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Appropriateness of surgical antimicrobial prophylaxis in a teaching hospital in Ghana: findings and implications.

ABSTRACT:

Background

Surgical site infections (SSIs) are among the most common infections seen in hospitalized patients in low- and middle-income countries (LMICs), accounting for up to 60% of hospital-acquired infections. Surgical antimicrobial prophylaxis (SAP) has shown to be an effective intervention for reducing SSIs and their impact. There are concerns of inappropriate use of SAP in Ghana and therefore our audit in this teaching hospital.

Methods

A retrospective cross sectional clinical audit of medical records of patients undergoing surgery over a 5 month duration from January to May 2021 in Ho Teaching Hospital. A data collection form was designed to collect key information including the age and gender of patients, type and duration of surgery, choice and duration of SAP. The collected data was assessed for the proportion of SAP compliance with Ghana Standard Treatment Guidelines (STGs) and any association with various patient, surgical wound and drug characteristics.

Results

Of the 597 medical records assessed, the mean age of patients was 35.6 ± 12.2 years with 86.8% (n = 518) female. Overall SAP compliance with the STG was 2.5% (n = 15). SAP compliance due to appropriate choice of antimicrobials was 67.0% (n = 400) and duration at 8.7% (n = 52). SAP compliance was predicted by duration of SAP (P < 0.000) and postoperative hospitalization duration (P = 0.005).

Conclusions

SAP compliance rate was suboptimal, principally due to a longer duration of prescription. Quality improvement measures such as education of front-line staff on guideline compliance, coupled with clinical audit and regular updates, are urgently needed to combat inappropriate prescribing and rising resistance rates.

SUBMITTER: Sefah IA

PROVIDER: S-EPMC9549739 | biostudies-literature | 2022 Oct

REPOSITORIES: biostudies-literature

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Appropriateness of surgical antimicrobial prophylaxis in a teaching hospital in Ghana: findings and implications.

Sefah Israel Abebrese IA Denoo Edinam Yawo EY Bangalee Varsha V Kurdi Amanj A Sneddon Jacqueline J Godman Brian B

JAC-antimicrobial resistance 20221010 5

<h4>Background</h4>Surgical site infections (SSIs) are among the most common infections seen in hospitalized patients in low- and middle-income countries (LMICs), accounting for up to 60% of hospital-acquired infections. Surgical antimicrobial prophylaxis (SAP) has shown to be an effective intervention for reducing SSIs and their impact. There are concerns of inappropriate use of SAP in Ghana and therefore our audit in this teaching hospital.<h4>Methods</h4>A retrospective cross sectional clinic ...[more]

PMID: 36226227

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Project description:Importance:Surgical antimicrobial prophylaxis (SAP) is a common indication for antibiotic use in hospitals and is associated with high rates of inappropriateness. Objective:To describe the SAP prescribing practices and assess hospital, surgical, and patient factors associated with appropriate SAP prescribing. Design, Setting, and Participants:Multicenter, national, quality improvement study with retrospective analysis of data collected from Australian hospitals via Surgical National Antimicrobial Prescribing Survey audits from January 1, 2016, to June 30, 2018. Data were analyzed using multivariable logistic regression. Crude estimates of appropriateness were adjusted for factors included in the model by calculating estimated marginal means and presented as adjusted-appropriateness with 95% confidence intervals. Main Outcomes and Measures:Adjusted appropriateness and factors associated with inappropriate prescriptions. Results:A total of 9351 surgical episodes and 15 395 prescriptions (10 740 procedural and 4655 postprocedural) were analyzed. Crude appropriateness of total prescriptions was 48.7% (7492 prescriptions). The adjusted appropriateness of each surgical procedure group was low for procedural SAP, ranging from 33.7% (95% CI, 26.3%-41.2%) for dentoalveolar surgery to 68.9% (95% CI, 63.2%-74.5%) for neurosurgery. The adjusted appropriateness of postprocedural prescriptions was also low, ranging from 21.5% (95% CI, 13.4%-29.7%) for breast surgery to 58.7% (95% CI, 47.9%-69.4%) for ophthalmological procedures. The most common reason for inappropriate procedural SAP was incorrect timing (44.9%), while duration greater than 24 hours was the most common reason for inappropriate postprocedural SAP (54.3%). Conclusions and Relevance:High rates of inappropriate procedural and postprocedural antimicrobial use were demonstrated across all surgical specialties. Reasons for inappropriateness, such as timing and duration, varied according to the type of SAP and surgical specialty. These findings highlight the need for improvement in SAP prescribing and suggest potential targeted areas for action.

Project description:BackgroundSurgical antibiotic prophylaxis (SAP) is one of the most effective measures to prevent surgical site infections (SSIs). According to WHO SAP guidelines, SAP requires appropriate indication for administration and delivery of the antimicrobial agent to the operative site through intravenous administration within 60-120 min before the initial surgical incision is made. In Liberia, it is unknown how surgeons practice and there has been anecdotal observation of antibiotic overuse.ObjectiveTo elucidate baseline SAP compliance, particularly appropriate SAP use based on wound class and time of antibiotic administration.MethodsAn observational, cross-sectional study was conducted from November to December 2017. One-day training was provided on SAP/SSI to 24 health workers by the Ministry of Health and WHO. Following this training, surgical cases (general surgery and obstetrics and gynaecology (OB/GYN) underwent chart review with focus on time of SAP administration and appropriate SAP based on Centers for Disease Control and Prevention (CDC) wound classification.ResultsA total of 143 charts were reviewed. Twenty-nine (20.3%) cases showed appropriate prophylaxis through administrations of antibiotics 120 min before surgical incision, resulting in SAP compliance. One hundred and fourteen cases (79.7%) showed SAP noncompliance with timing of antibiotic administration. Of the OB/Gyn cases, 109 wounds were classified as Class I (clean) and one wound was classified as Class III (contaminated). For General Surgical cases, 32 wounds were classified as Class I and one as Class III. Of the 109 Class I OB/Gyn surgeries, 24 (22%) were appropriately given antibiotics based on the CDC wound guidelines while 78% were non-compliant with recommendations. Of the 32 Class I General surgery cases, 4 (12.5%) were compliant with antibiotics guidelines while 28 (87.5%) were not.ConclusionCompliance with SAP is low. More studies need to be done to explore the contributing factors to this. Implementing mechanisms to achieve proper use of SAP is needed.

Project description:BackgroundSurgical antimicrobial prophylaxis remains the most common indication for antimicrobial use in Australian hospitals. Despite efforts to improve practice, adherence to guideline recommendations continues to be suboptimal across surgical disciplines, including orthopaedics. The Therapeutic Guidelines: Antibiotic v16 currently advocates for single dose prophylaxis for open reduction internal fixation (ORIF) procedures. Audits undertaken in one Australian tertiary hospital have identified low levels of adherence to this recommendation. It is unclear as to why guidelines are not adhered to in this setting.AimTo understand the factors that influence multidose prescribing for ORIF procedures and the barriers and enablers to guideline use in an Australian tertiary hospital.Materials and methodsInterviews (focus groups and one-on-one sessions) were held with orthopaedic surgeons (consultants), orthopaedic registrars, pharmacists, and anaesthetists from a tertiary public hospital in Australia. The Theoretical Domains Framework (TDF) was used to analyse results.ResultsSix focus groups and three one-on-one interviews were conducted. Data were mapped to 12 TDF domains. Although clinicians were aware of guideline recommendations, this alone did not encourage the use of single dose prophylaxis. The decision to prescribe postoperative antibiotics was influenced by a combination of patient and environmental factors as well as fear of infection development. The lack of guideline specificity was commonly highlighted as a barrier to guideline use, as well as lack of agreement with guideline content. Enablers to guideline use included education that was targeted and repetitive, as well as improved dissemination of guidelines.ConclusionThere are myriad factors that influence the decision to prescribe postoperative antibiotics for ORIF procedures. By understanding the social and cultural context of a local setting and the barriers and enablers that pertain to an environment, interventions can be developed to enhance guideline use, thereby improving antimicrobial prescribing.

Project description:IntroductionThe population of the aged is increasing globally and in Ghana. In 2020, the population aged over 60 years in Ghana was 2,051,903 and this is expected to reach 2.5 million by 2025 and 6.3 million by 2050. Despite the envisaged increase in the number and life expectancy of the older population in Ghana that will require nursing care, there is a paucity of data on nursing staff knowledge and attitudes toward elderly patients in Ghana.ObjectivesThis study, therefore, assessed factors affecting the care of elderly patients among nursing staff in a tertiary referral health facility in the Volta region of Ghana.MethodsThe study employed a descriptive cross-sectional design using quantitative data collection approaches. A total of 150 nurses were sampled with a response rate of 95%. Data were analyzed using the Statistical Package for Social Sciences (SPSS) version 23. The analysis included logistic regression to predict factors associated with nurses' knowledge and attitude in caring for elderly patients, after multicollinearity diagnosis and controlling the effect of confounding variables.ResultsMajority (83.8%) of the nurses demonstrated good knowledge of the aging process, knowledge in the care of the elderly (88.7%), and (84.5%) had a positive caring attitude towards the elderly. Professional education, professional qualification, and knowledge on aged care were significantly associated with nurses' attitude towards the elderly (p<0.001), (p<0.005), and (p<0.010), respectively. Lack of special wards/facilities emerged as the predominantly perceived barrier to caring for the elderly as per the nurses' responses.ConclusionThe majority of nurses demonstrated good knowledge and attitude in the aging process and care of the aged. Lack of special wards/facilities and lack of staff motivation were the leading perceived barriers to rendering care to the elderly. Scaling up gerontological nursing programs and establishing special aged care facilities in Ghana with appropriate policy guidelines and regulations for implementation of care will help improve nurses' knowledge and caring attitudes toward the care of elderly patients. Likewise, a national geriatric care policy would help consolidate standard geriatric care in Ghana.

Project description:Background: Stress ulcer prophylaxis (SUP) prescribed in patients admitted to surgical wards with a low risk of stress-related mucosal disease (SRMD) accounted for a considerable proportion of improper use of proton pump inhibitors (PPIs). This study aimed to analyze the appropriateness of SUP prescribing patterns and identify its associated factors in the orthopedics department of a tertiary hospital in the Northwestern China. Methods: In this cross-sectional study, information regarding the demographic and clinical characteristics of 1,200 fracture inpatients who underwent surgical operations from January 2020 to August 2021 were collected from medical records. Established criteria were used to assess the appropriateness of the prescribing pattern for SUP, and the incidence of inappropriate SUP medication was calculated. Logistic regression analyses were used to identify factors associated with inappropriate SUP medication. Results: Approximately, 42.4% of the study population was interpreted as inappropriate prescription of SUP. A total of 397 (33.1%) patients received SUP without a proper indication (overprescription), and the incidence of inappropriate SUP medication was calculated to be 43.11 per 100 patient-days. In addition, 112 (9.3%) inpatients for whom SUP was indicated did not receive SUP (underprescription). PPIs were prescribed in 96.1% of the inpatients who used acid suppression therapy (AST), and intravenous PPIs accounted for 95.3% thereof. In a multivariate logistic regression analysis, age above 65 years and prolonged hospitalization were associated with overprescription of SUP. Increased number of drugs excluding PPIs, the concurrent use of systemic corticosteroids, comorbidity of hypertension, and unemployed or retired status in inpatients were associated with a reduced likelihood of overprescription for SUP. Conversely, prolonged hospitalization, the concurrent use of systemic corticosteroids or anticoagulants, and unemployed status in inpatients were positively associated with underprescription of SUP. Conclusion: There was a high prevalence of inappropriate SUP prescription among noncritically ill inpatients of fracture who underwent surgical operations. We delineated the associated factors with inappropriate SUP medication, which indicated that more information was required for clinicians about rationality and efficiency of their prescribing practices. Effective intervention strategies should be executed by clinical pharmacists to reduce improper SUP medication.

Project description:BackgroundAntimicrobial resistance threatens adequate healthcare provision against infectious diseases. Antibiograms, combined with patient clinical history, enable clinicians and pharmacists to select the best empirical treatments prior to culture results.ObjectivesTo develop a local antibiogram for the Ho Teaching Hospital.MethodsThis was a retrospective cross-sectional study, using data collected on bacterial isolates from January-December 2021. Samples from urine, stool, sputum, blood, and cerebrospinal fluid (CSF) were considered as well as, aspirates and swabs from wound, ears and vagina of patients. Bacteria were cultured on both enrichment and selective media including blood agar supplemented with 5% sheep blood and MacConkey agar, and identified by both the VITEK 2 system and routine biochemical tests. Data on routine culture and sensitivity tests performed on bacterial isolates from patient samples were retrieved from the hospital's health information system. Data were then entered into and analysed using WHONET.ResultsIn all, 891 pathogenic microorganisms were isolated from 835 patients who had positive culture tests. Gram-negative isolates accounted for about 77% of the total bacterial species. Escherichia coli (246), Pseudomonas spp. (180), Klebsiella spp. (168), Citrobacter spp. (101) and Staphylococcus spp. (78) were the five most isolated pathogens. Most of the bacterial isolates showed high resistance (>70%) to ampicillin, piperacillin, ceftazidime, ceftriaxone, cefotaxime, penicillin G, amoxicillin, amoxicillin/clavulanic acid, ticarcillin/clavulanic acid and trimethoprim/sulfamethoxazole.ConclusionsThe isolates from the various samples were not susceptible to most of the antibiotics used in the study. The study reveals the resistance patterns of E. coli and Klebsiella spp. to some antibiotics on the WHO 'Watch' and 'Reserve' lists. Using antibiograms as part of antimicrobial stewardship programmes would optimize antibiotic use and preserve their efficacy.

Dataset Information

Appropriateness of surgical antimicrobial prophylaxis in a teaching hospital in Ghana: findings and implications.

Background

Methods

Results

Conclusions

Publications

Appropriateness of surgical antimicrobial prophylaxis in a teaching hospital in Ghana: findings and implications.

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