Supporting global antimicrobial stewardship: antibiotic prophylaxis for the prevention of surgical site infection in low- and middle-income countries (LMICs): a scoping review and meta-analysis

Multipronged interventions to reduce surgical site infections: A multicenter implementation research protocol

BACKGROUND

Surgical site infections (SSIs) are a major yet preventable cause of poor post-operative clinical outcomes, prolonged ICU/hospital stay, increased antibiotic consumption and added cost of therapy. Low- and Middle-income Countries (LMICs) have disproportionately higher rates of SSIs as compared to high-income countries despite various national and international guidelines in place as multipronged, combined interventions are seldom used. The IMPRESS project aims to respond to this urgent need to identify and evaluate the quality improvement measures contextualized to the logistic constraints of LMIC settings such as India.

METHODS AND ANALYSIS

We adopt a multi-center longitudinal mixed-methods study to be conducted over a period of 2 years in various phases. Phase 1 will be formative research with the objective of identifying knowledge gaps and baseline data collection. Phase II will involve co-development of multipronged interventions addressing identified barriers. Phase III will focus on the deployment of the selected multipronged interventions. Phase IV will be the post-intervention phase to evaluate the impact of the interventions. The study has been prospectively registered with CTRI and is supported by a funding grant from the Indian Council of Medical Research, New Delhi. The Institutional Ethics Committee approval has been obtained from all the sites involved in the study.

Impact of antibiotic prophylaxis on gut microbiota in colorectal surgery: insights from an Eastern European stewardship study

Introduction

Antibiotic overuse is driving a global rise in antibiotic resistance, highlighting the need for robust antimicrobial stewardship (AMS) initiatives to improve prescription practices. While antimicrobials are essential for treating sepsis and preventing surgical site infections (SSIs), they can inadvertently disrupt the gut microbiota, leading to postoperative complications. Treatment methods vary widely across nations due to differences in drug choice, dosage, and therapy duration, affecting antibiotic resistance rates, which can reach up to 51% in some countries. In Romania and the Republic of Moldova, healthcare practices for surgical antibiotic prophylaxis differ significantly despite similarities in genetics, culture, and diet. Romania's stricter healthcare regulations result in more standardized antibiotic protocols, whereas Moldova's limited healthcare funding leads to less consistent practices and greater variability in treatment outcomes.

Methods

This study presents the results of a prospective cross-border investigation involving 86 colorectal cancer patients from major oncological hospitals in Romania and Moldova. We analyzed fecal samples collected from patients before and 7 days post-antibiotic treatment, focusing on the V3-V4 region of the 16S rRNA gene.

Results

Our findings indicate that inconsistent antibiotic prophylaxis policies-varying in type, dosage, or therapy duration-significantly impacted the gut microbiota and led to more frequent dysbiosis compared to stricter prophylactic antibiotic practices (single dose, single product, limited time).

Discussion

We emphasize the need for standardized antibiotic prophylaxis protocols to minimize dysbiosis and its associated risks, promoting more effective antimicrobial use, particularly in low- and middle-income countries (LMICs).

Synthesizing evidence to guide the design and implementation of effective strategies for discontinuing postoperative antibiotic prophylaxis in surgical settings: an umbrella review post-WHO 2018 recommendations

BACKGROUND

Postoperative antibiotic prophylaxis (PAP) involves using antibiotics after surgery to prevent surgical site infections (SSIs). However, studies have shown that PAP offers no additional benefits compared to discontinuation after surgical incision closure, prompting its de-implementation to prevent unnecessary antibiotic use that may contribute to antibiotic resistance. We conducted this review to synthesize evidence for guiding the design and implementation of effective strategies for discontinuing PAP practice and optimizing antibiotic use in surgical settings.

METHODS

This umbrella review searched for articles from PubMed/MEDLINE and Scopus, focusing on reviews conducted on human subjects on PAP to prevent SSIs, published in English language from 2019 to 5th July 2024. This review followed guidelines from PRISMA-P and PRIOR. The risk of bias (methodological quality) was assessed using AMSTAR-2. The pooled risk ratio (RR) was estimated using a fixed-effects model (Mantel-Haenszel method), while I2 was used to assess the heterogeneity between reviews. This review was registered with PROSPERO (CRD42024566124).

RESULTS

In our umbrella review, we screened 1156 articles, with 28 review articles found eligible for final analysis, involving over 457 primary studies. About 80,483 patients were involved in 9 meta-analysis reviews, which were used to estimate the pooled RR. We found no significant benefits to patients from continuing PAP beyond 24-h post-surgery compared to immediate discontinuation, RR: 1.07 (95% CI: 0.97-1.17, I2: 25%, p-value: 0.22). Strategies such as regularly assessing and refining guidelines to fit specific surgical settings and patients' characteristics, multidisciplinary collaboration, availability of resources needed for best practices, education and training healthcare workers on SSI prevention and antibiotic stewardship, and patient education in SSI prevention and proper antibiotic use were recommended to improve best practices in surgical settings.

CONCLUSIONS

Prolonging antibiotic prophylaxis beyond 24-h post-surgery did not show significant protective benefits against SSIs. Our findings support the 2018 WHO recommendation for the immediate discontinuation of PAP following surgical incision closure in clean and clean-contaminated procedures. Further de-implementation research studies are needed to guide the effective discontinuation of PAP practice.

The impact of antimicrobial stewardship interventions on appropriate use of surgical antimicrobial prophylaxis in low- and middle-income countries: a systematic review

BACKGROUND

Surgical antimicrobial prophylaxis (SAP) is an effective infection prevention strategy used to reduce postoperative surgical site infection. Inappropriate use of SAP is a concern in low-middle-income countries (LMICs) due to increased mortality risks, adverse reactions, re-admission rates and length of hospital stay. Antimicrobial Stewardship Programs (ASP) have been shown to be effective in improving the appropriate use of antibiotics including the use of SAP. The aim of this review was to evaluate the impact of ASP on the appropriate use of SAP and its implication on patient outcomes in LMICs.

METHOD

The protocol for this review was registered in PROSPERO. Studies published between 1st January 2010 and 31st December 2023 were searched electronically from Medline, Central Cochrane Library, web of science, CINAHL and APA PsychInfo databases. Studies were included if they assessed the impact of ASP interventions on SAP use in low- and middle-income countries (LMICs). Studies were evaluated using the Risk of Bias in Non-Randomized Studies-of Interventions (ROBINS-I) tool for non-randomized and before and after studies as well as the Cochrane Risk of Bias 2 (ROB 2) tool for randomized studies. Findings were summarized in tables.

RESULTS

Twenty studies comprising of seventeen before-after studies, two interrupted time series, and one randomized controlled trial were included. Penicillins and cephalosporins were the most commonly used antibiotics for SAP. Most (50%) of the studies were conducted in Asia followed by Africa (45%). While 80% of the studies showed the impact of ASP on compliance to SAP guidelines, only 45% showed an impact on antibiotic utilization. Again, 50% and 60% showed an impact on reducing antibiotic costs and patient length of stay at hospitals respectively. Patient outcomes including rates of surgical site infections and mortality showed no significant change. The studies showed a high risk of bias mainly due to the choice of study designs.

CONCLUSION

ASP interventions in LMICs are effective in improving SAP guideline adherence, antibiotic utilization and their cost. Deliberate effort must be made to improve on the quality of future interventional studies in these settings to guide practice and encourage other LMICs to conduct such studies to assess the influence of different geographical contexts on SAP use.

Antimicrobial Use Among Hospitalized Neonates and Children; Findings and Implications from a Comprehensive Point Prevalence Survey Among General Tertiary Hospitals in Pakistan

Purpose

Antimicrobial resistance is a global health crisis exacerbated by excessive and inappropriate use of antibiotics, especially among low- and middle-income countries including Pakistan. The paediatric population is a key area in view of their vulnerability and excessive prescribing of antibiotics in Pakistan. Consequently, there is an urgent need to robustly assess antimicrobial use among hospitalized neonates and children in tertiary hospitals in Pakistan as they are generally the training centres for new physicians subsequently treating children.

Patients and Methods

A point prevalence survey (PPS) was conducted in the children's wards of 14 tertiary care hospitals in Punjab Province, covering over 50% of the population of Pakistan. This builds on a previous PPS among tertiary care hospitals treating exclusively neonates and children.

Results

A total of 1811 neonates and children were surveyed with 1744 patients prescribed antibiotics, a prevalence of 96.3%. A total of 2747 antibiotics were prescribed to these 1744 neonates and children, averaging 1.57 antibiotics per patient. Overall, 57.7% of the patients were prescribed one antibiotic and 27.2% two antibiotics, with 85.6% of antibiotics administered parenterally. Over a third (34.4%) of the antibiotics were prescribed prophylactically, with 44.7% of them for surgical procedures. Among those prescribed antibiotics for surgical procedures, 75.2% were prescribed for more than one day. Overall, 92.2% of antibiotics were prescribed empirically, with 86.2% prescribed without mentioning the rationale for their choice in the notes, with 77.6% having no stop date. Respiratory tract infections were the most common indication (43.4%). Staphylococcus species (36.0%) were the most common pathogen with limited Culture and Sensitivity Testing performed. Three quarters (75.2%) of antibiotics were from the Watch list, and 24.4% were Access antibiotics.

Conclusion

A very high prevalence of antibiotic use among neonates and children in tertiary hospitals in Pakistan, including Watch antibiotics, mirroring previous studies. Consequently, initiatives including antimicrobial stewardship programmes are urgently needed to address current inappropriate prescribing.

Impact of a persuasive antimicrobial stewardship programme on the appropriateness of surgical antimicrobial prophylaxis in a tertiary care hospital in southern Italy

BACKGROUND AND AIM

The aim of our study was to evaluate the rate of compliance to institutional guidelines on surgical antimicrobial prophylaxis (SAP) among the surgical wards of our facility and to evaluate the impact of our antimicrobial stewardship programme (ASP) on the adherence rate.

METHODS

We conducted a cross-sectional study including all 14 surgical wards of our hospital. Eight of these wards participate in a non-restrictive ASP. All patients admitted to one of the wards who had been prescribed SAP were included; the appropriateness of prophylaxis was defined according to the institutional protocols.

RESULTS

During the study period, we evaluated 169 patients undergoing a surgical procedure, of whom 105 (62.1%) received SAP. Overall, 10 (10.5%) patients were prescribed unnecessary prophylaxis; among the remaining 95, 30 (31.6%) received appropriate prophylaxis, while 65 (68.4%) were prescribed SAP deemed inappropriate for one or more reasons (38.5% received a drug with a larger spectrum of activity, 9.2% a molecule with a narrower spectrum, 36.9% an incorrect dose and 76.9% a longer duration of prophylaxis). A higher number of patients in the inappropriate prophylaxis group received abdominal surgery (P = 0.001) and were admitted to a ward not participating in the ASP (P < 0.001). At multivariate analysis, being admitted to an ASP unit was the only factor independently related to having received appropriate prophylaxis.

CONCLUSIONS

A low rate of adherence to local guidelines on SAP was observed, but a non-restrictive ASP can significantly impact the appropriateness of surgical prophylaxis.

Qualitative drivers of postoperative prophylactic antibiotics use and resistance in Ethiopia

BACKGROUND

The World Health Organization (WHO) cautions against unnecessary prolongation of postoperative antibiotics to prevent surgical site infections (SSI), however this practice is still common in many countries. This study aims to describe drivers of prolonged postoperative antibiotic prescribing and clinicians' perspectives on antibiotics resistance and stewardship in Ethiopia.

METHODS

We conducted semi-structured interviews of 16 surgeons and nine surgical ward nurses at three academic referral hospitals in Addis Ababa. Audio recordings were transcribed verbatim and coded. Codes were inductively and iteratively derived between two researchers, tested for inter-rater reliability (IRR), and the codebook was consistently applied to all transcripts. Thematic analysis was performed to understand drivers of prolonged prophylactic antibiotic use in surgical patients.

RESULTS

Interviews revealed factors contributing to postoperative prophylactic antibiotics overprescribing, including inadequate infection prevention and control (IPC) practices, wide variability in local prescribing practices, and distrust in the applicability of WHO guidelines. Antimicrobial resistance was also identified as a major concern by staff. Barriers to improving stewardship included a lack of multidisciplinary teamwork to inform prescribing decisions, while solutions included constructing appropriate context-specific guidelines and improving evidence-based practices through input from local stakeholders, including surgeons, clinical pharmacists, and nurses.

CONCLUSIONS

Study participants perceived that existing evidence and guidelines did not apply in their settings due to high rates of surgical site infections and gaps in perioperative IPC practices (e.g., availability of water for handwashing, sterility breaches). These gaps were a key contributor to prophylactic antibiotic overprescribing, reinforcing the need to strengthen upstream and perioperative surgical antisepsis processes. The findings of this study underscore the importance of engaging multidisciplinary teams in strengthening antimicrobial stewardship efforts, aligning processes to achieve compliance with best practices, and the need for rigorous, contextually appropriate studies from these settings to inform policy.

Point prevalence survey of antibiotics use among hospitalised neonates and children in Saudi Arabia: findings and implications

Background

Neonates and children are more susceptible to a variety of infections, leading to frequent antibiotic prescriptions. However, the inappropriate use of antibiotics leads to antibiotic resistance and higher mortality rates. Therefore, this study aimed to determine the prevalence of antibiotic use, and current antibiotic prescribing practices among neonates and children admitted in the selected hospitals of Saudi Arabia.

Methods

A cross-sectional study was conducted from September to November 2023 to assess the prevalence of antibiotic use, and the current antibiotic prescribing practices across six hospitals of Saudi Arabia.

Results

The study included 499 children and neonates, with 94.6% receiving antibiotic prescriptions. The most frequently prescribed antibiotic class was third-generation cephalosporin (31.5%), with ceftriaxone being the most commonly prescribed antibiotic (15%). The majority of patients were prescribed one antibiotic (81.4%), and the intravenous route (96.4%) was the primary route for administration. The majority of patients were prescribed antibiotics empirically (69.7%), and community-acquired infections (64.2%) were the most common type of infection for antibiotic prescription. Similarly, sepsis (39.2%) was the most common indication for antibiotics, and the majority of prescribed antibiotics (61.7%) belonged to the 'Watch' category as per WHO AWaRe classification.

Conclusion

Our study revealed excessive antibiotic consumption in neonates and children, therefore quality improvement programmes including antimicrobial stewardship programmes are urgently needed to address ongoing issues.

Antimicrobial stewardship program for gastrointestinal surgeries at a Vietnamese tertiary hospital

Background

Antimicrobial Stewardship Programs (ASP) have been applied widely in high-resource countries to prevent surgical site infections (SSI). Evidence favoring ASP interventions (ASPi) in gastrointestinal surgeries from low and middle-income countries has been limited, especially in antimicrobial prophylaxis. We aimed to investigate this gap at a Vietnamese tertiary hospital.

Methods

We conducted a retrospective cohort study on patients undergoing clean-contaminated surgeries in 2015 who received standard of care (SoC) or SoC + ASPi. Primary outcome was 30-day SSI incidence. Secondary outcomes included length of stay (LoS) after surgery (days), cost of antibiotics, and cost of treatment (USD). Results were controlled for multiplicity and reported with treatment effect and 95% confidence interval (95%CI). A predictive model was built and cross-validated to detect patients at high risk of SSI.

Results

We included 395 patients for analysis (48.1% being female, mean age 49.4 years). Compared to patients receiving SoC, those with SoC + ASPi had a lower incidence of 30-day SSI (-8.8, 95%CI: -16.0 to -1.6, p = 0.042), shorter LoS after surgery (-1.1 days, 95%CI: -1.8 to -0.4, p = 0.004), and lower cost of antibiotics (-37.3 USD, 95%CI: -59.8 to -14.8, p = 0.012) and treatment (-191.1 USD, 95%CI: -348.4 to -33.8, p = 0.042). We estimated that by detecting patients at high risk of SSI with the predictive model and providing prophylactic measures, we could save 398120.7 USD per 1,000 cases of SSI.

Conclusion

We found that ASPi were associated with a reduction in risks of SSI, hospital stays, and cost of antibiotics/treatment in a Vietnamese tertiary hospital.

Perceptions of antibiotic stewardship programmes and determinants of antibiotic prescribing patterns among physicians in tertiary hospitals in Bangladesh: implications for future policy and practice

BACKGROUND

The concerning growth of antimicrobial resistance (AMR) renders common infections life-threatening due to irrational antibiotic use and a lack of effective antimicrobial stewardship programmes (ASPs).

AIM

To investigate the awareness, perceptions and practices of physicians regarding ASPs, AMR and antibiotic prescribing in tertiary care hospitals in Bangladesh.

METHODS

This hospital-based cross-sectional survey was conducted in 11 tertiary care hospitals across Bangladesh between September 2020 and January 2021. A semi-structured questionnaire was administered through face-to-face interviews for data collection. Descriptive and multi-variate analyses were performed using STATA Version 13.

RESULTS

In total, 559 physicians were enrolled in this survey. Overall, 40.6% [95% confidence interval (CI) 36.5-44.8] of physicians reported being aware of ASPs, and this figure was higher in public hospitals compared with private hospitals (43.8% vs 27.1%). None of the study hospitals had any ASP initiatives. More than half (55.1%) of the participants were willing to receive feedback from an ASP on their antibiotic selection. Only 30.9% of respondents stated that they wait for the findings of microbiological tests before prescribing antibiotics, although challenges included empiric use of broad-spectrum antibiotics, delayed laboratory results and the existence of drug-resistant patients. In contrast, physicians aware of ASPs were 33% (adjusted odds ratio 0.67, 95% CI 0.45-0.98; P=0.033) less likely to wait for laboratory results before prescribing antibiotics. However, 42.5% of physicians considered patient affordability of purchasing antibiotics when prescribing.

CONCLUSIONS

Physicians' fundamental knowledge of ASPs and rational antibiotic prescription were found to fall short of the standard. Context-specific and integrated ASP activities, availability and use of guidelines, and improved laboratory facilities are required to battle AMR in Bangladesh.

An observational cohort study on the effects of extended postoperative antibiotic prophylaxis on surgical-site infections in low- and middle-income countries

BACKGROUND

Worldwide, approximately one in six inpatient antibiotic prescriptions are for surgical-infection prophylaxis, including postoperative prophylaxis. The WHO recommends against prolonged postoperative antibiotics to prevent surgical-site infection. However, in many low- and middle-income countries, postoperative antibiotic prophylaxis is common due to perceptions that it protects against surgical-site infection and data informing recommendations against antibiotic administration are largely derived from high-income countries. The aim of this study was to describe postoperative antibiotic-prescribing patterns and related surgical-site infection rates in hospitals in low- and middle-income countries.

METHODS

Patients from 19 hospitals in Ethiopia, Madagascar, India, and Bolivia with wound class I and II operations were included. Data on antibiotic administration, indication, surgical-site infection, length of hospital stay, and adherence to perioperative infection-prevention standards were collected by trained personnel. The association between postoperative antibiotic prophylaxis for greater than or equal to 24 h and surgical-site infection was analysed via modified robust Poisson regression, controlling for patient and procedural factors and degree of adherence to perioperative infection-prevention practices.

RESULTS

Of 8714 patients, 92.9% received antibiotics for prophylaxis after surgery and 27.7% received antibiotics for greater than or equal to 24 h. Patients receiving postoperative prophylaxis for greater than or equal to 24 h did not have lower surgical-site infection rates (Relative risk 1.09 (95% c.i. 0.89 to 1.33); P = 0.399), but the length of hospital stay was 1.4 days longer (P < 0.001).

CONCLUSION

Prolonged postoperative antibiotics did not reduce surgical-site infection, but pervasive use was associated with a longer length of hospital stay, in resource-limited healthcare systems. With the growing threat of antimicrobial resistance, surgical initiatives to implement antimicrobial stewardship programmes in low- and middle-income countries are critical.

Etiquette of the antibiotic decision-making process for surgical prophylaxis in Ethiopia: a triangulated ethnographic study

Background

Prophylactic antibiotics reduce surgery-associated infections and healthcare costs. While quantitative methods have been widely used to evaluate antibiotic use practices in surgical wards, they fall short of fully capturing the intricacies of antibiotic decision-making in these settings. Qualitative methods can bridge this gap by delving into the often-overlooked healthcare customs that shape antibiotic prescribing practices.

Aim

This study aimed to explore the etiquette of the antibiotic decision-making process of surgical prophylaxis antibiotic use at Tikur Anbessa Specialized Hospital (TASH).

Methods

The observational study was carried out at TASH, a teaching and referral hospital in Addis Ababa, Ethiopia, from 26 August 2021 to 1 January 2022. Overall, 21 business ward rounds, 30 medical record reviews, and 11 face-to-face interviews were performed sequentially to triangulate and cross-validate the qualitative observation. The data were collected until saturation. The data were cleaned, coded, summarized, and analyzed using the thematic analysis approach.

Result

Surgical antibiotic prophylaxis (SAP) discussions were infrequent during surgical ward rounds in TASH, leading to practices that deviated from established recommendations. Clear documentation differentiating SAP from other antibiotic uses was also lacking, which contributed to unjustified extended SAP use in the postoperative period. Missed SAP documentation was common for emergency surgeries, as well as initial dose timing and pre-operative metronidazole administration. Importantly, there was no standardized facility guideline or clinical protocol for SAP use. Furthermore, SAP prescriptions were often signed by junior residents and medical interns, and administration was typically handled by anesthesiologists/anesthetists at the operating theater and by nurses in the wards. This suggests a delegation of SAP decision-making from surgeons to senior residents, then to junior residents, and finally to medical interns. Moreover, there was no adequate representation from pharmacy, nursing, and other staff during ward rounds.

Conclusion

Deeply ingrained customs hinder evidence-based SAP decisions, leading to suboptimal practices and increased surgical site infection risks. Engaging SAP care services and implementing antimicrobial stewardship practices could optimize SAP usage and mitigate SSI risks.

Optimizing prophylactic antibiotic use among surgery patients in Ethiopian hospitals

BACKGROUND

Since 2018, the Ethiopian Ministry of Health (MOH) has been working to institutionalize antimicrobial stewardship (AMS) programs across the country. The US Agency for International Development Medicines, Technologies, and Pharmaceutical Services Program supported Ethiopia's multipronged One Health approach to combat AMR. The objective of this paper was to evaluate the effect of a quality improvement intervention to optimize the use of antimicrobials for surgical prophylaxis.

METHODS

Basic AMS interventions were introduced in five hospitals from January to May 2023. The AMS committees and multidisciplinary teams working at the surgical wards were trained and provided on-site support to implement surgical antibiotic prophylaxis (SAP) interventions. A before-after comparison was made for 206 medical records at baseline and 213 during the intervention phase. Qualitative data were gathered through discussions during experience-sharing workshops to supplement the quantitative results.

RESULT

There were improvements in the presurgery dose of the prophylactic antibiotic and its timing: the doses within the recommended range increased from 11.2 % to 61.0 % (p < 0.001) and the optimal timing increased from 68 % to 82.6 % (p < 0.001). The hospitals also demonstrated some nonsignificant improvement in the duration of prophylactic antibiotic use (from 35 % to 44.6 % [p = 0.106]), with change in practice hampered by practitioners' resistance to early discontinuation for fear of infection due to perceived weaknesses in infection prevention and control practices. Nonavailability of the recommended antibiotic of choice for surgical prophylaxis was another major challenge in addressing all the elements of SAP. The intervention demonstrated a significant antibiotic-related average cost saving, 51.8 Ethiopian birr (∼1 US dollar) per patient (p = 0.028).

CONCLUSION

Short-term investments with basic AMS interventions can help to improve SAP use in surgical wards. However, comprehensive success requires complementing AMS interventions with concurrent attention to proper supply chain and infection prevention and control.

An interview study to explore applied psychologists' experiences of implementing health psychology in global health partnerships: The Change Exchange

INTRODUCTION

Health partnerships in global health aim to build capacity by strengthening training and education. Health psychology has an important role to play, as traditionally health partnerships focus upon increasing capability such as increasing knowledge but do not tackle opportunity and motivation. The Change Exchange recruits applied psychologist volunteers to utilize health psychology in global health partnerships, which is a novel approach. This study aimed to understand the experiences of applied psychologist volunteers working in health partnerships and how such interventions were implemented.

METHODS

Semi-structured interviews were carried out. Interviews were analysed using inductive thematic analysis to explore the translation and implementation of health psychology in health partnerships. A deductive approach was then taken using the higher level constructs of the Normalization Process Theory to inform and interpret the themes into recommendations.

RESULTS

Fifteen applied psychologists, all of whom were from the UK and had volunteered in health partnerships between the UK and low- to middle-income countries participated. Key themes and sub-themes were identified: (1) The challenges of the application of behavioural science within the health partnerships, (2) Building relationships within the health partnership, (3) Exploring the communal and individual effort carried out within the health partnership and (4) Reflecting on the work carried out within the health partnership.

DISCUSSION

Barriers exist in regards to the implementation of health psychology in health partnerships but capacity building is possible. Recommendations suggest, future work should establish clear roles for applied psychologists in health partnerships and critical evaluation of current psychological models, methods and measures for use outside of Western, Educated, Industrialized, Rich and Democratic societies.

Using Culture Sensitivity Reports to Optimize Antimicrobial Therapy: Findings and Implications of Antimicrobial Stewardship Activity in a Hospital in Pakistan

Background: There are concerns with inappropriate prescribing of antibiotics in hospitals especially broad spectrum in Pakistan and the subsequent impact on antimicrobial resistance rates. One recognized way to reduce inappropriate prescribing is for empiric therapy to be adjusted according to the result of culture sensitivity reports. Objective: Using culture sensitivity reports to optimize antibiotic prescribing in a teaching hospital in Pakistan. Methods: A retrospective observational study was undertaken in Ghurki Trust Teaching Hospital. A total of 465 positive cultures were taken from patients during the study period (May 2018 and December 2018). The results of pathogen identification and susceptibility testing from patient-infected sites were assessed. Additional data was collected from the patient's medical file. This included demographic data, sample type, causative microbe, antimicrobial treatment, and whether empiric or definitive treatment as well as medicine costs. Antimicrobial data was assessed using World Health Organization's Defined Daily Dose methodology. Results: A total of 497 isolates were detected from the 465 patient samples as 32 patients had polymicrobes, which included 309 g-negative rods and 188 g-positive cocci. Out of 497 isolates, the most common Gram-positive pathogen isolated was Staphylococcus aureus (Methicillin-sensitive Staphylococcus aureus) (125) (25.1%) and the most common Gram-negative pathogen was Escherichia coli (140) (28.1%). Most of the gram-negative isolates were found to be resistant to ampicillin and co-amoxiclav. Most of the Acinetobacter baumannii isolates were resistant to carbapenems. Gram-positive bacteria showed the maximum sensitivity to linezolid and vancomycin. The most widely used antibiotics for empiric therapy were cefoperazone plus sulbactam, ceftriaxone, amikacin, vancomycin, and metronidazole whereas high use of linezolid, clindamycin, meropenem, and piperacillin + tazobactam was seen in definitive treatment. Empiric therapy was adjusted in 220 (71.1%) cases of Gram-negative infections and 134 (71.2%) cases of Gram-positive infections. Compared with empiric therapy, there was a 13.8% reduction in the number of antibiotics in definitive treatment. The average cost of antibiotics in definitive treatment was less than seen with empiric treatment (8.2%) and the length of hospitalization also decreased. Conclusions: Culture sensitivity reports helped reduced antibiotic utilization and costs as well as helped select the most appropriate treatment. We also found an urgent need for implementing antimicrobial stewardship programs in hospitals and the development of hospital antibiotic guidelines to reduce unnecessary prescribing of broad-spectrum antibiotics.

Healthcare Cost and Outcomes Associated With Surgical Site Infection and Patient Outcomes in Low- and Middle-Income Countries

Surgical site infection (SSI) is a growing global concern. The principal explanation for this is its adverse clinical outcomes, such as morbidity and mortality. However, the link between the economic burden of SSIs and patient outcomes needs to be sufficiently characterized. This review aims to describe the financial implications of SSIs on patient outcomes in low- and middle-income countries (LMIC). Despite the heterogeneity in study designs from multiple LMIC countries, there is a significant correlation between SSI-associated healthcare costs from increased length of stay (LOS), readmissions, reoperations, and adverse patient outcomes. This varies based on the size, degree of infection, or other patient comorbidities. SSIs are much more prevalent in LMICs. The additional financial burden incurred in managing SSIs reinforces the need to prioritize practicing interventions to prevent this complication, which resource-limited health institutions are unequipped to do and consequently have significant adverse patient outcomes.

Ongoing Strategies to Improve Antimicrobial Utilization in Hospitals across the Middle East and North Africa (MENA): Findings and Implications

Antimicrobial resistance (AMR) is an increasing global concern, increasing costs, morbidity, and mortality. National action plans (NAPs) to minimize AMR are one of several global and national initiatives to slow down rising AMR rates. NAPs are also helping key stakeholders understand current antimicrobial utilization patterns and resistance rates. The Middle East is no exception, with high AMR rates. Antibiotic point prevalence surveys (PPS) provide a better understanding of existing antimicrobial consumption trends in hospitals and assist with the subsequent implementation of antimicrobial stewardship programs (ASPs). These are important NAP activities. We examined current hospital consumption trends across the Middle East along with documented ASPs. A narrative assessment of 24 PPS studies in the region found that, on average, more than 50% of in-patients received antibiotics, with Jordan having the highest rate of 98.1%. Published studies ranged in size from a single to 18 hospitals. The most prescribed antibiotics were ceftriaxone, metronidazole, and penicillin. In addition, significant postoperative antibiotic prescribing lasting up to five days or longer was common to avoid surgical site infections. These findings have resulted in a variety of suggested short-, medium-, and long-term actions among key stakeholders, including governments and healthcare workers, to improve and sustain future antibiotic prescribing in order to decrease AMR throughout the Middle East.

Antibiotic Utilization Patterns for Different Wound Types among Surgical Patients: Findings and Implications

Antimicrobial prophylaxis is effective in reducing the rate of surgical site infections (SSIs) post-operatively. However, there are concerns with the extent of prophylaxis post-operatively, especially in low- and middle-income countries (LMICs). This increases antimicrobial resistance (AMR), which is a key issue in Pakistan. Consequently, we conducted an observational cross-sectional study on 583 patients undergoing surgery at a leading teaching hospital in Pakistan with respect to the choice, time and duration of antimicrobials to prevent SSIs. The identified variables included post-operative prophylactic antimicrobials given to all patients for all surgical procedures. In addition, cephalosporins were frequently used for all surgical procedures, and among these, the use of third-generation cephalosporins was common. The duration of post-operative prophylaxis was 3-4 days, appreciably longer than the suggestions of the guidelines, with most patients prescribed antimicrobials until discharge. The inappropriate choice of antimicrobials combined with prolonged post-operative antibiotic administration need to be addressed. This includes appropriate interventions, such as antimicrobial stewardship programs, which have been successful in other LMICs to improve antibiotic utilization associated with SSIs and to reduce AMR.

Analyzing complications and implementing solutions in a pediatric inguinal hernia cooperation program in Equatorial Guinea: a prospective cohort study

Background

Few studies have evaluated the efficacy of short-term medical missions. This study was aimed to evaluate complication rates and determine the effects of protocol changes in a pediatric inguinal hernia campaign in Equatorial Guinea and analyze post-operative follow-up capacity.

Methods

In this prospective observational cohort study, we evaluated two patient cohorts (group A, 2017-2018; group B, 2019) treated during campaigns in Equatorial Guinea for congenital inguinal pathology (hernia, hydrocele, and cryptorchidism). Patients aged < 18 years treated in referral campaigns were included. Complications occurring up to 6 months post-operatively were evaluated. Two stages were defined: Stage 1, wherein, complication rate in group A was compared to that in a control group from a tertiary hospital in Spain (with a case-control ratio of 1:2, paired according to age, sex and diagnosis); stage 2, wherein, complication rates between groups A and B were compared. Group B received a single dose of prophylactic amoxicillin-clavulanic acid. Follow-up capacity was assessed through follow-up appointments.

Results

In stage 1, complication and surgical site infection (SSI) rates were 21.3% and 7.4% in group A (n = 94), and 5.8% (p < 0.001) and 0.5% (p = 0.012) in the control group, respectively. Group A had 20.2% loss-to-follow-up. In group B (n = 62), 6-month postoperative follow-up could not be assessed owing to restrictions due to the COVID-19 pandemic, so only early complications were considered in stage 2, were complication and surgical site infection rates were 18.1% and 7.4% in group A and 11.3% (p = 0.350) and 1.6% (p = 0.150) in group B.

Conclusion

Our results showed higher than expected complication rates. Pre-operative prophylactic antibiotic could not show to reduce SSI. Further studies are needed to reduce complication rates in these campaigns. Patient loss-to-follow-up ratio warrants considering new strategies.

Ongoing Efforts to Improve Antimicrobial Utilization in Hospitals among African Countries and Implications for the Future

There are serious concerns with rising antimicrobial resistance (AMR) across countries increasing morbidity, mortality and costs. These concerns have resulted in a plethora of initiatives globally and nationally including national action plans (NAPs) to reduce AMR. Africa is no exception, especially with the highest rates of AMR globally. Key activities in NAPs include gaining a greater understanding of current antimicrobial utilization patterns through point prevalence surveys (PPS) and subsequently instigating antimicrobial stewardship programs (ASPs). Consequently, there is a need to comprehensively document current utilization patterns among hospitals across Africa coupled with ASP studies. In total, 33 PPS studies ranging from single up to 18 hospitals were documented from a narrative review with typically over 50% of in-patients prescribed antimicrobials, up to 97.6% in Nigeria. The penicillins, ceftriaxone and metronidazole, were the most prescribed antibiotics. Appreciable extended prescribing of antibiotics up to 6 days or more post-operatively was seen across Africa to prevent surgical site infections. At least 19 ASPs have been instigated across Africa in recent years to improve future prescribing utilizing a range of prescribing indicators. The various findings resulted in a range of suggested activities that key stakeholders, including governments and healthcare professionals, should undertake in the short, medium and long term to improve future antimicrobial prescribing and reduce AMR across Africa.

Appropriateness of surgical antimicrobial prophylaxis in a teaching hospital in Ghana: findings and implications

Background

Surgical site infections (SSIs) are among the most common infections seen in hospitalized patients in low- and middle-income countries (LMICs), accounting for up to 60% of hospital-acquired infections. Surgical antimicrobial prophylaxis (SAP) has shown to be an effective intervention for reducing SSIs and their impact. There are concerns of inappropriate use of SAP in Ghana and therefore our audit in this teaching hospital.

Methods

A retrospective cross sectional clinical audit of medical records of patients undergoing surgery over a 5 month duration from January to May 2021 in Ho Teaching Hospital. A data collection form was designed to collect key information including the age and gender of patients, type and duration of surgery, choice and duration of SAP. The collected data was assessed for the proportion of SAP compliance with Ghana Standard Treatment Guidelines (STGs) and any association with various patient, surgical wound and drug characteristics.

Results

Of the 597 medical records assessed, the mean age of patients was 35.6 ± 12.2 years with 86.8% (n = 518) female. Overall SAP compliance with the STG was 2.5% (n = 15). SAP compliance due to appropriate choice of antimicrobials was 67.0% (n = 400) and duration at 8.7% (n = 52). SAP compliance was predicted by duration of SAP (P < 0.000) and postoperative hospitalization duration (P = 0.005).

Conclusions

SAP compliance rate was suboptimal, principally due to a longer duration of prescription. Quality improvement measures such as education of front-line staff on guideline compliance, coupled with clinical audit and regular updates, are urgently needed to combat inappropriate prescribing and rising resistance rates.

A web-based point prevalence survey of antimicrobial use and quality indicators at Raleigh Fitkin Memorial Hospital in the Kingdom of Eswatini and the implications

OBJECTIVES

Currently there is limited knowledge regarding antimicrobial utilization patterns among public hospitals in Eswatini. This is a concern given rising resistance rates among African countries. This study aimed to address this by determining antimicrobial utilization patterns using a point prevalence survey (PPS) methodology at Raleigh Fitkin Memorial (RFM) Hospital. The findings would be used to identify potential interventions to improve future antimicrobial utilization.

METHOD

A PPS was conducted using a web-based application (App). Antimicrobials were categorized according to the World Health Organization (WHO) Access, Watch, and Reserve (AWaRe) classification. Each ward in the hospital was surveyed in one day using patient files. All patients in the ward, admitted by 08h30 on the day of the survey, were included. Ethical clearance was granted by the university and at country level.

RESULTS

Overall, 68 patient files in 12 wards were surveyed, with 88.2% (60/68) receiving at least one antimicrobial. The most widely prescribed antimicrobials were amoxicillin (24.3%), and ceftriaxone IV (21.6%), mostly from the Access group (69.9%), and zero from the Reserve group. In the past 90 days prior to admission, most patients (60.3%; 41/68) were not receiving any antimicrobials. Of concern was that antimicrobial use was empirical for all patients (100%) with mostly parenteral administration (88.3%; 91/103). In addition, the majority of surgical prophylaxis patients (80%; 12/15) were given an extended course post surgery. There was also no documented switch or stop dates, or patient culture and drug sensitivity results.

CONCLUSION

Antimicrobial utilization is high at RFM hospital. Identified targets for quality improvement programs include encouraging earlier switching to oral antimicrobials, reducing extended use for surgical prophylaxis and encouraging greater sensitivity testing and documentation stop dates. The development of the App appreciably reduced data collection times and analysis, and would be recommended for use in other public hospitals.

Tackling antimicrobial resistance across sub-Saharan Africa: current challenges and implications for the future

INTRODUCTION

Antimicrobial resistance (AMR) is a concern as this increases morbidity, mortality, and costs, with sub-Saharan Africa having the highest rates globally. Concerns with rising AMR have resulted in international, Pan-African, and country activities including the development of national action plans (NAPs). However, there is variable implementation across Africa with key challenges persisting.

AREAS COVERED

Consequently, there is an urgent need to document current NAP activities and challenges across sub-Saharan Africa to provide future guidance. This builds on a narrative review of the literature.

EXPERT OPINION

All surveyed sub-Saharan African countries have developed their NAPs; however, there is variable implementation. Countries including Botswana and Namibia are yet to officially launch their NAPs with Eswatini only recently launching its NAP. Cameroon is further ahead with its NAP than these countries; though there are concerns with implementation. South Africa appears to have made the greatest strides with implementing its NAP including regular monitoring of activities and instigation of antimicrobial stewardship programs. Key challenges remain across Africa. These include available personnel, expertise, capacity, and resources to undertake agreed NAP activities including active surveillance, lack of focal points to drive NAPs, and competing demands and priorities including among donors. These challenges are being addressed, with further co-ordinated efforts needed to reduce AMR.

Surgical antimicrobial prophylaxis among surgical patients: results from a retrospective observational study at a public hospital in Liberia

BACKGROUND

Surgical antibiotic prophylaxis (SAP) is one of the most effective measures to prevent surgical site infections (SSIs). According to WHO SAP guidelines, SAP requires appropriate indication for administration and delivery of the antimicrobial agent to the operative site through intravenous administration within 60-120 min before the initial surgical incision is made. In Liberia, it is unknown how surgeons practice and there has been anecdotal observation of antibiotic overuse.

OBJECTIVE

To elucidate baseline SAP compliance, particularly appropriate SAP use based on wound class and time of antibiotic administration.

METHODS

An observational, cross-sectional study was conducted from November to December 2017. One-day training was provided on SAP/SSI to 24 health workers by the Ministry of Health and WHO. Following this training, surgical cases (general surgery and obstetrics and gynaecology (OB/GYN) underwent chart review with focus on time of SAP administration and appropriate SAP based on Centers for Disease Control and Prevention (CDC) wound classification.

RESULTS

A total of 143 charts were reviewed. Twenty-nine (20.3%) cases showed appropriate prophylaxis through administrations of antibiotics 120 min before surgical incision, resulting in SAP compliance. One hundred and fourteen cases (79.7%) showed SAP noncompliance with timing of antibiotic administration. Of the OB/Gyn cases, 109 wounds were classified as Class I (clean) and one wound was classified as Class III (contaminated). For General Surgical cases, 32 wounds were classified as Class I and one as Class III. Of the 109 Class I OB/Gyn surgeries, 24 (22%) were appropriately given antibiotics based on the CDC wound guidelines while 78% were non-compliant with recommendations. Of the 32 Class I General surgery cases, 4 (12.5%) were compliant with antibiotics guidelines while 28 (87.5%) were not.

CONCLUSION

Compliance with SAP is low. More studies need to be done to explore the contributing factors to this. Implementing mechanisms to achieve proper use of SAP is needed.

Exploring Knowledge of Antibiotic Use, Resistance, and Stewardship Programs among Pharmacy Technicians Serving in Ambulatory Care Settings in Pakistan and the Implications

Antimicrobial resistance (AMR) is a leading global health threat, increasing morbidity, mortality, and costs, with excessive and irrational use of antimicrobials contributing to the development of AMR. Consequently, the aims of this study were to evaluate the understanding of antibiotic use, AMR, and antimicrobial stewardship programs (ASPs) among pharmacy technicians serving in ambulatory healthcare settings in Pakistan. A cross-sectional survey was conducted among pharmacy technicians serving in 144 ambulatory care settings in seven districts of Punjab province using a validated questionnaire. Overall, 376 technicians completed the survey (85.8% response rate). The majority were men (89.1%), aged 25−35 years (45.1%), serving in emergency departments (43.9%) and filling 31−60 prescriptions per day (37.5%). Most (79.5%) knew that antibiotics were one of the most frequently prescribed drug classes, while 59.8% believed antibiotics for common colds did not speed up recovery. Inadequate duration (59.6%) and inadequate dosages (57.7%) of antibiotic therapy were reported as the leading causes of AMR. Terms including ‘superbugs’, ‘multidrug resistance’, and ‘extensively drug resistance’ were known to 42.0%, 25.3%, and 20.7% of participants, respectively; however, <10% knew about ASPs, including their core elements and purpose. Our study revealed that pharmacy technicians have adequate awareness of antibiotic use but are currently unaware of AMR and ASPs, which is a concern.

High levels of surgical antibiotic prophylaxis: Implications for hospital-based antibiotic stewardship in Sierra Leone

Objective

Despite the impact of inappropriate prescribing on antibiotic resistance, data on surgical antibiotic prophylaxis in sub-Saharan Africa are limited. In this study, we evaluated antibiotic use and consumption in surgical prophylaxis in 4 hospitals located in 2 geographic regions of Sierra Leone.

Methods

We used a prospective cohort design to collect data from surgical patients aged 18 years or older between February and October 2021. Data were analyzed using Stata version 16 software.

Results

Of the 753 surgical patients, 439 (58.3%) were females, and 723 (96%) had received at least 1 dose of antibiotics. Only 410 (54.4%) patients had indications for surgical antibiotic prophylaxis consistent with local guidelines. Factors associated with preoperative antibiotic prophylaxis were the type of surgery, wound class, and consistency of surgical antibiotic prophylaxis with local guidelines. Postoperatively, type of surgery, wound class, and consistency of antibiotic use with local guidelines were important factors associated with antibiotic use. Of the 2,482 doses administered, 1,410 (56.8%) were given postoperatively. Preoperative and intraoperative antibiotic use was reported in 645 (26%) and 427 (17.2%) cases, respectively. The most commonly used antibiotic was ceftriaxone 949 (38.2%) with a consumption of 41.6 defined daily doses (DDD) per 100 bed days. Overall, antibiotic consumption was 117.9 DDD per 100 bed days. The Access antibiotics had 72.7 DDD per 100 bed days (61.7%).

Conclusions

We report a high rate of antibiotic consumption for surgical prophylaxis, most of which was not based on local guidelines. To address this growing threat, urgent action is needed to reduce irrational antibiotic prescribing for surgical prophylaxis.

An opportunity for global antimicrobial stewardship research: Refugee populations

Antimicrobial resistance is a well-known global health threat that has higher prevalence in the refugee population. Although guidance has been provided by the World Health Organization and Centers for Disease Control and Prevention on implementing antimicrobial stewardship in lower- and middle-income countries, as well as by the United Nations Refugee Agency on other infection prevention and control efforts, no specific guidance exists for implementation of stewardship in this population. We highlight challenges specific to this population, review recent studies of interest within this space, and propose a research agenda to help move stewardship forward in the refugee population. We advocate for the importance of this issue, particularly given recent current events of geopolitical volatility that render this population more vulnerable, in the setting of its already well-known numerous health challenges.

Point Prevalence Survey of Antibiotic Use across 13 Hospitals in Uganda

Standardized monitoring of antibiotic use underpins the effective implementation of antimicrobial stewardship interventions in combatting antimicrobial resistance (AMR). To date, few studies have assessed antibiotic use in hospitals in Uganda to identify gaps that require intervention. This study applied the World Health Organization’s standardized point prevalence survey methodology to assess antibiotic use in 13 public and private not-for-profit hospitals across the country. Data for 1077 patients and 1387 prescriptions were collected between December 2020 and April 2021 and analyzed to understand the characteristics of antibiotic use and the prevalence of the types of antibiotics to assess compliance with Uganda Clinical Guidelines; and classify antibiotics according to the WHO Access, Watch, and Reserve classification. This study found that 74% of patients were on one or more antibiotics. Compliance with Uganda Clinical Guidelines was low (30%); Watch-classified antibiotics were used to a high degree (44% of prescriptions), mainly driven by the wide use of ceftriaxone, which was the most frequently used antibiotic (37% of prescriptions). The results of this study identify key areas for the improvement of antimicrobial stewardship in Uganda and are important benchmarks for future evaluations.

ROLE OF PRE-CESAREAN SECTION CEFOTAXIME IN AMELIORATED POST-CESAREAN COMPLICATION

OBJECTIVE

The aim: The purpose of this study was to examine the efficacy of cefotaxime before and after skin incision in avoiding post-operative infection complications in caesarean section women, also evaluation the efficacy of cefotaxime in reducing post-caesarean section complications.

PATIENTS AND METHODS

Materials and methods: We conducted 150 women who undergoing caesarean section in the Obstetrics & Gynecological Department, Babylon government from January, 2021 to March, 2021. The caesarean operations were done by using standard protocols. Each patient was examined daily and post-operative infectious. Women were randomly divided into three groups; each group contains 50 women; Group 1: (control) given normal saline 12 hr. before and after skin incision. Group 2 (pre-operation antibiotic): given single dose of cefotaxime 1 g intravenously 12 hr. before skin incision, and Group 3 (post-operation antibiotic): given single dose of cefotaxime 1 g intravenously 12 hr after operation.

RESULTS

Results: The outcome measures were post-operative febrile morbidity, healing period and urinary tract infections, in addition to socioeconomic state of each woman.

CONCLUSION

Conclusions: cefotaxime pre-cesarean section could ameliorate post-operative problems such as infection of surgical wound, febrile, and urinary tract infections.

Antibiotic consumption among hospitalized neonates and children in Punjab province, Pakistan

BACKGROUND

Periodic surveillance of antibiotic consumption in the form of point prevalence studies is a quick and robust methodology to evaluate prescribing trends in hospitals. The current study was undertaken to document antibiotic consumption among neonates and children from hospitals in Pakistan.

METHODS

This large multicenter study using the World Health Organization standardized methodology and AWaRe (Access, Watch, and Reserve) classification examined antibiotic consumption for suspected bacterial infection among neonates and children admitted hospitals in Punjab, Pakistan.

RESULTS

A total of 708 beds of children wards of the 16 health facilities were examined. Almost all (97%) hospitalized children were prescribed antibiotics on the day of the assessment with 2.6 antibiotics per patient. The three most common indications were respiratory tract infections (31.58%), sepsis (26.52%), and prophylaxis for medical problems (10.30%). The three most frequently prescribed antibiotics were ceftriaxone (24.2%), amikacin (23.2%), and ampicillin (16.7%). Almost half of the antibiotics were prescribed from the 'Access' (49.5%) and 'Watch' (45.5%) categories under the AWaRe classification. However, no antimicrobial was prescribed from the 'Reserved' category.

CONCLUSIONS

Our findings indicate that empirical antimicrobials use among hospitalized children is highly prevalent in Pakistan. The utilization of 'Watch' category of antimicrobials is frequent, stressing immediate action.

Progress on the national action plan of Pakistan on antimicrobial resistance (AMR): a narrative review and the implications

Introduction: The emergence of antimicrobial resistance (AMR) is a threat to public health. In 2015, the World Health Organization (WHO) introduced a global action plan to tackle AMR in the World Health Assembly. Pakistan's national action plan (NAP) for AMR was released in May 2017 by the Ministry of National Health Services. Based on the NAP, strategies have been initiated on a national and provincial scale in Pakistan.Areas covered: This narrative review of the five components of the Pakistan NAP has been undertaken to discuss some of the challenges in implementation of the NAP for AMR in Pakistan including different opinions and views of key stakeholders, combined with suggestions on potential ways to reduce the burden of the AMR.Expert opinion: Going forward, healthcare authorities should focus on screening and monitoring of all the objectives of the NAP by establishing proper policies as well as promoting antimicrobial stewardship interventions and Infection prevention and control (IPC) practices. Overall, the comprehensive strengthening of the healthcare system is required to adequately implement the NAP, tackle continued inappropriate antimicrobial use and high AMR rates in Pakistan.

The Impact of Quality Improvement Interventions in Improving Surgical Infections and Mortality in Low and Middle-Income Countries: A Systematic Review and Meta-Analysis

BACKGROUND

Morbidity and mortality in surgical systems in low- and middle-income countries (LMICs) remain high compared to high-income countries. Quality improvement processes, interventions, and structure are essential in the effort to improve peri-operative outcomes.

METHODS

A systematic review and meta-analysis of interventional studies assessing quality improvement processes, interventions, and structure in developing country surgical systems was conducted according to the Preferred Reporting Items of Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies were included if they were conducted in an LMIC, occurred in a surgical setting, and measured the effect of an implementation and its impact. The primary outcome was mortality, and secondary outcomes were rates of rates of hospital-acquired infection (HAI) and surgical site infections (SSI). Prospero Registration: CRD42020171542.

RESULT

Of 38,273 search results, 31 studies were included in a qualitative synthesis, and 28 articles were included in a meta-analysis. Implementation of multimodal bundled interventions reduced the incidence of HAI by a relative risk (RR) of 0.39 (95%CI 0.26 to 0.59), the effect of hand hygiene interventions on HAIs showed a non-significant effect of RR of 0.69 (0.46-1.05). The WHO Safe Surgery Checklist reduced mortality by RR 0.68 (0.49 to 0.95) and SSI by RR 0.50 (0.33 to 0.63) and antimicrobial stewardship interventions reduced SSI by RR 0.67 (0.48-0.93).

CONCLUSION

There is evidence that a number of quality improvement processes, interventions and structural changes can improve mortality, HAI and SSI outcomes in the peri-operative setting in LMICs.

A multicentre point prevalence study of antibiotics utilization in hospitalized patients in an urban secondary and a tertiary healthcare facilities in Nigeria: findings and implications

OBJECTIVES

The understanding of antimicrobial utilization patterns is pertinent to successful implementation of the National Action Plans on Antimicrobial Resistance (AMR). There is, however, limited information on antibiotics utilization in Nigeria. This study was undertaken to build on existing information and provide direction for appropriate interventions including Antibiotics Stewardship Programs (ASP).

METHOD

A Point Prevalence Study (PPS) was conducted in two public urban health facilities in Lagos, Nigeria using a design adapted from the European Center for Disease Prevention and Control (ECDC) and Global-PPS surveys.

RESULTS

The prevalence of antibiotics use was 80.6% administered mostly parenterally (83.1% of total prescriptions) with concerns with extended surgical antibiotics prophylaxis. The mostly used antibiotics in the secondary hospital were parenteral metronidazole (32.4%), ceftriaxone (27.5%), and amoxicillin + clavulanate (8.2%) while the mostly used in the tertiary hospital were ceftriaxone (25.3%), parenteral metronidazole (19.1%), and amoxicillin + clavulanate (9.3%). There was an appreciable lack of specific functional capacities, policies, and processes to promote appropriate antimicrobial use in both hospitals.

CONCLUSIONS

There is high rate of antibiotics utilization in these facilities with lack of institutional frameworks and processes for ensuring appropriate antibiotic use. The study provides the information needed to improve future antimicrobial use in hospitals and reduce AMR.

Strategies to Improve Antimicrobial Utilization with a Special Focus on Developing Countries

Antimicrobial resistance (AMR) is a high priority across countries as it increases morbidity, mortality and costs. Concerns with AMR have resulted in multiple initiatives internationally, nationally and regionally to enhance appropriate antibiotic utilization across sectors to reduce AMR, with the overuse of antibiotics exacerbated by the COVID-19 pandemic. Effectively tackling AMR is crucial for all countries. Principally a narrative review of ongoing activities across sectors was undertaken to improve antimicrobial use and address issues with vaccines including COVID-19. Point prevalence surveys have been successful in hospitals to identify areas for quality improvement programs, principally centering on antimicrobial stewardship programs. These include reducing prolonged antibiotic use to prevent surgical site infections. Multiple activities centering on education have been successful in reducing inappropriate prescribing and dispensing of antimicrobials in ambulatory care for essentially viral infections such as acute respiratory infections. It is imperative to develop new quality indicators for ambulatory care given current concerns, and instigate programs with clear public health messaging to reduce misinformation, essential for pandemics. Regular access to effective treatments is needed to reduce resistance to treatments for HIV, malaria and tuberculosis. Key stakeholder groups can instigate multiple initiatives to reduce AMR. These need to be followed up.

A point prevalence survey of antimicrobial utilisation patterns and quality indices amongst hospitals in South Africa; findings and implications

Objectives: Antimicrobial use is growing, driven mainly by rising demands in developing countries. Knowing how antimicrobials are prescribed is important. Consequently, we undertook a point prevalence survey (PPS) quantifying antimicrobial consumption among 18 public sector hospitals across South Africa.Method: A purpose-built web-based application was used to collect PPS data.Results: Out of 4407 adult patients surveyed, 33.6% were treated with an antimicrobial. The most frequently prescribed groups were a combination of penicillins including β-lactamase inhibitors. Amoxicillin combined with an enzyme inhibitor accounted for 21.4% total DDDs. In the medical and surgical wards, Access antimicrobials (54.1%) were mostly used, while in the ICU, Watch antimicrobials (51.5%) were mostly used. Compliance with the South African Standard Treatment Guidelines and Essential Medicines List was 90.2%; however, concerns with extended use of antimicrobials for surgical prophylaxis (73.2% of patients).Conclusion: The web-based PPS tool was easy to use and successful in capturing PPS data since the results were comparable to other PPS studies across Africa. High use of amoxicillin combined with an enzyme inhibitor, possibly because it was among the broad-spectrum antimicrobials in the Access group. The findings will assist with future targets to improve antimicrobial prescribing among public sector hospitals in South Africa.

Development of a web-based application to improve data collection of antimicrobial utilization in the public health care system in South Africa

Objective

Determining antimicrobial utilization patterns in hospitals can be a challenge given personnel and resource constraints with paper-based systems. A web-based application (APP) was developed in South Africa to address this, building on a recent point prevalence survey (PPS) using a paper-based system. Consequently, there was a need to test and evaluate the ease of use of a newly developed app and potential time saving versus paper-based methods for PPS. The findings can be used to further refine the APP.

Methods

The developed app was tested in a large academic public hospital in a PPS in South Africa. During data collection, the app was evaluated for functionality on 35 variables and subsequently refined. After data collection, the app was evaluated in terms of its time-saving potential and ease of use.

Results

181 patient’s files were surveyed across 13 wards in the hospital, with the antimicrobial usage findings similar to the previous paper-based study in the same hospital. The median age for males was 45.5 years and 42 years for females. Overall 80 out of 181 (44%) patients received antibiotics. Whilst 38% (12 out of 31) of patients in the adult surgical ward received antimicrobials, the prevalence was the highest (78%) in the pediatric medical wards. All the data collectors were confident in using the app after training and found the tool is not complex at all to use. In addition, the time taken to plan for the study and to collect data was considerably reduced. Reduced time spent in data collection and analysis is important for timely instigation of quality improvement programs in resource limited settings.

Conclusions

All data collectors would recommend the app for future PPSs. Several concerns with data entry were identified, which have now been addressed. The app development has been successful and is now being deployed across South Africa as part of a national PPS as well as wider.

Key Issues Surrounding Appropriate Antibiotic Use for Prevention of Surgical Site Infections in Low- and Middle-Income Countries: A Narrative Review and the Implications

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.