Changing Use of Surgical Antibiotic Prophylaxis in Thika Hospital, Kenya: A Quality Improvement Intervention with an Interrupted Time Series Design

Abstract

IntroductionIn low-income countries, Surgical Site Infection (SSI) is a common form of hospital-acquired infection. Antibiotic prophylaxis is an effective method of preventing these infections, if given immediately before the start of surgery. Although several studies in Africa have compared pre-operative versus post-operative prophylaxis, there are no studies describing the implementation of policies to improve prescribing of surgical antibiotic prophylaxis in African hospitals.MethodsWe conducted SSI surveillance at a typical Government hospital in Kenya over a 16 month period between August 2010 and December 2011, using standard definitions of SSI and the extent of contamination of surgical wounds. As an intervention, we developed a hospital policy that advised pre-operative antibiotic prophylaxis and discouraged extended post-operative antibiotics use. We measured process, outcome and balancing effects of this intervention in using an interrupted time series design.ResultsFrom a starting point of near-exclusive post-operative antibiotic use, after policy introduction in February 2011 there was rapid adoption of the use of pre-operative antibiotic prophylaxis (60% of operations at 1 week; 98% at 6 weeks) and a substantial decrease in the use of post-operative antibiotics (40% of operations at 1 week; 10% at 6 weeks) in Clean and Clean-Contaminated surgery. There was no immediate step-change in risk of SSI, but overall, there appeared to be a moderate reduction in the risk of superficial SSI across all levels of wound contamination. There were marked reductions in the costs associated with antibiotic use, the number of intravenous injections performed and nursing time spent administering these.ConclusionImplementation of a locally developed policy regarding surgical antibiotic prophylaxis is an achievable quality improvement target for hospitals in low-income countries, and can lead to substantial benefits for individual patients and the institution.

Antibiotic stewardship interventions in hospitals in low-and middle-income countries: a systematic review

“…Eight studies evaluated bundles combining different interventions. 36 – 43 A cluster randomized controlled trial in eight Kenyan hospitals compared a bundle containing guidelines, education and face-to-face feedback to prescribers with a similar, but less intensive bundle (fewer hours of training, written feedback; Table 2 ). 37 Comparing prescriptions for 594 children in intervention hospitals and 566 children in control hospitals showed that the intensive bundle was associated with a non-significant absolute risk reduction in inappropriate use of antibiotics for non-bloody diarrhoea of 41% (95% CI: −6 to 88%).…”

Fear and hierarchy: critical influences on antibiotic decision-making in the operating theatre

“…What is currently being done to address SAP internationally? Successful interventions to improve SAP prescribing include studies in both resource limited and resource rich settings, and include the collaborative development of guidelines, data collection on compliance with guidelines and quality assurance cycles with audit and direct prescriber feedback [7,[9][10][11]. However, in both contexts suboptimal SAP prescribing persists, and barriers to implementation are evident, including the enduring belief within surgery regarding the benefit of post-operative SAP administration to prevent SSI [10,12,13].…”

Adherence to American Society of Health‐System Pharmacists guidelines for antibiotic prophylaxis in thoracic surgery: a prospective observational study

“…However, different results were reported from the Netherlands (50%) and Nicaragua (22%) . A study conducted in Africa also found that > 99% of surgical patients received the first dose of SAP after the end of the surgical procedure . If the prophylaxis is started at the wrong time, the patients will have inadequate serum and tissue concentrations of antibiotic at the time of incision and during the surgery.…”

“…18 A study conducted in Africa also found that > 99% of surgical patients received the first dose of SAP after the end of the surgical procedure. 19 If the prophylaxis is started at the wrong time, the patients will have inadequate serum and tissue concentrations of antibiotic at the time of incision and during the surgery. This, in turn, may lead to a greater risk of contamination and SSIs.…”