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.