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

Abstract

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, MalaysiaCorrespondence: Brian GodmanStrathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UKTel [phone]Email [email protected]: 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

Keywords

• surgical site infections
• antibiotic prophylaxis
• timing of prophylaxis
• duration of prophylaxis
• lmics
• quality indicators