Four parameters of the appropriateness of the antimicrobial prophylaxis, such as the choice of the antimicrobial agent, the timing of administration of the first dose, the intraoperative redosing and the duration of the prophylaxis, were analysed.
All the cases in our study received prophylactic antimicrobials prior to the surgery, even though prophylactic systemic antimicrobials are not typically indicated for the patients who undergo clean surgical procedures [11
The intravenous route which is ideally recommended, as it produces reliable and predictable serum and tissue concentrations,[13
] was used in all the cases for the preincisional antimicrobial administration.
As for the choice of the antimicrobial agent, the third generation cephalosporins were commonly used in our hospital, as noted in earlier studies which were done in India and elsewhere in Asia [9
]. The use of antimicrobials in most of these cases seemed to be empirical, based on operating surgeon’s clinical experience. The local resistance pattern might have a major influence during the drug selection.
The combination of amikacin/metronidazole with the third generation cephalosporins was noted in 30% and 32% of the pre and the postoperative cases respectively. Metronidazole has shown benefit and it has been recommended as a combination in the surgical prophylaxis, to provide an adequate anaerobic cover [2
]. A number of antimicrobial trials which had compared a variety of broad-spectrum single agents with aminoglycoside- based combinations, showed no significant differences in their efficacy [19
]. Therefore, the routine addition of an aminoglycoside to other agents which have a broad-spectrum gram-negative coverage, such as the 3rd
generation cephalosporins, has been shown to provide no additional benefit [16
Antimicrobials should be administered within sixty minutes prior to the making of the incision and ideally, as near to the time of making of the incision as possible [20
]. Achieving the proper timing and redosing when necessary, are dependent on the multidisciplinary organization of the hospital and the operating room [5
Our study faced limitations in this regards. Since our findings were limited to the information which was documented in the case records, we came across 83 cases (32%) out of 258, which had incomplete and unclear documentations, especially with regards to the timing of administration which was relative to the start of the surgery, which was similarly experienced by previous researchers as well [21
None of the patients in our study received any parenteral second or third antimicrobial doses intraoperatively, as the duration of the surgery did not exceed the recommended duration. Usually, a single dose of the antimicrobial is found to be sufficient if the duration of the surgery is four hours or less or if there is no substantial blood loss during the surgery [20
Very similar to most of the previous studies, the main parameter of concern which was noted in our study was the prolonged duration of the antibiotic prophylaxis [7
]. Overall, only 10 (3.9%) patients in our study received the antimicrobials for less than 36 hours, inspite of the published guidelines which had recommended discontinuation of the prophylaxis within 24-48 hours [17
]. A prolonged antimicrobial administration can also be harmful to the patients, as it promotes antimicrobial-resistant bacteria and increases the incidence of the antibiotic associated complications [17
About half of the patients were also prescribed topical antimicrobials like fusidic acid and povidone iodine alone and as a combination with topical metronidazole. The use of topical antimicrobials as prophylaxis is not evidence-based. A recent prospective trial which examined the use of topical fusidic acid in addition to the routine systemic antibiotics which were applied immediately after the surgical closure in the patients who underwent emergency caesarean sections, found a decrease in the SSIs from 17.1% 673-2.8% (P¼0.046) through a topical antibiotic use. However, this was a small trial (only 70 patients in total) with a high baseline rate of SSIs in the control patients [23
]. The broad-spectrum ointments provide occlusion and they may increase the epithelialization while the wound heals, but they offer only little benefit to the already epithelialized wounds [1
All the above findings suggested that the antimicrobial prophylaxis was clearly overused in our study, which was similar to the findings of several earlier studies which had reported an overuse and/or misuse of the preoperative antimicrobials in different countries [12
]. Various measures like the development of local hospital guidelines, surveillance on SSIs, educational interventions, hospital antibiotic policy, promoting good surgical techniques and strict asepsis in the operating theatre, are suggested to prevent the emergence of multiresistant organisms [14
]. The local antibiograms with organism-specific susceptibility data should be updated at least yearly, to facilitate and optimize the expert-based recommendations for the empirical therapy [6
]. Complete documentations and clear entries in the medical case records should be encouraged and ensured to assist the future studies. Our study has several limitations. Our findings were restricted to the information which was available in the medical records, the data on the postoperative infections was limited and the information on the post discharge complications was not available, thereby limiting our ability in comparing the incidence of SSIs with the data which have been reported elsewhere.
However, the findings from this baseline study represent the first step among a number of interventions which have been designed to improve the antimicrobial prescribing in our institution.