For a 35-year-old woman with acute appendicitis, fever, and stable asthma scheduled for laparoscopic appendectomy, which of the following actions most improves surgical safety: site marking and equipment preparation, preoperative intravenous antibiotics, ignoring asthma history, or omitting informed consent?

Preoperative IV Antibiotics Improve Surgical Safety

The correct answer is B: Pre-operative IV antibiotics administered within 60 minutes before skin incision will most improve surgical safety for this patient with acute appendicitis and fever. 1, 2

Why Preoperative Antibiotics Are Critical

For a patient with appendicitis and fever (>38°C), administering broad-spectrum IV antibiotics 30-60 minutes before surgical incision significantly reduces surgical site infections and intra-abdominal abscesses. 1, 2

Specific Antibiotic Recommendations

The following single-dose regimens should be administered before incision:

• Cefoxitin 2 g IV (preferred first-line agent) 2
• Cefazolin 2 g IV (repeat 1 g if surgery exceeds 4 hours) 1, 2
• Cefuroxime 1.5 g IV (repeat 0.75 g if surgery exceeds 2 hours) 1, 2
• For β-lactam allergy: Gentamicin 5 mg/kg/day plus clindamycin 900 mg IV (repeat clindamycin 600 mg if surgery exceeds 4 hours) 1, 2

Timing Is Essential

Antibiotics must be given within 30-60 minutes before skin incision to ensure adequate serum and tissue concentrations during the period of potential contamination. 1, 2 Some agents like fluoroquinolones and vancomycin require 1-2 hours for administration, so they should begin within 120 minutes of incision. 1

Why the Other Options Are Inadequate or Dangerous

Site Marking and Equipment Preparation (Option A)

While site marking and equipment preparation are standard surgical practices, they are not the primary safety intervention for a patient with appendicitis and fever. 1 Site marking is more relevant for lateralized procedures (e.g., limb surgery, kidney surgery) where wrong-site surgery is a risk—appendectomy does not require site marking. 1

Ignoring Asthma History (Option C)

This is dangerous and violates basic perioperative care principles. 1 Even stable asthma requires:

• Perioperative optimization of patient risk factors 1
• Appropriate anesthetic planning to avoid bronchospasm triggers 1
• Ensuring rescue inhalers are available perioperatively 1

Ignoring medical comorbidities increases perioperative morbidity and mortality. 1

Not Taking Consent (Option D)

Omitting informed consent is both unethical and illegal, regardless of procedure complexity. 1 Appendectomy carries risks including:

• Surgical site infection (16-35% in emergency cases) 1, 3
• Intra-abdominal abscess 1
• Bleeding, bowel injury, and anesthetic complications 1

All surgical procedures require informed consent documenting risks, benefits, and alternatives. 1

Postoperative Antibiotic Management

For uncomplicated appendicitis found at surgery, discontinue antibiotics immediately postoperatively—a single preoperative dose is sufficient. 2, 4, 3 This is a Grade 1A recommendation based on high-quality evidence. 2, 4

For complicated appendicitis (perforation, abscess, gangrenous with peritonitis), continue antibiotics for 24 hours up to a maximum of 3-5 days after adequate source control. 2, 4 Extending beyond 5 days provides no additional benefit and increases antimicrobial resistance. 2, 4

Common Pitfalls to Avoid

• Do not delay surgery to administer antibiotics beyond the 30-60 minute window—give antibiotics and proceed to the operating room promptly. 1
• Do not continue antibiotics postoperatively for uncomplicated appendicitis—this increases wound infections (odds ratio 6.53) without benefit. 3
• Do not use ampicillin-sulbactam as E. coli resistance exceeds 20% in this context. 2
• Do not ignore fever (>38°C)—this indicates active infection requiring immediate antibiotic coverage before incision. 1

Integration with Other Safety Measures

While preoperative antibiotics are the single most important modifiable factor for this patient, comprehensive infection prevention includes: 1

• Hand hygiene and infection prevention strategies 1
• Perioperative normothermia and glycemic control 1
• Meticulous surgical technique 1
• Appropriate wound management 1

However, none of these measures substitute for timely preoperative antibiotic administration in a febrile patient with appendicitis. 1, 2