Main Findings
In our study, antibiotic prescribing at KDH showed noteworthy divergence
from the SHEA/IDSA recommendations for the prevention of SSIs in acute
care hospitals.15 This divergence is consistent with
the 29-country WHO Multicountry Survey on Maternal and Newborn Health
which found that 34.3% of included facilities in Africa, Asia, Latin
America and the Middle East reported less than 90% pre-surgical
prophylaxis coverage.31 A recent systematic review on
c-sections in SSA, which summarized 17 studies that reported on
antibiotic prescribing practices, similarly noted divergence from the
WHO’s SSI prevention guidelines.32 Deviations noted in
our study included under-use of pre-operative antibiotics, with only
67.4% of our study participants having a pre-operative antibiotic
prescribed within an hour prior to the first incision. Of concern,
nearly all patients received two antibiotics after surgery and
before discharge, while the WHO guidelines indicate none should be
prescribed in the absence of indications of infection.
One challenge for pre-operative antibiotics is that neither KDH nor RMOH
obstetrics and gynaecology guidelines specify the timing of these
antibiotics during c-section care.14 While this study
did not explore reasons for failure to administer pre-operative
antibiotics, or for the timing deviations, lack of local guidelines and
inconsistencies in guidelines released by entities like the WHO, CDC and
SHEA/IDSA may contribute to the observed variations. In fact, in the
multicountry survey conducted by the WHO, coverage of pre-surgical
prophylaxis was greater in facilities using local and WHO guidelines, as
well those reporting clinical audits of antibiotic prescribing
practices.31
Our observation of over-prescription of antibiotics post-operatively has
been noted elsewhere in SSA,33,34 and
internationally,35 showing high rates of poorly-timed
pre-surgical antibiotic doses with prophylaxis often extending beyond
the operative period. In a study at a Sudanese hospital where an overall
SSI rate of 7.8% was reported, a lack of evidence-based guidelines and
fear of the patient developing SSI complications were suggested as
possible contributors to extended post-operative prescribing by
healthcare providers.33 A follow-up study in this
setting is currently underway.
Beyond the timing and duration of the antibiotics prescribed, selection
of an antibiotic with appropriate coverage and half-life is also
important in achieving adequate pre-operative prophylaxis. At KDH,
Ceftriaxone (83.9%) was overwhelmingly the most frequently prescribed
pre-operative antibiotic, followed by Ampicillin (15.2%), the
antibiotic recommended in Rwanda’s national obstetrics and gynaecology
guidelines.14 Reasons for the predominate use of
Ceftriaxone were not elucidated in this study. Such discrepancies may
partly be explained by a GP’s training-based prescribing habits, a
consequence of antibiotic availability, a preference for oral rather
than invasively provided medications or differential pharma-driven
marketing influences. A further exploration of influencers of antibiotic
prescribing habits is needed.
When compared to international guidelines, antibiotics were over-used in
this study with respect to prolonged duration, too broad a spectrum of
antimicrobial coverage or use of multiple antimicrobial agents, as
reported elsewhere.33,35 What is not clear is whether
international guidelines—based predominantly on data from high-income
countries—are optimized for settings such as rural district hospitals
in SSA. In support of international guidelines, a recent RCT in rural
Tanzania demonstrated non-inferiority of single-dose antibiotic
prophylaxis when compared to extended antibiotic administration for
patients undergoing a c-section.9 Furthermore, despite
the high prevalence of post-operative prescribing seen in this study,
the 10.9% SSI rate found during the RCT is comparable to rates seen
throughout the region, possibly suggesting no benefit to prolonged
antibiotic duration for SSI prevention.17 However, a
recent study at KDH showed that women delivering via c-section who were
hospitalized on a day without running water were significantly more
likely to develop a SSI (manuscript in draft), suggesting that infection
risk, and therefore effective prophylaxis, may need to extend beyond the
first incision in this setting.