We are all pretty comfortable with the idea that we have used too many antibiotics in the past and now we are reaping the consequences. I think we are also all in agreement that we need to start using antibiotics much more rationally – and keep the big guns firmly on the top shelf, double-wrapped in password-protected packaging that you can only access with a fingerprint and retinal scan (whilst acknowledging that they will still somehow be prescribed by a junior doctor at 3am for a sniffle). But I get the feeling that we all have a bit of a blind spot (or soft spot) for surgical prophylaxis. Here, the situation is different, surely, because the consequence of an SSI is so great that the likely ‘cost’ of widespread surgical prophylaxis is outweighed by the gain of fewer SSIs? But has this become stewardship’s elephant in the room? We are comfortable talking about restricting carbapenem use in acute hospitals, but I don’t hear as much discussion about stopping the use of antibiotics for surgical prophylaxis! On one level, isn’t this is the same arguments as for ‘selective’ digestive or oral decontamination (SDD / SOD) in the ICU? Here, the argument in factor of SDD / SOD is compelling: fewer deaths and less spread of resistant bacteria. But indiscriminate use of antibiotics, which is bound to fuel antibiotic resistance in the long run, just cannot be a good idea, particularly in the high-risk ICU population.

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