physical status ≥III	440 (29.7)	33 (31.7)	0.666
Preoperative hematocrit (%)	35.9±5.2	35.2±5.6	0.187
Preoperative albumin (g/dL)	4.0±1.1	3.6±0.7	<0.001^*
Diabetes mellitus	367 (24.8)	16 (15.4)	0.030^*
Hypertension	817 (55.2)	43 (41.3)	0.006^*
Coronary artery disease	117 (7.9)	9 (8.7)	0.785
History of intra-abdominal surgery	416 (28.1)	30 (28.8)	0.871
History of abdominal or pelvic radiation	186 (12.6)	16 (15.4)	0.405
Surgical variable
Type of surgery
Right hemicolectomy	371 (25.1)	24 (23.1)	0.650
Left hemicolectomy	150 (10.1)	13 (12.5)	0.443
Sigmoidectomy	270 (18.2)	18 (17.3)	0.811
Hartmann procedure	84 (5.7)	5 (4.8)	0.710
Anterior resection	439 (29.7)	31 (29.8)	0.975
Abdominoperineal resection	108 (7.3)	10 (9.6)	0.384
Other	58 (3.9)	3 (2.9)	0.596
Surgery with stoma formation	210 (14.2)	18 (17.3)	0.381
Multivisceral resection	163 (11.0)	21 (20.2)	0.005^*
Laparotomy	951 (64.3)	79 (76.0)	0.016^*
Operative time (min)	200 (150–270)	215 (165–300)	0.052
Intraoperative blood loss (mL)	100 (50–285)	200 (68–463)	0.005^*
No usage of wound protector	309 (20.9)	31 (29.8)	0.032^*
Intraoperative hypothermia	705 (47.6)	54 (51.9)	0.397
Broader-spectrum and/or prolonged AP	1,094 (73.9)	85 (81.7)	0.078

Variable	No. of patients (%)	No. of SSIs (%)	Univariate analysis		Multivariate analysis
Variable	No. of patients (%)	No. of SSIs (%)	OR (95% CI)	P-value	OR (95% CI)	P-value
Sex
Female	762 (48.1)	42/762 (5.5)	1 (Reference)		1 (Reference)
Male	822 (51.9)	62/822 (7.5)	1.40 (0.93–2.10)	0.103	1.39 (0.90–2.14)	0.141
Body mass index
<25 kg/m²	1,146 (72.3)	58/1,146 (5.1)	1 (Reference)		1 (Reference)
≥25 kg/m²	438 (27.7)	46/438 (10.5)	2.20 (1.47–3.30)	<0.001^*	1.89 (1.08–3.32)	0.026^*
Albumin level
Normal	1,364 (86.1)	74/1,364 (5.4)	1 (Reference)		1 (Reference)
Hypoalbuminemia	220 (13.9)	30/220 (13.6)	2.75 (1.75–4.32)	<0.001^*	2.53 (1.54–4.16)	<0.001^*
Surgical approach
Non-laparotomy	554 (35.0)	25/554 (4.5)	1 (Reference)		1 (Reference)
Laparotomy	1,030 (65.0)	79/1,030 (7.7)	1.76 (1.11–2.79)	0.016^*	1.42 (0.85–2.36)	0.209
Operative time
≤4 hr	1,105 (69.8)	64/1,105 (5.8)	1 (Reference)		1 (Reference)
>4 hr	479 (30.2)	40/479 (8.4)	1.48 (0.98–2.23)	0.059	1.02 (0.60–1.69)	0.895
Multivisceral resection
No	1,400 (88.4)	83/1,400 (5.9)	1 (Reference)		1 (Reference)
Yes	184 (11.6)	21/184 (11.4)	2.04 (1.23–3.39)	0.005^*	1.43 (0.81–2.56)	0.124
Blood loss
≤400 mL	1,343 (84.8)	74/1,343 (5.5)	1 (Reference)		1 (Reference)
>400 mL	241 (15.2)	30/241 (12.4)	2.44 (1.56–3.82)	<0.001^*	1.83 (1.06–3.16)	0.031^*
Wound protector use
Yes	1,244 (78.5)	73/1,244 (5.9)	1 (Reference)		1 (Reference)
No	340 (21.5)	31/340 (9.1)	1.61 (1.04–2.50)	0.032^*	1.16 (0.71–1.89)	0.495
Antibiotic prophylaxis
Guideline-concordant AP	405 (25.6)	19/405 (4.7)	1 (Reference)		1 (Reference)
Broad-spectrum/prolonged AP	1,179 (74.4)	85/1,179 (7.2)	1.58 (0.95–2.63)	0.077	1.36 (0.78–2.35)	0.274

Table 1. Patient demographics and surgical variables (n=1,584)

ASA, American Society of Anesthesiologists; SSI, surgical site infection.

P<0.05.

Table 2. Patient characteristics and surgical variables according to the presence or absence of SSIs (n=1,584)

Values are presented as mean±standard deviation, number (%), or median (interquartile range).

SSI, surgical site infection; ASA, American Society of Anesthesiologists; AP, antibiotic prophylaxis.

P<0.05.

Table 3. Potential patient- and surgical-related variables associated with the SSI rate (n=1,584)

Notably, the overall SSI rate was 6.6% (104 of 1,584 patients).

SSI, surgical site infection; OR, odds ratio; CI, confidence interval; AP, antibiotic prophylaxis.

P<0.05.