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.