Adherence to world health organization guidelines on the practice of surgical antimicrobial prophylaxis at Moi Teaching and Referral Hospital, Eldoret, Kenya

Abstract

Background: Surgical antimicrobial prophylaxis (SAP) is important in prevention of postoperative infections which would otherwise cause morbidity and mortality. However, there are concerns about its inappropriate use globally which may account for emergence of drug-resistant pathogens. Guidelines have been developed but adherence is suboptimal. Objective: To determine the level of adherence to World Health Organization (WHO) guidelines on the practice of SAP at Moi Teaching and Referral Hospital (MTRH) and identify reasons for non-adherence. Methods: The study was done in two stages. In stage one, an audit was conducted between March 2019 and March 2020 using observational study design. In this stage a total of 224 patients who underwent elective surgical procedures were recruited using stratified sampling based on the operating specialty. By reviewing patients’ treatment sheets, discharge summaries, nursing and anesthetic charts, and by direct observations at the operating theatres, the practice of SAP was compared with WHO recommendations on timing of the 1st dose, the choice of antimicrobial, indication and duration of prophylaxis to determine adherence. In this stage, means and standard deviations were used to summarize continuous variables while categorical data were summarized using percentages and frequencies. Fisher’s exact test was used to assess association between variables and adherence. In stage 2, a crossectional study was done to obtain quantitative data that could explain reasons for non-adherence. A total of 86 healthcare providers (surgeons, anesthesiologist, nurses and pharmacists) filled self-administered closed-ended questionnaires. The tool used was formulated using information obtained from the guideline and published literature. Data was then summarized using frequencies and corresponding percentages. Results: Adherence to optimal timing of 1st dose, antimicrobial selection, indication and duration of prophylaxis were 100%, 39.7%, 85.7% and 39.7% respectively. The overall adherence to the four aspects of SAP guideline is 12.5%. Greatest discordance was observed in the duration of prophylaxis which was prolonged in 60.3%. Wound class (P=0.028) and presence of comorbidity (P= 0.003) were significantly associated with appropriate SAP use. Only 73% of the healthcare providers are aware of the WHO recommendations. The main reason for non-adherence are perceived increased risk of infection at the theatres and post-operative care rooms and lack of local hospital protocols adopting WHO recommendations cited by 81% and 47% of the healthcare providers respectively. Conclusion: Adherence to WHO guideline is low mainly due to inappropriate antimicrobial selection and their prolonged use. Lack of hospital protocols and perceived increased risk for postsurgical infection are some of the reasons for noncompliance. Recommendations: There is urgent need for intervention programs targeting the surgical team regarding SAP to create awareness and improve adherence to the guidelines. The hospital should prioritize development of local policies on the use of antimicrobials for prophylaxis in surgery. There is need to objectively assess the actual risk of postsurgical infection in the hospital to guide decision making regarding SAP use.