Surgical Antibiotic Prophylaxis Use and Surgical Site Infection Pattern in Dessie Referral Hospital, Dessie, Northeast of Ethiopia

Surgical site infection and antimicrobial prophylaxis prescribing profile, and its determinants among hospitalized patients in Northeast Ethiopia: a hospital based cross-sectional study

The inappropriate use of surgical antimicrobial prophylaxis is a common cause for increased risk of morbidity and mortality from surgical site infection in patients who underwent surgical procedures. The study aimed to evaluate surgical antimicrobial prophylaxis prescribing patterns, Surgical Site Infection (SSI), and its determinants in the surgical ward of Debre Berhan Comprehensive Specialized Hospital, northeast Ethiopia. A prospective cross-sectional study was conducted from October 1st 2022 to January 31st, 2023. Data collected from patient medical record cards and patient interviews were entered and analyzed using SPSS V26.0. The determinants of surgical site infection were determined from the multivariable logistic regression. P-value ≤ 0.05 was considered statistically significant. Ceftriaxone (70.5%) followed by a combination of ceftriaxone with metronidazole (21.90%) was the most frequently used prophylactic antibiotic. One hundred fifty-nine (78%) of patients were exposed to inappropriately used prophylactic antimicrobials and 62.2% of these were exposed to inappropriately selected antibiotics. One hundred twenty-six (61.9%) patients developed Surgical Site Infection (SSI). Duration of procedure longer than an hour and inappropriate use of antimicrobial prophylaxiswere the independent predictors for the occurrence of surgical site infections. Patients whose operation was lasted in longer than an hour were 3.39 times more likely to develop SSI compared to those whose operation was completed in less than an hour, AOR = 3.39 (95% CI: 1.24-9.30). Similarly, controlling the effect of other covariate variables, individuals who were given inappropriate antimicrobial prophylaxis were 6.67 times more likely to develop SSI compared to those given appropriate prophylaxis, AOR = 6.67 (95% CI: 1.05-42.49). The high rate of SSI requires due attention from clinicians as well as health policymakers. Duration of surgical procedure greater than an hour and inappropriate antimicrobial prophylaxis use was the independent predictor of surgical site infections.

Open tibial shaft fractures: treatment patterns in sub-Saharan Africa

Objective

Open tibial shaft fractures are a leading cause of disability worldwide, particularly in low and middle-income countries (LMICs). Guidelines for these injuries have been developed in many high-income countries, but treatment patterns across Africa are less well-documented.

Methods

A survey was distributed to orthopaedic service providers across sub-Saharan Africa. Information gathered included surgeon and practice setting demographics and treatment preferences for open tibial shaft fractures across 3 domains: initial debridement, antibiotic administration, and fracture stabilization. Responses were grouped according to country income level and were compared between LMICs and upper middle-income countries (UMICs).

Results

Responses from 261 survey participants from 31 countries were analyzed, with 80% of respondents practicing in LMICs. Most respondents were male practicing orthopaedic surgeons at a tertiary referral hospital. For all respondents, initial debridement occurred most frequently in the operating room (OR) within the first 24 hours, but LMIC surgeons more frequently reported delays due to equipment availability, treatment cost, and OR availability. Compared with their UMIC counterparts, LMIC surgeons less frequently confirmed tetanus vaccination status and more frequently used extended courses of postoperative antibiotics. LMIC surgeons reported lower rates of using internal fixation, particularly for high-grade and late-presenting fractures.

Conclusions

This study describes management characteristics of open tibial shaft fractures in sub-Saharan Africa. Notably, there were reported differences in wound management, antibiotic administration, and fracture stabilization between LMICs and UMICs. These findings suggest opportunities for standardization where evidence is available and further research where it is lacking.

Level of Evidence

VI-Cross-Sectional Study.

Cefazolin access and use in Ethiopia: A policy implication

Healthcare systems in resource-limited nations have been challenged by the shortage of essential medicines. This study explores cefazolin access and uses history in the Ethiopian healthcare delivery system, for possible policy implications. An exploratory qualitative study was conducted from July to August 2021. Semi-structured questions and observation guides were used to extract necessary data from people, documents, and field visits to hospitals, government supply agencies, and pharmaceutical business firms. The data were transcribed, coded, organized into themes, and presented. Cefazoline is the recommended first-line surgical antibiotic prophylaxis (SAP) in the Ethiopian Standard Treatment Guideline (STG) and is included in the national Essential Medicine List (EML). However, it was not available for use in the Ethiopian pharmaceutical markets for years. While the shortage might stem from supply-demand mismatches, multiple unknown issues exist in the background of the shortage. This is evidenced by the removal of cefazolin from the recent government procurement list regardless of the recommendation set in the national EML and STG. This study found a historic shortage of cefazolin in Ethiopian healthcare settings. This implies that the antibiotic availability in the pull market may not reflect required usage at facilities for several reasons including the misalignment of national guidelines and national procurement processes, and miscommunication between pharmacies and clinicians at sites on drug availability. Changing the essential medicines list and/or procurement requests without active review of the supply chain system and prescribing practices at facilities can lead to the elimination of necessary antimicrobial agents from the national public health sector supply.

Impact of COVID-19 Pandemic Lockdown on the Prognosis, Morbidity, and Mortality of Patients Undergoing Elective and Emergency Abdominal Surgery: A Retrospective Cohort Study in a Tertiary Center, Saudi Arabia

The SARS-CoV-2 pandemic's main concerns are limiting the spread of infectious diseases and upgrading the delivery of health services, infrastructure, and therapeutic provision. The goal of this retrospective cohort study was to evaluate the emergency experience and delay of elective abdominal surgical intervention at King Abdul-Aziz University Hospital from October 2019 to October 2020, with a focus on post-operative morbidity and mortality before and during the COVID-19 pandemic. This study compares two groups of patients with emergent and elective abdominal surgical procedures between two different periods; the population was divided into two groups: the control group, which included 403 surgical patients, and the lockdown group, which included 253 surgical patients. During the lockdown, surgical activity was reduced by 37.2% (p = 0.014), and patients were more likely to require reoperations and blood transfusions during or after surgery (p= 0.002, 0.021, and 0.018, respectively). During the lockdown period, the average length of stay increased from 3.43 to 5.83 days (p = 0.002), and the patients who developed complications (53.9%) were more than those in the control period (46.1%) (p = 0.001). Our tertiary teaching hospital observed a significant decline in the overall number of surgeries performed during the COVID-19 pandemic and lockdown period. During the lockdown, abdominal surgery was performed only on four patients; they were positive for COVID-19. Three of them underwent exploratory laparotomy; two of the three developed shock post-operative; one patient had colon cancer (ASA score 3), one had colon disease (ASA score 2), and two had perforated bowels (ASA scores 2 and 4, respectively). Two out of four deaths occurred after surgery. Our results showed the impact of the COVID-19 lockdown on surgical care as both 30-day mortality and total morbidity have risen considerably.

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.

Development and characterization of catechin-in-cyclodextrin-in-phospholipid liposome to eradicate MRSA-mediated surgical site infection: Investigation of their anti-infective efficacy through in vitro and in vivo studies

Methicillin-resistant Staphylococcus aureus (MRSA) is one of the prime pathogens responsible for surgical site infection (SSI). Treatment of SSI remains challenging because of resistant nature of MRSA, which is a major threat in recent years. Our previous work revealed the antibacterial potential of catechin isolated from cashewnut shell against MRSA. However, the application of catechin to treat MRSA-mediated SSI is hampered because of its poor solubility and low trans-dermal delivery. Hence, the present study focused on developing catechin-in-cyclodextrin-in-phospholipid liposome (CCPL) and evaluating its physicochemical characteristics and anti-infective efficacy through in vitro and in vivo models. Encapsulation of catechin with β-cyclodextrin and soybean lecithin was confirmed through UV-Vis spectroscopy, FTIR, and XRD techniques, while TEM imaging revealed the size of CCPL (206 nm). The CCPL displayed a higher level of water solubility (25.13%) and in vitro permeability (42.14%) compared to pure catechin. A higher level of encapsulation efficiency (98.9%) and antibacterial activity (19.8 mm of ZOI and 31.25 μg/mL of MIC) were noted in CCPL compared to the catechin/cyclodextrin complex. CCPL recorded significant and dose-dependent healing of the incision, significant reduction of bacterial count, improved epithelization, and effective prevention of inflammation in skin samples of SSI-induced Balb/c mice. Data of the present work suggest that the CCPL could be considered as a novel and potential candidate to mitigate MRSA-mediated SSI after clinical trials.

Current practices and evaluation of barriers and facilitators to surgical site infection prevention measures in Jimma, Ethiopia

Objective:

Surgical site infections (SSIs) greatly burden healthcare systems around the world, particularly in low- and middle-income countries. We sought to employ the Systems Engineering Initiative for Patient Safety (SEIPS) model to better characterize SSI prevention practices and factors affecting adherence to prevention guidelines at Jimma University Medical Center (JUMC).

Design:

Our cross-sectional study consisted of semistructured interviews designed to elicit perceptions of and barriers and facilitators to SSI prevention among surgical staff and observations of current preoperative, perioperative, and postoperative SSI prevention practices in surgical cases. Interviews were recorded, manually transcribed, and thematically coded within the SEIPS framework. Trained observers recorded compliance with the World Health Organization’s SSI prevention recommendations.

Setting:

A tertiary-care hospital in Jimma, Ethiopia.

Participants:

Surgical nurses, surgeons, and anesthetists at JUMC.

Results:

Within 16 individual and group interviews, participants cited multiple barriers to SSI prevention including shortages of water and antiseptic materials, lack of clear SSI guidelines and training, minimal Infection Prevention Control (IPC) interaction with surgical staff, and poor SSI tracking. Observations from nineteen surgical cases revealed high compliance with antibiotic prophylaxis (94.7%), hand scrubbing (100%), sterile gloves and instrument use (100%), incision site sterilization (100%), and use of surgical safety checklist (94.7%) but lower compliance with preoperative bathing (26.3%), MRSA screening (0%), and pre- and postoperative glucose (0%, 10.5%) and temperature (57.9%, 47.3%) monitoring.

Conclusions:

Utilizing the SEIPS model helped identify institution-specific barriers and facilitators that can inform targeted interventions to increase compliance with currently underperformed SSI prevention practices at JUMC.

Surgical Site Infections and Prophylaxis Antibiotic Use in the Surgical Ward of Public Hospital in Western Ethiopia: A Hospital-Based Retrospective Cross-Sectional Study

Objective

Surgical site infection (SSI) is one of the leading causes of hospital-acquired infection among hospitalized patients. It causes significant health problems and results in an extended length of hospital stay, increased cost, and increased patient morbidity and mortality. To prevent the development of SSI, surgical antibiotic prophylaxis (SAP) administration before surgery is an evidence-based practice. Therefore, this study aimed to assess the prevalence of SSIs and surgical antibiotic prophylaxis practice, and identifying the gap in practicing prophylactic surgical antibiotic use.

Methods

A retrospective cross-sectional study design was conducted on randomly selected 281 participants who fulfilled the inclusion criteria. Appropriateness of surgical antibiotic prophylaxis was assessed by clinical pharmacists based on the standard treatment guideline. Descriptive and multivariate logistic regression analyses were performed in SPSS version 25. Statistical significance was set at p <0.05.

Results

The overall prevalence of SSI was 19.6% (95% CI: 19-20.2). Majority of surgical patients (88.6%) got surgical antibiotic prophylaxis. Ceftriaxone and metronidazole (45.4%), and ceftriaxone (33.3%) were the most frequently used prophylactic antibiotics. Presence of comorbidity (AOR=9.18, 95% CI: 5.17-17.9, p<0.001), contaminated (AOR=6.01, 95% CI: 1.77-16.8, p=0.019) and dirty (AOR=7.20, 95% CI: 1.23-12.1, p=0.029) wound classes, devoid of prophylactic antibiotics (AOR=6.63, 95% CI: 0.89-19.3, p=0.006), the timing of prophylactic antibiotic administration between 1 hour and 2 hours before incision (AOR=8.2, 95% CI: 4.34-18.1, p=0.001), and 48 hours duration of surgical antimicrobial prophylaxis (AOR=7.20, 95% CI: 1.23-28.17, p=0.027) were significantly associated with the development of SSIs.

Conclusion

The prevalence of SSI was relatively high despite most surgical patients were given prophylactic antibiotics. The presence of comorbidity, contaminated and dirty wound classes, devoid of prophylactic antibiotics, administering prophylactic antibiotics between 1 hour and 2 hours before incision, and 48 hours duration of surgical antibiotic prophylaxis were significantly associated with SSIs.

Compliance of antibiotics used for surgical site infection prophylaxis among patients undergoing surgery in a Congolese teaching hospital

BACKGROUND

Surgical antibiotic prophylaxis (SAP) is one of the measures used for preventing surgical site infections. SAP has high impact but there is low compliance with antimicrobial guidelines in many developing countries like the Democratic Republic of the Congo. This study aimed to assess the compliance of antibiotics used for surgical site infection prophylaxis with international guidelines among patients undergoing surgery at the "Cliniques Universitaires du Graben" (CUG).

METHODS

This was a retrospective study including all patients who underwent surgery and received SAP between January 2017 and December 2018 at CUG. Surgical and Gynaecology-Obstetric patients were included. A total of 265 patients were included in the analysis. A standardized questionnaire was used for collecting pre-, per-, and post-operative data. The compliance of SAP was assessed for all patients. Data were analysed using SPSS version 22.

RESULTS

The compliance rate ofSAP among patients undergoing surgery at CUG was 18.1%. Emergency surgery increased the risk of SAP non-compliance by three fold (OR=3.5, 95% CI: 1.0-11.8, p = 0.033). The most frequent antibiotics used in SAP were ampicillin, cloxacillin, gentamicin and ceftriaxone, alone or in combination. Categories of non-compliance included; inappropriate initial dose of antibiotic (compliance rate of 23.8%) and incorrect duration of antibiotic use (compliance rate of 30.9%). Among the included patients, 22 (8.3%) presented with a surgical site infection, of those 20 (90.9%) had received non-compliant SAP.

CONCLUSION

The correct use of SAP among patients undergoing surgery at CUG is low. Implementing measures to optimize adherence to SAP guidelines should be encouraged. A high rate of surgical site infections is observed in cases where the SAP is prescribed or administered in a non-compliant manner.