Review of antibiotic prophylaxis for the prevention of surgical site infection in low and middle income countries (LMICs)

The Scottish Antimicrobial Prescribing Group (SAPG) is supporting two hospitals in Ghana via a Fleming Fund healthcare partnership to develop antimicrobial stewardship. Initial intelligence gathering suggests that antibiotic prophylaxis to prevent surgical site infection (SSI) is suboptimal. To inform a quality improvement programme we have reviewed the evidence for use of surgical prophylaxis in LMICs including staff behaviours and attitudes.

MEDLINE, Embase, Cochrane, CINHAL and Google Scholar were searched from inception to 22 July 2019 for trials, audits, guidelines and systematic review in English. Grey literature, websites and reference lists of included studies were searched. The following data were extracted; study characteristics, interventions, outcomes and recommendations. In view of heterogeneity between studies descriptive analysis was conducted.

Of 185 records screened, 26 studies related to SSI and timing of antibiotic prophylaxis in LMICs were included. The incidence of SSI is significantly higher in LMICs compared with high income countries, recording of infection surveillance data is poor and a lack of local guidelines for antibiotic prophylaxis. Several projects in Africa have reported reduction in SSI with single dose preoperative antibiotic use compared with post-operative prophylaxis and a reduction in cost and nurse time. Despite evidence to the contrary, many surgeons continue to use post-operative antibiotic prophylaxis.

Education to improve incidence of SSI in LMICs through appropriate antibiotic prophylaxis can be successful. Interventions must include local context and address strongly held beliefs. The establishment of local multidisciplinary teams will promote ownership and sustainability of change.