Updates in Prevention of Surgical Site Infection: Reply

We thank Drs. Mundangepfupfu and Nadler for their letter¹  regarding our review, “Emerging Paradigms in the Prevention of Surgical Site Infection,”²  in which they comment that other common anesthetic medications, beyond those highlighted in the article (volatile agents and opioids), may influence the microbiome or host immunologic response—specifically propofol and ketamine. We agree and thank them for raising this point. In addition, local anesthetics,³  dexmedetomidine⁴  and cisatracurium,⁵  have also been shown to have immunomodulatory properties.

The authors further caution that evidence to date (primarily from animal models) is conflicted regarding the potential detrimental or protective effects of these agents on infection and that it is premature to advocate for the use of total intravenous anesthesia on such grounds. We agree with this statement and would like to emphasize that our review similarly does not advocate for use of total intravenous or any other anesthetic technique on this basis. Rather, our intent is to highlight the plausible influence of common anesthetics exposures on postoperative infection and the need for clinical research in this area.

The persistence of infection as a leading postoperative complication contrasts with historic improvements in other aspects of perioperative care and requires us to examine new avenues by which our practice may contribute to patient safety in this domain. We appreciate the insights and enthusiasm of Drs. Mundangepfupfu and Nadler and, particularly, their call for a multidisciplinary approach to studying the role of anesthetic factors in microbiome-mediated outcomes of surgery.

Drs. Long, Vavilala, and Alverdy receive funding from the National Institutes of Health (Bethesda, Maryland).

Dr. Alverdy is the founder of Covira Surgical (North Chicago, Illinois) and has received Royalties from ReShape Medical (San Clemente, California).