Evidence Suggests Prophylactic Antibiotics May Be Unnecessary in Anorectal Surgery—A Systematic Review and Meta‐Analysis

BACKGROUND: Amid increasing global concerns regarding antimicrobial resistance, the routine use of prophylactic antibiotics in anorectal surgery has been questioned. In practice, prescribing practices vary widely among surgeons, highlighting the need for stronger evidence-based guidance. The aim of this study is to perform a systematic, critical assessment of the current literature to determine the role of prophylactic antibiotics in elective anorectal surgery. METHODS: A comprehensive search of studies published between January 1980 and June 2025 was performed using PubMed, Embase, and Cochrane Library. The primary outcome was surgical site infection (SSI); secondary outcomes included systemic infection, wound dehiscence, abscess formation, bleeding, and recurrence. Study quality was assessed using the Cochrane RoB 2.0 tool for randomized controlled trials (RCTs) and the ROBINS-I tool for observational studies. The certainty of evidence was evaluated using the GRADE approach. RESULTS: Nine studies including 2317 participants were included, and five were eligible for meta-analysis. Overall, prophylactic antibiotics were not associated with a significant reduction in postoperative infectious or wound-related complications in RCTs (RR 0.76, 95% CI 0.43-1.33, and p = 0.66, moderate GRADE certainty of evidence) or observational studies (RR 0.60 (95% CI 0.01-48.4) and p = 0.53, very low certainty). All studies concluded that routine antibiotic prophylaxis may be unnecessary in anorectal surgery. CONCLUSION: Current evidence does not support the routine use of prophylactic antibiotics in uncomplicated anorectal procedures. However, the certainty of evidence is limited by small sample sizes, methodological heterogeneity, and limited number of available studies. Large-scale randomized trials are required to strengthen this evidence base. TRIAL REGISTRATION: The review protocol was registered in the PROSPERO database CRD420251159850.