Key issues surrounding appropriate antibiotic use for prevention of surgical site infections in low- and middle-income countries; a narrative review and the implications

Mwita, Julius C and Ogunleye, Olayinka O. and Olalekan, Adesola and Kalungia, Aubrey C and Kurdi, Amanj and Saleem, Zikria and Sneddon, Jacqueline and Godman, Brian (2021) Key issues surrounding appropriate antibiotic use for prevention of surgical site infections in low- and middle-income countries; a narrative review and the implications. International Journal of General Medicine, 2021 (14). pp. 515-530. ISSN 1178-7074

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    Abstract

    Background: There is 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 utilisation 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 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 increase from 30.1% to 91.4%, prolonged duration reduced to 5.7% of patients and mean costs of antibiotics decreased eleven-fold. Conclusion: There are considerable concerns with timing and duration of SAP among LMICs. Multiple interventions among LMICs can address this providing future direction.