Localised guidelines for antibiotic use before surgery can help fight superbugs

Antimicrobial resistance (AMR), the phenomenon where bacteria and other infectious agents no longer respond to treatments, is a serious and growing problem, particularly in low- and middle-income countries.

AMR is dramatically accelerated by the overuse and misuse of antibiotics and other antimicrobials in people and animals. Antibiotic-resistant infections directly resulted in the deaths of more than 1.25 million people in 2019, according to The Lancet.

The highest AMR burden is found in the western sub-Saharan African region.

In Uganda, as in other low- and middle-income countries, the trends in AMR are troubling.

A recent situational analysis conducted by the Uganda National Academy of Sciences found that “resistance to the most commonly used antimicrobials (e.g., penicillins, tetracyclines, cotrimoxazole) was in some cases above 80 percent” and that the “high prevalence” of multi-drug-resistant bacteria was particularly concerning.

Some conditions, such as upper respiratory tract infections (URTIs), have been associated with higher and/or inappropriate use of antimicrobials. Although fewer than 20 per cent of all URTIs are caused by bacteria and evidence suggests that antimicrobials play a limited role in managing URTIs, data from Uganda shows that over 50 percent of children with symptoms of acute respiratory tract infection receive an antibiotic. This indicates that a significant number of these prescriptions may be unnecessary.

One way to respond to the challenge of inappropriate antimicrobial use in hospitals is to adapt existing global best practices to local norms at the health facility level, as demonstrated by a recent study that showed some promising potential courses of action. 

A new study published in BMJ Open Quality found that notable improvements are being made in the use of antimicrobials for the treatment of urinary tract infections (UTIs) and URTIs, with fewer patients being prescribed unnecessary medicines. Like URTIs, UTIs have been associated with higher and/or inappropriate use of antimicrobials.

The authors of the study examined steps taken by six Ugandan hospitals from June 2019 to July 2022 to better manage the use of antimicrobials by clinical staff. The study found that along with training and mentorship, continuous quality improvement (CQI) can reduce the unnecessary use of antimicrobials. CQI is an iterative process for identifying performance challenges, developing and testing interventions to address those challenges, and mainstreaming the interventions into health facility practices.  

Similar significant change was not seen with respect to surgical prophylaxis, as the number of patients being prescribed antibiotics prior to surgery in an effort to prevent infection remained about the same as before the interventions.

We believe this is because Uganda lacks clinical guidelines around the use of surgical antibiotic prophylaxis (SAP). Other contributing factors to the lack of improvement could be that prescribers and other health care providers face pressure from patients and the drug industry to continue offering SAP and that some hospitals lack adequate water, sanitation, hygiene, and infection prevention and control capacity. All these factors together can lead to doctors prescribing potentially unnecessary broad-spectrum antibiotics prior to surgery. 

As a first step in addressing these issues, we believe Uganda should introduce clinical guidelines for prescribing antibiotics prior to surgery.

The World Health Organization (WHO) has guidelines for the prevention of surgical site infection, including the prophylactic use of antibiotics, which could provide a starting point.

However, like other countries, Uganda must adapt those guidelines to fit the local context and spell out clear directives for the use of antibiotics prior to surgery.

Senior Ugandan surgeons should lead the process of adapting the guidelines, which should include reinforcing infection prevention and control procedures and surveillance of surgical site infections to improve compliance with the guidelines.

The Uganda study clearly showed that guidelines are most effective in conjunction with CQI and an information ecosystem through which providers can exchange knowledge as they work to adhere to the guidelines. But even once SAP guidelines are in place, barriers to implementing them will remain. Some of those barriers include guidelines that may be unavailable to surgeons when needed (either in print form or electronically), a lack of knowledge and awareness of the guidelines, excessive workloads and time constraints, and inadequate communication about roles and responsibilities.

Stakeholders therefore must employ effective educational activities to raise knowledge and awareness of the guidelines. Other factors that have contributed to the successful adoption of SAP guidelines in other contexts include periodic audits, opportunities to give and receive feedback, and tools for computer-assisted, real-time decision-making in the surgical theatre. 

But it all must start with the guidelines themselves. When guidelines were introduced in Kenya for the use of antibiotics prior to surgery, the net cost per operation associated with IV antibiotic use was reduced by $2.50 and the nursing time spent administering those antibiotics dropped by 70 per cent Until we implement such measures in local contexts, the problem of AMR will continue to grow. We urge the Ministry of Health of Uganda to formally adopt global best practices and the recommendations of this new important research to create guidelines for the use of antibiotics before surgery as an important first step in avoiding unnecessary loss of life.