In the past year I've spent more time than I expected talking to surgeons, pharmacists and infection-control nurses about something most patients never think about until the moment it matters: the availability of antibiotics. Shortages of key antibiotics — from first-line prophylactics used in routine clean surgeries to broad-spectrum agents for complicated infections — are quietly changing how hospitals schedule operations, choose drugs and measure risk. I want to walk you through what this means for routine surgery, why it matters, and how hospitals are coping in ways that are sometimes creative, sometimes uncomfortable, and often pragmatic.
Why antibiotic shortages matter for routine surgery
Antibiotic prophylaxis is a small but critical step in routine surgery. For many procedures — joint replacements, hernia repairs, appendectomies — a single dose of a particular antibiotic given at the right time can drastically reduce surgical site infections (SSIs). When those drugs are unavailable or in short supply, the immediate consequences are practical: delays or cancellations, substitution with less ideal agents, or new infection risks that can lengthen hospital stays and burden patients.
But there’s a second-order problem that I hear about again and again: shortages can fuel the overuse of remaining antibiotics, accelerating antimicrobial resistance (AMR). If multiple hospitals start using the same broad-spectrum alternative because the narrow, preferred drug is unavailable, selection pressure for resistant organisms rises. That's the last thing we need when the global goal is to preserve effective antibiotics.
Which antibiotics are most affected?
Shortages have not been uniform. Cefazolin — a workhorse first‑generation cephalosporin widely used for surgical prophylaxis — has been intermittently scarce in various markets. Other commonly mentioned drugs include piperacillin‑tazobactam, certain aminoglycosides, and even basic oral agents like amoxicillin-clavulanate in some regions. At tertiary centres, shortages of vancomycin or gentamicin have cropped up, complicating treatment for suspected MRSA or gram‑negative infections.
To translate that into plain terms: when cefazolin is missing, surgeons and pharmacists must decide between using a different cephalosporin, switching to clindamycin for beta‑lactam allergic patients, or selecting broader agents that are less ideal from an AMR perspective.
Immediate impacts on patients and surgical practice
- Delays and cancellations: Elective surgeries can be postponed if the necessary prophylactic antibiotic is not available — a source of frustration and health risk for patients waiting for joint replacements or cancer-related procedures.
- Substitution risks: Alternatives may be less effective, have different side‑effect profiles, or require different timing/dosing, increasing the chance of postoperative infection or adverse reactions.
- Broader antibiotic use: Using broad‑spectrum agents as substitutes can increase the risk of Clostridioides difficile infections and promote resistance.
- Supply unevenness: Smaller hospitals and rural centres often bear the brunt of shortages, unable to outbid larger systems for scarce supplies.
How hospitals are coping — practical strategies I’ve observed
Hospitals are not waiting passively. From the conversations I’ve had with pharmacy directors and OR managers, several strategies have become widespread:
- Therapeutic substitution protocols: Antimicrobial stewardship teams draw evidence-based substitution lists so clinicians know which alternatives are acceptable for specific procedures. These lists take into account local resistance patterns and allergy profiles.
- Prioritisation and conservation: Hospitals triage who receives the scarce drug. For instance, cefazolin stock may be reserved for prosthetic joint surgery, where the benefit is highest, while a different agent is used for low‑risk procedures.
- Pre-op assessment intensification: Infection prevention teams ramp up preoperative optimisation — stricter glycemic control, nasal decolonisation for Staphylococcus aureus carriers, and improved skin antisepsis — to reduce reliance on antibiotics alone.
- Centralised purchasing and sharing: Regional health networks coordinate purchases and redistribute supplies based on need. Some systems have created “antibiotic banks” to allocate limited vials transparently.
- Compounding and local production: Where regulations allow, hospital pharmacies increase on‑site compounding or partner with compounding pharmacies to produce certain formulations, though this raises quality and regulatory hurdles.
- Scheduling changes: Elective cases are rescheduled to align with supply deliveries, or performed using alternative prophylaxis plans discussed and consented with patients.
- Enhanced surveillance: Infection control teams monitor surgical site infection rates more closely to detect any signal that substitutions are causing harm.
Examples from the field
At one large university hospital I visited, the stewardship team had created a two‑column substitution table. The left column listed the preferred prophylactic (e.g., cefazolin 2 g IV for most adult surgeries), and the right column showed acceptable alternatives and dosing adjustments by weight and renal function. When cefazolin ran low, pharmacists would auto‑substitute with cefuroxime for most cases, reserving the scarce stock for joint arthroplasties and vascular grafts. The hospital also extended pre-op MRSA screening and used mupirocin decolonisation more aggressively to compensate.
In contrast, a community hospital told me about relying on local compounding pharmacies to provide injectable doses when commercial vials were out. That solution worked technically but required extra paperwork, quality checks, and staffing — a resource many smaller centres don’t have.
What patients should ask
If you’re scheduled for surgery, here are practical questions to raise with your care team — short, specific, and aimed at understanding risk and planning:
- Which antibiotic will be used for my surgery and why?
- Are there any known shortages affecting my operation?
- If a substitute is used, what are the risks and side effects of that alternative?
- Is anything being done preoperatively (e.g., nasal swabs, skin preparation) to reduce infection risk?
- Are there timing or fasting changes I should be aware of related to antibiotics?
Comparing common prophylactic antibiotics and typical substitutions
| Typical use | Preferred agent | Common substitute | Key considerations |
|---|---|---|---|
| Clean orthopedic and general surgery | cefazolin | cefuroxime or ceftriaxone | Substitutes may have broader spectrum or different dosing; consider local resistance |
| Beta‑lactam allergic patients | clindamycin or vancomycin | doxycycline or aztreonam (based on organism risks) | Allergy verification and alternative coverage for gram‑negatives are needed |
| High MRSA risk | vancomycin | linezolid (rare for prophylaxis) or ceftaroline (limited use) | Broad alternatives are costly and may not be ideal for prophylaxis |
Longer-term changes I’m watching
Shortages expose fragilities in the supply chain and spark innovation. I’m seeing more hospitals invest in antimicrobial stewardship not as a cost center but as central to care delivery. There’s also momentum for policy fixes — from better shortage reporting by manufacturers to incentives for producing older, low‑margin antibiotics that remain essential for public health.
Finally, there’s growing interest in non‑antibiotic infection prevention: improved surgical techniques, antiseptic technologies, vaccines that reduce surgical infection risk, and even point‑of‑care diagnostics that let clinicians tailor prophylaxis more precisely. Those aren’t overnight solutions, but they represent a healthier reliance on fewer, better‑used drugs.
What I take away from talking to clinicians on the front lines is simple: hospitals are adapting, but shortages force trade-offs. As a patient or family member, asking the right questions and trusting that your surgical team has a plan can make a real difference when supply uncertainties arise.
