Surgical site infections in GI surgery: update on bacteriology, antibiotic resistance, and ERAS integration

Surgical site infections (SSIs) remain one of the most significant complications following gastrointestinal (GI) surgery, contributing to increased morbidity, prolonged hospitalization, and heightened healthcare costs. Despite major strides in perioperative care, SSI rates in GI surgery still range between 10–30%, particularly in high-risk emergency settings. The microbial landscape of SSIs is shifting, driven by rising antimicrobial resistance and regional variability in bacteriology. Multidrug-resistant (MDR) organisms- especially extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae, methicillin-resistant Staphylococcus aureus (MRSA), and carbapenem-resistant Klebsiella pneumoniae- have emerged as formidable threats. Parallelly, enhanced recovery after surgery (ERAS) pathways are gaining traction as comprehensive perioperative bundles that reduce SSI incidence through patient optimization, minimally invasive approaches, targeted prophylaxis, and early mobilization. This review consolidates evidence from 2015-2025 to present a comprehensive overview of: (a) the evolving microbiology and antibiotic resistance trends in GI SSIs; (b) contemporary antimicrobial prophylaxis strategies and stewardship programs; (c) the impact of ERAS protocols in mitigating SSI risks; and (d) future directions including precision SSI prevention, AI-assisted risk stratification, and rapid diagnostics. Effective SSI prevention in GI surgery necessitates a multidisciplinary approach rooted in local bacteriology, rational antibiotic use, and evidence-based perioperative care. Integrating ERAS with antimicrobial stewardship and personalized risk models may herald a new era in surgical infection control.