Introduction
Globally, approximately 5 million cases of pregnancy-related infection occur annually, of which 75,000 result in death.1 Risk of developing a post-partum infection is much higher in low- and middle-income countries (LMICs) due to poor hygiene conditions coupled with limited resources.1,2 While access to caesarean sections (c-sections) in sub-Saharan Africa (SSA) has improved, associated surgical site infections (SSIs) present a new challenge. SSIs are one of the most common healthcare-associated infections worldwide.3 Given that c-sections comprise a large portion of surgical care in SSA, they account for a large portion of SSIs in this setting.4–6
Pre-operative antibiotic prophylaxis reduces post-caesarean infection rates,7 with one systematic review reporting a 39% decrease in SSI incidence among those receiving antibiotic prophylaxis.8 Several studies, including randomized control trials (RCTs), conducted in resource-limited settings suggest non-inferiority of single dose pre-surgical prophylaxis compared to prolonged antibiotic administration.9–11 Yet, rational antibiotic use remains a significant challenge in SSA where there are limited antimicrobial stewardship-related trainings, compliance processes, and on-site access to data-informed prescribing protocols that collectively support effective, context-specific antibiotic use practices.12
According to the World Health Organization (WHO) global guidelines for the prevention of SSIs, antibiotic prophylaxis should be administered within 120 minutes before the first incision without prolongation after completion of the operation.13 Locally, the Rwandan Ministry of Health (RMOH) protocol published in 2012 recommends use of Ampicillin for c-section pre-operative prophylaxis, but doesn’t specify timing.14 At the hospital where the study was conducted, anecdotal reports indicate general practitioners (GPs) follow Society for Healthcare Epidemiology of America (SHEA)/Infectious Disease Society of America (IDSA) guidelines, which recommend administration of intravenous antibiotics within 1 hour of incision to maximize tissue concentration.15 Inconsistences in guidance may partly account for variation in antibiotic prescribing.
In SSA, SSI incidence among women undergoing a c-section ranges from 7.1-12%.7,16 Our group recently reported a post-caesarean SSI rate of 10.9% at the district hospital involved in this study.17 While there is limited information on pathogens and antibiotic sensitivity within SSA,18–22especially with respect to post-caesarean wound infections,23–26 existing data suggest emerging antimicrobial resistance. However, to our knowledge, no study has focused on rural district hospitals. Moreover, there is a paucity of systematic data on antibiotic prescribing practices aimed at SSI prevention.22,27,28 Here, we characterize perioperative antibiotic prescriptions for women who underwent a c-section at a rural Rwandan district hospital to better understand prescribing practices as they relate to international protocols.