In this study, in which the appropriateness of SAP applied to inpatients and operated patients in general surgery wards and the prevalence of SSIs developing in patients were evaluated, cefazolin (86.8%) and metronidazole (9.6%) were the most preferred prophylactic antibiotics in both periods. In a study in which 281 patients were included, the most commonly used antibiotic was the combination of ceftriaxone–metronidazole (45.4%), while the rate of only ceftriaxone use was 33.3% [12]. This is thought to be due to the difference in the approach to the surgical procedures applied between the studies and the difference in drug accessibility.

In our study, 703 of 810 patients received cefazolin for SAP. According to the ASHP guideline, the rate of patients with correct antibiotic selection was 87.2%; the rate of patients with correct antibiotic dose was 66.1%; and patients with correct antibiotic administration time was 52.2%. The ratio of patients who met all three criteria was 31.7%. In another study conducted to evaluate the appropriateness of SAP, it was observed that correct antibiotic selection was observed in 64% of patients, correct antibiotic dose in 34%, correct time of administration in 83% [13]. In our study, the rate of correct antibiotic selection for SAP was found to be higher. However, awareness should be raised not only about the correct choice of antibiotic but also about the appropriate dose and timing of antibiotic administration.

In our study, the cefazolin dose compliance rate significantly increased post-TP according to ASHP guidelines (41 and 92.6%). There was a statistically significant improvement in cefazolin and metronidazole administration timing. The accuracy rate at the time of intraoperative re-administration of cefazolin significantly increased from 14.3% in pre-TP to 100% in post-TP. Therefore, it is thought that sharing the information specified in the ASHP guideline by mentioning the deficiencies in the hospital protocol at the training meeting made a great contribution.

In a study evaluating the impact of educational intervention on SAP compliance in surgical specialties in Turkey, the overall compliance rate decreased in post-TP (34.3% vs 28.5%; p = 0.59). Long-term antibiotic use in post-TP was significantly higher (p = 0.01). There was a significant decrease in the 'antibiotic administration without indication' rate in post-TP (p = 0.009). Although improvements were achieved in the indications, selection and dose of SAP in the study, insufficient success was achieved in improving long-term antibiotic use and overall compliance rate. It has been concluded that surgeons’ adherence to existing protocols and guidelines and educational programs will probably provide better outcomes through mandatory measures to ensure appropriate SAP implementation [14].

In another study conducted by clinical pharmacists in a general surgery ward, 64% of 660 antibiotic prescriptions of 614 patients were found to be inappropriate. The most common cause of inappropriate cases was overuse of antibiotics with a rate of 35.29%. It was observed that inappropriate prescriptions were mostly in cases involving the gastrointestinal system (28%) [15]. In our study, the lowest rate of appropriateness of cefazolin selection according to ASHP guidelines was thyroid and/or parathyroid surgery, with 13.6%, followed by breast surgery, with 89.9%. It is recommended that THYR should not receive antibiotics in the ASHP guideline. Since cefazolin was administered to the majority of patients with THYR, inappropriate use rates were high. The reason why the rate of inappropriate antibiotic use in this study was higher than in our study may be due to the lack of antibiotic stewardship programs and local antibiotic policies. It is thought that the main reason underlying the cefazolin prophylaxis given due to THYR, which was the most frequently observed inappropriate use in our study, was not taking the risk of possible SSI development.

In our study, the SSI development rate was 9.9% in pre-TP and 13.3% in post-TP (p = 0.131). The total SSI development rate was 11.6%. In a study conducted by clinical pharmacists in general surgery patients, the criteria for identifying SSI were evaluated according to the definition of SSI in the CDC and SAP compliance according to the ASHP 2013 guideline. SAP was correctly applied in only 19.7% of the total 269 patients, and the incidence of SSI was found to be 16.7%. Independent predictors for SSI were found to be ASA 3–4 (p < 0.0001) [16]. In a study of 12,539 patients in 66 countries, the incidence of CAE was 9.4% in high-income countries, 14% in middle-income countries and 23.2% in low-income countries. Therefore, it has been stated that measures should be increased and more randomized controlled studies are needed to reduce the risk of preventable complications in low- and middle-income countries by considering World Health Organization recommendations [17].

In our study, a statistically significant correlation was found between the age of the patients, the duration of the operation, the presence of an emergency surgical procedure and the risk of developing SSI. No significant difference was found between ASA score and the risk of developing SSI. In another study involving general surgery patients, the risk of SSI increased in patients who underwent emergency surgery, in patients aged 60 years and older, for every 10 min of prolonged operation time and in patients with ASA 3 (p < 0.05) [18]. In another study involving more than 16,000 general surgery patients, the risk of SSI increased in male patients, in patients with an ASA 3 score, in emergency surgery, and with each 30-min increase in the duration of surgery. No significant relationship was found between age and the risk of developing SSI [19]. In our study, it was realized that SAP was generally not applied to patients undergoing emergency operations. This is thought to be because SAP is not considered due to rapid interventions in emergency procedures and/or not having enough antibiotics on hand. As a result, it was inevitable that the increase in the risk of SSI development in patients undergoing emergency surgical procedures was higher than in other studies. In the patients included in our study, an increase in the risk of SSI development was observed with increasing age and/or prolonged operation time, as in other studies. Still, in our study, unlike other studies, the increase in ASA score did not cause a significant increase in the development of SSI, which gives an idea about which of these risk factors should be emphasized more by evaluating the risk factors that may cause SSI development within each institution.

In our study, beta-lactam allergy was detected in 46 patients, and the SAP that was most preferred in this patient group was ciprofloxacin (32 patients, 69.6%). In 5 (10.9%) of these patients, no antibiotic was administered, and in 3 (6.5%) beta-lactam group antibiotics were administered as SAP. None of the 810 patients had any allergic reaction due to SAP administration. SSI developed in 7 (15.2%) of 46 patients with beta-lactam allergy and 87 (11.4%) of 764 patients without reported beta-lactam allergy (p = 0.582). In another study, 11% of patients with beta-lactam allergy received SAP. Vancomycin, levofloxacin, aztreonam and clindamycin were the most preferred agents. No allergic reaction developed in any patient [20]. In another study involving more than 3000 patients, beta-lactam allergy was reported in 369 patients (10.3%). The most preferred agents were clindamycin, gentamicin and vancomycin. SSI developed in 27 (7.3%) patients with beta-lactam allergy and 154 (4.8%) patients without beta-lactam allergy (p = 0.03) [21]. The reason why the rate of SAP administration to individuals with beta-lactam allergy was higher in our study compared to other studies may be due to the hesitation of surgeons about the development of SSI and the differences between the precautions taken accordingly. This may have caused the SSIs that developed in the beta-lactam allergic groups in other studies to be significantly higher.

The limitations of our study are that not all faculty members and resident physicians could attend the training meeting and the training messages could not be conveyed in detail due to the insufficient duration of the meeting. The SAP compliance status given to the patients could not be evaluated in the preoperative process and intervention could not be made accordingly. For the evaluation of SSI development, only telephone interviews were made with the patients and passive surveillance method was preferred. We think that we have increased physicians' awareness on SAP application by including clinical pharmacy practices in general surgery services.