Key Issues Surrounding Appropriate Antibiotic Use for Prevention of Surgical Site Infections in Low- and Middle-Income Countries: A Narrative Review and the Implications
Received 1 December 2020
Accepted for publication 7 January 2021
Published 18 February 2021 Volume 2021:14 Pages 515—530
Checked for plagiarism Yes
Review by Single anonymous peer review
Peer reviewer comments 3
Editor who approved publication: Dr Scott Fraser
Julius C Mwita,1 Olayinka O Ogunleye,2,3 Adesola Olalekan,4,5 Aubrey C Kalungia,6 Amanj Kurdi,7,8 Zikria Saleem,9 Jacqueline Sneddon,10 Brian Godman7,11,12
1Department of Internal Medicine, Faculty of Medicine, University of Botswana, Gaborone, Botswana; 2Department of Pharmacology, Therapeutics and Toxicology, Lagos State University College of Medicine, Lagos, Nigeria; 3Department of Medicine, Lagos State University Teaching Hospital, Lagos, Nigeria; 4Department of Medical Laboratory Science, University of Lagos, Lagos, Nigeria; 5Centre for Genomics of Non-Diseases and Personalized Healthcare (CGNPH), University of Lagos, Lagos, Nigeria; 6Department of Pharmacy, University of Zambia, Lusaka, Zambia; 7Strathclyde Institute of Pharmacy and Biomedical Sciences, Strathclyde University, Glasgow, UK; 8Department of Pharmacology, College of Pharmacy, Hawler Medical University, Erbil, Iraq; 9Department of Pharmacy Practice, Faculty of Pharmacy, The University of Lahore, Lahore, Pakistan; 10Healthcare Improvement Scotland, Glasgow, UK; 11School of Pharmacy, Sefako Makgatho Health Sciences University, Pretoria, South Africa; 12School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, Malaysia
Correspondence: Brian Godman
Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK
Tel +44 141 548 3825
Background: There is a concern with the growing use of antimicrobials across countries increasing antimicrobial resistance (AMR) rates. A key area within hospitals is their use for the prevention of surgical site infections (SSI) with concerns with timing of the first dose, which can appreciably impact on effectiveness, as well as duration with extended prophylaxis common among low- and middle-income countries (LMICs). This is a concern as extended duration increases utilization rates and AMR as well as adverse events. Consequently, there is a need to document issues of timing and duration of surgical antibiotic prophylaxis (SAP) among LMICs together with potential ways forward to address current concerns.
Methods: Narrative review of timings and duration of SAP among LMICs combined with publications documenting successful approaches to improve SAP to provide future direction to all key stakeholder groups.
Results: There were documented concerns with the timing of the first dose of antibiotics, with appropriate timing as low as 6.7% in Egypt, although as high as 81.9% in Turkey. There was also an extensive duration of SAP, ranging from long duration times in all patients in a study in Nigeria with a mean of 8.7 days and 97% of patients in Egypt to 42.9% of patients in Pakistan and 35% in Turkey. Successful interventions to improve SAP typically involved multiple approaches including education of all key stakeholder groups, monitoring of usage against agreed guidelines,as well as quality targets. Multiple approaches typically improved timing and duration as well as reduced costs. For instance, in one study appropriateness increased from 30.1% to 91.4%, prolonged duration reduced to 5.7% of patients, and mean costs of antibiotics decreased 11-fold.
Conclusion: There are considerable concerns with the timing and duration of SAP among LMICs. Multiple interventions among LMICs can address this providing future directions.
Keywords: surgical site infections, antibiotic prophylaxis, timing of prophylaxis, duration of prophylaxis, LMICs, quality indicators
Globally, utilization of antibiotics rose by 39% between 2000 and 2015, which has been driven mainly by increasing consumption in lower- and middle-income (LMIC) countries.1–3 This is a concern as rising rates will increase antimicrobial resistance (AMR), increasing morbidity, mortality, and costs.4–7
One of the key areas to reduce inappropriate prescribing of antibiotics in hospitals surrounds their use in preventing surgical site infections (SSIs).8 SSIs are categorized as infections related to a given operative procedure that occurs at or near the surgical incision within 30 days of the procedure or longer if a prosthesis is implanted, and affects either the incision or deep tissue at the operation site or any part of the surrounding anatomy such as pertinent organs or spaces.9–11 They are currently the most common infectious complications seen among hospitalized patients in developing countries,12,13 and are among the most common and costly causes of hospital acquired infections (HAIs), especially in LMICs.14–22 SSIs can also account for appreciable antibiotic use in hospitals.23–26 Costs associated with SSIs are enhanced by associated increases in the length of hospital stay, which is in addition to increasing morbidity and mortality.15,–27–29 Published studies suggest consolidated incidence figures for SSIs for Nigeria and across Africa at between 14.5–14.8% of all operations,12,30 with rates typically higher in LMICs vs high-income countries.13,–30–35 Consequently, there is an urgent need to improve their prevention in LMICs.
Recognized measures to reduce SSIs include surgical hand preparation, antiseptic preparation, coated sutures, wound protector devices, and negative-pressure wound dressings.18,–29,–36–38 In addition, improving the quality of surgery through increased education as well as the development and monitoring of pertinent quality indicators (QIs).39–41 Measures also include administering antimicrobial prophylaxis, which is seen as the single most effective intervention to reduce SSI rates.42 The selection of antibiotics for SSIs is often based on the risk of wound infection according to the wound classification, ie, clean, clean–contaminated, contaminated, or dirty–infected, the normal floral distribution of the site to be operated on, and local antibiotic resistance patterns.14,43,44 Broad-spectrum antibiotics are often preferred to narrow spectrum antibiotics, and cephalosporins are commonly used.27,–45–47 For instance, cefazolin is commonly recommended for the gastroenterological, genitourinary tract, and hepatobiliary surgeries.48 Ideally, administration of the first antibiotic dose should be within 60 minutes of the first incision, longer for vancomycin and the fluoroquinolones, with a second dose administered for long procedures.18,–42,–49–51 Vicentini et al8 found that adequate antibiotic choices and length of administration were associated with significantly reduced risks of SSIs. Overall, published studies have shown that the risk of SSIs is almost 5-times higher when antibiotics are administered more than 120 minutes prior to the first incision and almost doubled when antibiotics are administered after the first incision.52 Extending prophylaxis beyond 1 day also does not appear to improve patient outcomes, whilst at the same time increasing the chances of acute kidney injury, Clostridium difficile infections, AMR, and costs.13,–42,–53–56
We are aware that there can be poor compliance to current guidelines when available to prevent SSIs across LMICs and wider.45,–57–62 This is in addition to the lack of antibiotic guidelines generally in some hospitals.63 For instance, Madubueze et al59 found that compliance with surgical antibiotic prophylaxis (SAP) protocols among orthopedic surgeons in Nigeria was only 30.3% of situations. Reasons for poor compliance to guidelines included following old practices (25%), concerns that the hospitals were not sufficiently clean (27.3%), and proper aseptic techniques were not being followed (27.3%).59 Other reasons for poor compliance include overcrowding in hospitals, resistance to change among physicians, poor knowledge regarding antibiotics among physicians, and concerns with malnutrition in some patients.45,50,64 Patient expectations may also play an important factor in decision-making.50,65
Principal areas of concern with current SAP approaches across countries including LMICs include timing of administration as well as prolonged use post-surgery.23,45,66,67 Consequently, we believe there is a need to document issues regarding the current timing of administration and the duration of antibiotic administration for SAP among LMICs as well as debate potential ways forward to improve this. This is because reducing the length of post-operative administration will reduce the extent of broad-spectrum antibiotic use for SAP, which in turn should reduce AMR as well as adverse events. Improved SAP can be part of the agreed National Action Plans as countries move to reduce their AMR rates.68–70 This was the objective behind this review article.
Materials and Methods
We have chosen LMICs as they typically have the highest rates of AMR with concerns with antibiotic prescribing common across countries and sectors.68,–71–73 We are also aware of the challenges involved with implementing quality improvement programs among hospitals in LMICs to improve future antibiotic prescribing, which include manpower and resource issues as well as physician resistance as part of any antibiotic stewardship program(ASP).74,75 ASPs are important as they can appreciably improve antibiotic use in hospitals and reduce costs.74,76 These challenges with improving the appropriate use of antibiotics in hospitals are exacerbated by variable knowledge regarding antibiotics, AMR, and ASPs among clinicians in LMICs.73,–77–85 Consequently, we will look to build upon successful approaches to improve SAP instigated among LMICs to give guidance on potential ways forward to address concerns where these continue to exist.50,86
The first step will be to document timings and the duration of antibiotic administration for SAP among a range of LMICs before documenting interventions that have been successful with improving SAP among LMICs. This will involve a narrative review of the published literature. The findings will be combined with the extensive experience of the senior-level co-authors to provide future guidance on potential ways to enhance SAP among LMICs including lessons generally from a range of former Soviet Union Republics that have variably instigated initiatives to reduce inappropriate prescribing of antibiotics. We have chosen former Soviet Union Republics as they typically have less Gross Domestic Product (GDP) per capita than among higher income Western European countries,87 ie, more akin to LMICs.
We did not undertake a systematic review since we were aware that there had been a number of reviews surrounding the use of antibiotic prophylaxis as well as other potential interventions to reduce SSIs.29,–50,–52,–86,–88–93 In addition, our aim was to provide possible guidance for key stakeholder groups within LMICs based on our experiences for potential debate. We have successfully used this approach across LMICs to stimulate debate in different key disease areas and topics.68,–94–97
The interventions that have been undertaken and proposed will be broken down into the 4Es where pertinent, namely Education, Engineering, Economics, and Enforcement,98,99 to enhance understanding and comparisons given the range of potential interventions that could be instigated. Education includes developing guidelines or formularies, with adherence to well-constructed guidelines increasingly seen as indicating good quality care.25,–100–103 Activities within hospitals to enhance the rational use of medicines are typically co-ordinated by Drug and Therapeutic Committees (DTCs).104–106 Antimicrobial stewardship groups may be part of DTCs; alternatively, separate groups working in the hospital as part of infection, prevention, and control groups.107,108 In addition, the development and dissemination of the WHO AWaRe list of antibiotics to improve future antibiotic prescribing and dispensing.109,110 Engineering includes organizational or managerial interventions such as instigating and monitoring prescribing targets and quality targets.99,100 Quality targets could include the percentage of antibiotics prescribed according to agreed guidance, the percentage of antibiotics prescribed within a specified time and for an agreed length to prevent SSIs, as well as monitoring drug and therapeutic committee (DTC) activities against agreed performance indicators.59,102,111 Economics includes financial incentives to hospitals, physicians, pharmacists, or patients, ie, providing financial incentives to hospitals to improve patient safety and not pay for preventable errors, to physicians for attaining agreed prescribing targets, and fining pharmacists for illegally dispensing an antibiotic without a prescription.99,100,112,113 Enforcement includes regulations by law.99 Examples include laws banning the dispensing of antibiotics in pharmacies without a prescription as well as national policies outlining the existence of DTCs in hospitals as currently seen in South Africa.105,114
Timing and Duration of Administration for SAP Among LMICs
Table 1 documents a range of timings and duration of administration for SAP among LMICs across continents. Ideally, administration of the first antibiotic dose should be within 60 minutes of the first incision and only for 1 day. However, wide variations were seen with only a limited number of patients across a range of LMICs generally receiving SAP within this time (Table 1). Documented rates for staying within agreed timings of the first incision ranged from as low as 6.7% of patients in Egypt, up to 81.9% in Turkey.
Table 1 Published Rates Regarding Inappropriate Timing and Length of Administration of Antibiotics for SAP Among LMICs
There were similar concerns regarding the extent of prophylactic antibiotics given for longer than 1 day across LMICs. Rates of extended prophylaxis ranged from all patients in Nigeria in the study by Abubakar et al (2018) with a mean of 8.7 days, to 97% of patients in Egypt and Pakistan (Saied et al 2015 and Saleem et al 2019, respectively), and 86.3% among surgical patients in Eastern Europe (part of the Global PPS study). Extended prophylaxis was seen in 42.9% of patients in Pakistan (Butt et al 2019) and 35% in Turkey (Ozgun et al 2020) (Table 1).
Interventions to Enhance Adherence to SAPs Among Countries
A number of interventions have been instigated across many LMICs to improve SAP broken down into Education, Engineering, Economics, and Enforcement where pertinent and by year to provide guidance.
Interventions principally centred around educational inputs. In addition, monitoring subsequent prescribing against agreed guidance (QIs) and providing feedback to help improve subsequent SAP (Engineering – Table 2). Multiple interventions resulted in appreciable improvements in SAP across LMICs. For instance, Bozkurt et al (2014) found that multiple interventions improved the duration of prophylaxis from 10.3% to 59.4% of cases, Saied et al (2015) that optimal timing of the first dose can be appreciably improved (6.7% to 38.7%), and Brink et al (2017) that the choice of antibiotic, consistent with agreed guidelines, can be improved to 95.9% of patients (Table 2).
Table 2 Summary of Published Studies Across Countries Documenting the Impact of Interventions on Subsequent Timing and Length of Antibiotic Administration Among a Range of LMICs
However, we are aware there are cases where interventions have not always been effective. In their study, Ozgun et al131 instigated a number of measures including analyzing key concerns regarding SAP with individual surgical teams, as well as educational meetings with all key stakeholders during which concerns including timing and duration of antibiotic use were discussed. However, compliance to agreed guidelines actually decreased post-intervention, and the number of patients receiving prolonged SAP was higher after the intervention than before, increasing from 34% of patients (Table 1) to 52%, which was statistically significant (P<0.01), with surgeons comfortable at the time with prolonged administration.131
Discussion and Recommendations
We have shown that there can be considerable concerns regarding the current use of SAP among LMICs to reduce SSIs. These include concerns with both the timing and duration of administration of antibiotics (Table 1). Both need to be addressed to enhance the effectiveness of appropriate SAP to prevent SSIs, reduce the extent of any adverse events including Clostridium difficile infections and AMR, as well as reduce costs.8,–52–55
Encouragingly, typically multifaceted interventions appear to be successful in addressing concerns with timing and duration of antibiotic prophylaxis providing direction to others (Table 2). This mirrors the successful impact of multiple interventions instigated by health authorities and others in different disease areas and situations, including antibiotics as well as medicines for acid-related stomach disorders, depression, hypertension, and hypercholesterolemia, to improve their prescribing.132–140 There have been limited changes in physician prescribing behavior in the absence of such interventions.141–143 In addition, we are aware that multiple demand-side measures in former Soviet Union Republics have improved appropriate use of antibiotics. In Azerbaijan, initiatives including Education, Economics, and Enforcement resulted in antibiotic utilization decreasing by 47% between 2011 and 2015.144 In Slovenia, multiple activities including all the 4Es also resulted in antibiotic utilization falling by 31% between 1999 to 2012,137 with multiple activities in the Republic of Srpska including all the 4Es resulting in a decreasing trend in antibiotic consumption in recent years, with utilization rates comparable or lower than those seen in neighboring countries.145 This contrasts with Poland, where limited activities among the authorities and other groups between 2007 and 2016 resulted in Poland continuing to have one of the highest rates of antibiotic consumption across Europe.146 However, we are aware of situations where multiple interventions have not improved SAP.131
Potential future activities to improve SAP center around the development of antimicrobial stewardship activities including ASPs which can be part of DTCs within countries and hospitals if not already instigated to address concerns and misconceptions (Table 3). This may include the need for additional educational activities surrounding antibiotics and concerns with hygiene, AMR, and SAP if pertinent, along with the development of any local guidelines and QIs. The outputs from subsequent monitoring of SAP post-intervention, including changes in any agreed QIs, can be used to develop and instigate additional pertinent interventions. This is because we have seen that multiple activities including Education, Engineering, and Enforcement can have a significant impact on both the timing and duration of antibiotic use as part of SAP, impacting on future prevalence and morbidity of SSIs as well as costs (Table 2).
Table 3 Potential Strategies to Improve SAP Within Hospitals in LMICs
More studies are needed though to assess the cost-effectiveness of different interventions as opposed to studies that principally measure individual cost components before and after interventions to provide future guidance (Table 3). In addition, any QI developed needs to be robust, appropriate, measurable, and improve future care, building on examples in other situations as well as suggestions from the WHO and others.25,–61,–147–149
We are aware that Health Technology Assessment (HTA) units are less developed in LMICs vs high-income countries and there can be concerns with implementing the findings of HTA analyses.150,151 However, this is starting to change in some countries, with suggestions for a more integrative approach.152,153 This is important as the outputs from HTA units can help hospitals and governments prioritize resources and personnel, with the situation becoming even more imperative post the current COVID-19 and its consequences.97 This is important to enhance the rational use of SAP in LMICs. However, HTA as a strategy to curb AMR requires appropriate legislative and institutional frameworks, as well as human and financial resources, to translate any findings into effective implementation and monitoring of health interventions.154 In addition, physicians, nurses, and pharmacists must confidently trust any STGs produced to enhance their acceptability and success in curbing AMR.155,156 This, complemented by enhancing healthcare worker’s knowledge regarding antibiotic use, AMR, and ASPs within hospitals through targeted educational interventions, can improve the rational use of antibiotics.
We are aware of some limitations with this paper. These include the fact that we did not undertake a systematic review for the reasons discussed. We have, though, contextualized the findings to provide direction to key stakeholder groups to improve SAP in LMICs based on the considerable experience of the co-authors. We believe these recommendations are robust based on their experience and knowledge across LMICs.
We believe this is the first review study to combine a narrative review of the timings and duration of antibiotic use for SAP among LMICs as well as approaches that have been successful in addressing current concerns with SAP to provide future direction. We have shown that there are considerable concerns with current SAP among LMICs, including timing and duration, which is important given rising antimicrobial consumption rates and AMR among LMICs. However, multiple interventions can appreciably improve the situation and reduce costs. As a result, there are multiple activities that all key stakeholder groups can undertake to improve future SAP where important issues have been identified, and we will be monitoring this.
All authors contributed to the design and development of the paper through their extensive activities to improve the use of antibiotics within hospitals and wider. All authors critically evaluated the first and subsequent drafts and approved the final version before submission.
There was no funding for this paper.
The authors have no relevant conflicts of interest to declare.
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