Postoperative antibiotic practices and surgical site infections in twenty low- and middle-income country hospitals
Author(s):
Alex Zhuang; Maia Nofal; Natnael Gebeyehu; Nichole Starr; Sara Taye Haile; Habtamu Woldeamanuel; Assefa Tesfaye; Senait Bitew; Abebe Bekele; Thomas Weiser; Tihitena Negussie Mammo
Background:
Worldwide, 1 in 6 inpatient antibiotic prescriptions are for surgical prophylaxis, including postoperative prophylaxis.1 The World Health Organization recommends against prophylactic antibiotics for preventing surgical site infection (SSI).1 In Sub-Saharan Africa, postoperative antibiotic use is common due to perceptions that it reduces SSI rates, but data informing recommendations against postoperative antibiotics are largely derived from high-income countries.1–4
Hypothesis:
Postoperative antibiotic use does not reduce SSI risk in patients undergoing clean and clean-contaminated operations in low- and middle-income hospitals.
Methods:
Prospective data was collected from 2019-2022 on patients enrolled in Clean Cut, an SSI reduction quality improvement program currently being implemented in Ethiopia, Liberia, Madagascar, India, and Bolivia.5 We included patients from 20 hospitals with wound class I or II operations without clinical sign of infection for 48 hours postoperatively (Figure 1). We assessed the association between postoperative antibiotic prophylaxis and SSI via logistic regression, controlling for patient and case factors, and degree of adherence to perioperative infection prevention practices.
Results:
Of 6,945 patients included, 6,529 (94.0%) received antibiotics postoperatively, of which 6,319 (91.0%) were for prophylaxis. Ceftriaxone was most frequently prescribed (2,486, 35.8%) for an average of 1.5 days. There was no difference in the risk of SSI between patients who received postoperative prophylactic antibiotics and those who did not (RR 1.21, 95% CI 0.95-1.54, p=0.143) (Table 1). Length of stay (LOS) was 1.4 days longer for those receiving postoperative prophylaxis.
Conclusions:
In this large prospective observational cohort, postoperative antibiotics did not reduce SSI rates for clean and clean-contaminated cases but was associated with longer LOS in resource-limited healthcare systems. With the growing threat of antimicrobial resistance, surgical initiatives to implement antimicrobial stewardship programs are critical.