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

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. Method: 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. Data collection form was designed to collect key information including the age and gender of patient, type and duration of surgery, choice and duration of SAP. Data collected were assessed for the proportion of SAP compliance with Ghana standard treatment guidelines (STG) and its 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 (pConclusion: SAP compliance rate was suboptimal, principally due to a longer duration of prescription. Quality improvement measures such as education and training 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.

Decolonizing Global Surgery

By bringing health professionals across a variety of disciplines together, we are able to share strategies and create solutions for improving surgical care to these under-serviced regions. The Bethune Round Table 2022 took place virtually, June 16 – 19 and was hosted by BGSC,in co-operation with the Canadian Network for International Surgery. The theme for the BRT 2022 was “Decolonizing Global Surgery”.

The conference program consisted of 28 panelists and speakers and 98 abstracts (46 podium presentations and 52 posters) touching upon diverse aspects of global surgery including women in surgery, indigenous health, and sustainability in global partnerships. All sessions were recorded, including abstracts. All the abstracts presented are contained within this document.

Health-care-associated bloodstream and urinary tract infections in a network of hospitals in India: a multicentre, hospital-based, prospective surveillance study

Background
Health-care-associated infections (HAIs) cause significant morbidity and mortality globally, including in low-income and middle-income countries (LMICs). Networks of hospitals implementing standardised HAI surveillance can provide valuable data on HAI burden, and identify and monitor HAI prevention gaps. Hospitals in many LMICs use HAI case definitions developed for higher-resourced settings, which require human resources and laboratory and imaging tests that are often not available.

Methods
A network of 26 tertiary-level hospitals in India was created to implement HAI surveillance and prevention activities. Existing HAI case definitions were modified to facilitate standardised, resource-appropriate surveillance across hospitals. Hospitals identified health-care-associated bloodstream infections and urinary tract infections (UTIs) and reported clinical and microbiological data to the network for analysis.

Findings
26 network hospitals reported 2622 health-care-associated bloodstream infections and 737 health-care-associated UTIs from 89 intensive care units (ICUs) between May 1, 2017, and Oct 31, 2018. Central line-associated bloodstream infection rates were highest in neonatal ICUs (>20 per 1000 central line days). Catheter-associated UTI rates were highest in paediatric medical ICUs (4·5 per 1000 urinary catheter days). Klebsiella spp (24·8%) were the most frequent organism in bloodstream infections and Candida spp (29·4%) in UTIs. Carbapenem resistance was common in Gram-negative infections, occurring in 72% of bloodstream infections and 76% of UTIs caused by Klebsiella spp, 77% of bloodstream infections and 76% of UTIs caused by Acinetobacter spp, and 64% of bloodstream infections and 72% of UTIs caused by Pseudomonas spp.

Interpretation
The first standardised HAI surveillance network in India has succeeded in implementing locally adapted and context-appropriate protocols consistently across hospitals and has been able to identify a large number of HAIs. Network data show high HAI and antimicrobial resistance rates in tertiary hospitals, showing the importance of implementing multimodal HAI prevention and antimicrobial resistance containment strategies.

Funding
US Centers for Disease Control and Prevention cooperative agreement with All India Institute of Medical Sciences, New Delhi.

Translation
For the Hindi translation of the abstract see Supplementary Materials section.

Health-care-associated infection surveillance in India

Health-care-associated infections (HAIs) are the infections acquired while patients receive treatment for medical or surgical conditions. HAIs are among the most common complications occurring during the health service delivery, often caused by endemic multidrug-resistant organisms on account of indiscriminate use of antibiotics.1 HAIs are associated with increased morbidity and mortality, prolonged hospital stays, and health-care costs. Surveillance for endemic HAIs is important to measure their burden, identify high-risk populations and procedures, and guide efforts to reduce HAI incidence. HAI surveillance is a core component of infection prevention and control programmes worldwide. The reliability of HAI surveillance depends on the use of standardised definitions. The case definitions used in National Healthcare Safety Network (NHSN) or European Centre for Disease Prevention and Control (ECDC) HAI surveillance are complex, requiring dedicated human resources and funds and expertise in diagnostics, epidemiology, and infection control. Probably on account of this, only 16% of low-income and middle-income countries (LMICs) in 2010 had HAI surveillance at the national and sub-national level.2
The frequency of different HAIs varies between countries and according to economic conditions. The risk of acquiring HAI is up to 20 times higher in LMICs.1 Surveillance from an International Nosocomial Infection Control Consortium comprising 45 LMICs, reported three to six times high pooled rates of catheter-associated urinary tract infection (CAUTI) and central line-associated bloodstream infections (CLABSI) compared with intensive care units (ICUs) in the USA.3 Surveillance data from 2004 to 2013 from 40 hospitals in India reported a pooled prevalence of CLABSI to be 5·1 per 1000 central line days and of CAUTI to be 2·1 per 1000 catheter days.4 A 2019, single-centre study in India reported a pooled CLABSI rate of 4·3 per 1000 central line days.5 In a global survey, the prevalence of resistance to antibiotics including third-generation cephalosporins and carbapenems among Enterobacteriaceae, was significantly higher in LMICs.6 High levels of resistance, including against carbapenems among Acinetobacter spp, Pseudomonas spp, and Klebsiella spp have been reported from India.7
In The Lancet Global Health, Purva Mathur and colleagues8 report results of health-care-associated bloodstream and urinary tract infections in 89 intensive care units of 26 tertiary care hospitals in India.8 The authors modified the NHSN and ECDC case definitions to facilitate standardised HAI surveillance, adjusting for the available resources in Indian hospitals. In adult and paediatric ICU types, the pooled rates of BSI ranged between 5·3–7·3 per 1000 patient days and CLABSI rates ranged between 8·3–12·1 per 1000 central line days. The pooled UTI and CAUTI rates in these ICUs ranged between 1·7–2·8 per 1000 patient days and 8·3–12·1 per 1000 catheter days, respectively. Neonatal ICUs had higher pooled BSI and CLABSI rates in all birthweight categories. The authors also report high levels of resistance to at least one carbapenem in HAIs caused by Klebsiella spp, Escherichia coli, Acinetobacter spp, and Pseudomonas spp. The rates of HAI and associated antibiotic resistance reported in this study are either similar to or higher than those from previous studies in India.
The HAI surveillance established by Mathur and colleagues8 represents a well laid foundation that needs to be continued and expanded further as a national-level surveillance system for major HAI, including ventilator-associated pneumonia and surgical site infection. However, the modified case definitions used in the study need to be validated before its large-scale implementation. This platform will also enable early detection and containment of outbreaks caused by novel or emerging infectious diseases and multidrug resistant organisms. The antimicrobial resistance data will inform local, regional, and national antimicrobial resistance stewardship strategies and initiatives. Linkage to other global HAI or antimicrobial resistance surveillance platforms, such as the Global Antimicrobial Resistance and Use Surveillance System, will enable learning and sharing of the best practices of infection prevention and control.
In India, a large segment of the population seeks in-patient health-care at secondary or district-level health facilities in public and private sectors, many of which have inadequate infection prevention and control measures. The major barriers to infection prevention and control implementation are scarcity of dedicated and trained staff, availability and inappropriate use of PPE, and sanitary and hygiene measures, compounded with patient overcrowding. The widespread transmission of infection in health facilities during the ongoing COVID-19 pandemic underscores the need for strengthening infection prevention and control practices.
In the past decade, there have been governmental initiatives, such as Kayakalp, aimed at improving and promoting the cleanliness, hygiene, waste management, and infection control practices in public health-care facilities in India.9 Although it is desirable that the national HAI surveillance system is eventually extended to district-level hospitals, the immediate priority should be to ensure that the minimum requirements of infection prevention and control are in place in these hospitals.10 The eventual outcomes of implementing evidence-based, best infection prevention and control practices will be a substantial reduction in HAIs and an improvement in the overall health-care quality.
We declare no competing interests.

Exploring the Use of Antibiotics for Dental Patients in a Middle-Income Country: Interviews with Clinicians in Two Ghanaian Hospitals

Background: Antimicrobial resistance is a global problem driven by the overuse of antibiotics. Dentists are responsible for about 10% of antibiotics usage across healthcare worldwide. Factors influencing dental antibiotic prescribing are numerous, with some differences in low- and middle-income countries compared with high-income countries. This study aimed to explore the antibiotic prescribing behaviour and knowledge of teams treating dental patients in two Ghanaian hospitals. Methods: Qualitative interviews were undertaken with dentists, pharmacists, and other healthcare team members at two hospitals in urban and rural locations. Thematic and behaviour analyses using the Actor, Action, Context, Target, Time framework were undertaken. Results: Knowledge about ‘antimicrobial resistance and antibiotic stewardship’ and ‘people and places’ were identified themes. Influences on dental prescribing decisions related to the organisational context (such as the hierarchical influence of colleagues and availability of specific antibiotics in the hospital setting), clinical issues (such as therapeutic versus prophylactic indications and availability of sterile dental instruments), and patient issues such as hygiene in the home environment, delays in seeking professional help, ability to access antibiotics in the community without a prescription and patient’s ability to pay for the complete prescription. Conclusions: This work provides new evidence on behavioural factors influencing dental antibiotic prescribing, including resource constraints which affect the availability of certain antibiotics and diagnostic tests. Further research is required to fully understand their influence and inform the development of new approaches to optimising antibiotic use by dentists in Ghana and potentially other low- and middle-income countries.

Achieving Antimicrobial Stewardship on the Global Scale: Challenges and Opportunities

Antimicrobial resistance (AMR) has been clearly identified as a major global health challenge. It is a leading cause of human deaths and also has a toll on animals, plants, and the environment. Despite the considerable socio-economic impacts, the level of awareness of the problem remains woefully inadequate, and antimicrobials are not generally recognized as a global common good, one that everyone has a role and responsibility to conserve. It is imperative for antimicrobial stewardship to be more widely implemented to achieve better control of the AMR phenomenon. The Food and Agriculture Organization (FAO) of the United Nations plays an important role in promoting and facilitating antimicrobial stewardship. The specific needs to be addressed and barriers to be overcome, in particular, in low- and middle-income countries in order to implement antimicrobial stewardship practices in agrifood systems are being identified. As a global community, it is essential that we now move beyond discussing the AMR problem and focus on implementing solutions. Thus, FAO provides multi-pronged support for nations to improve antimicrobial stewardship through programs to strengthen governance, increase awareness, develop and enhance AMR surveillance, and implement best practices related to antimicrobial resistance in agrifood systems. For example, FAO is developing a platform to collect data on AMR in animals and antimicrobial use (AMU) in plants (InFARM), working on a campaign to reduce the need to use antimicrobials, studying the use of alternatives to the use of antimicrobials (especially those used for growth promotion) and actively promoting the implementation of the Codex Alimentarius AMR standards. Together, these will contribute to the control of AMR and also bring us closer to the achievement of multiple sustainable development goals.

‘An Appraisal of the Contextual Drivers of Successful Antimicrobial Stewardship Implementation in Nigerian Healthcare Facilities.

Objectives
: Antimicrobial resistance (AMR) is a consequence of inappropriate actions, including irrational antimicrobial prescribing and use. AMR remains an emergent and significant public health threat, particularly in low and middle-income countries (LMICs), including Nigeria. Optimizing antimicrobial (AM) use through functional hospital antimicrobial stewardship (AMS) programs is one of the strategies to control the spread of AMR. Literature is replete with evidence, but few studies examined the contextual factors limiting AMS functionality at the facility levels. This study explored the intrinsic contextual factors shaping AMS practice at the three-tiered levels of care.

Methods
: This was a qualitative case study with a purposeful sample size of 30 participants drawn from two primary, two secondary, and two tertiary health facilities in Nigeria. Data were coded and categorized for thematic analysis.

Results
: Emergent themes include lack of AMS programs, inadequate guidelines, lack of modern equipment and incorrect diagnosis, absence of continuous medical education, imbalance of power among professionals, and pervasive external influence of pharmaceutical marketing companies. These finding demonstrate that the AMS program is lacking or poorly implemented at the three-tiered level of care.

Conclusion
: We recommended that health facilities establish AMS programs in line with World Health Organization’s stepwise approach. These challenges, if addressed, will promote the successful performance of the AMS program, contributing to rational AM use at all levels of care. Since primary health centres constitute 85.4% of all health facilities, customizing the AMS core elements at this level will contribute to achieving the goals of universal health care.

High levels of surgical antibiotic prophylaxis: Implications for hospital-based antibiotic stewardship in Sierra Leone

Objective:
Despite the impact of inappropriate prescribing on antibiotic resistance, data on surgical antibiotic prophylaxis in sub-Saharan Africa are limited. In this study, we evaluated antibiotic use and consumption in surgical prophylaxis in 4 hospitals located in 2 geographic regions of Sierra Leone.

Methods:
We used a prospective cohort design to collect data from surgical patients aged 18 years or older between February and October 2021. Data were analyzed using Stata version 16 software.

Results:
Of the 753 surgical patients, 439 (58.3%) were females, and 723 (96%) had received at least 1 dose of antibiotics. Only 410 (54.4%) patients had indications for surgical antibiotic prophylaxis consistent with local guidelines. Factors associated with preoperative antibiotic prophylaxis were the type of surgery, wound class, and consistency of surgical antibiotic prophylaxis with local guidelines. Postoperatively, type of surgery, wound class, and consistency of antibiotic use with local guidelines were important factors associated with antibiotic use. Of the 2,482 doses administered, 1,410 (56.8%) were given postoperatively. Preoperative and intraoperative antibiotic use was reported in 645 (26%) and 427 (17.2%) cases, respectively. The most commonly used antibiotic was ceftriaxone 949 (38.2%) with a consumption of 41.6 defined daily doses (DDD) per 100 bed days. Overall, antibiotic consumption was 117.9 DDD per 100 bed days. The Access antibiotics had 72.7 DDD per 100 bed days (61.7%).

Conclusions:
We report a high rate of antibiotic consumption for surgical prophylaxis, most of which was not based on local guidelines. To address this growing threat, urgent action is needed to reduce irrational antibiotic prescribing for surgical prophylaxis.

The Effect and Feasibility of mHealth-Supported Surgical Site Infection Diagnosis by Community Health Workers After Cesarean Section in Rural Rwanda: Randomized Controlled Trial

Background:
The development of a surgical site infection (SSI) after cesarean section (c-section) is a significant cause of morbidity and mortality in low- and middle-income countries, including Rwanda. Rwanda relies on a robust community health worker (CHW)–led, home-based paradigm for delivering follow-up care for women after childbirth. However, this program does not currently include postoperative care for women after c-section, such as SSI screenings.

Objective:
This trial assesses whether CHW’s use of a mobile health (mHealth)–facilitated checklist administered in person or via phone call improved rates of return to care among women who develop an SSI following c-section at a rural Rwandan district hospital. A secondary objective was to assess the feasibility of implementing the CHW-led mHealth intervention in this rural district.

Methods:
A total of 1025 women aged ≥18 years who underwent a c-section between November 2017 and September 2018 at Kirehe District Hospital were randomized into the three following postoperative care arms: (1) home visit intervention (n=335, 32.7%), (2) phone call intervention (n=334, 32.6%), and (3) standard of care (n=356, 34.7%). A CHW-led, mHealth-supported SSI diagnostic protocol was delivered in the two intervention arms, while patients in the standard of care arm were instructed to adhere to routine health center follow-up. We assessed intervention completion in each intervention arm and used logistic regression to assess the odds of returning to care.

Results:
The majority of women in Arm 1 (n=295, 88.1%) and Arm 2 (n=226, 67.7%) returned to care and were assessed for an SSI at their local health clinic. There were no significant differences in the rates of returning to clinic within 30 days (P=.21), with high rates found consistently across all three arms (Arm 1: 99.7%, Arm 2: 98.4%, and Arm 3: 99.7%, respectively).

Conclusions:
Home-based post–c-section follow-up is feasible in rural Africa when performed by mHealth-supported CHWs. In this study, we found no difference in return to care rates between the intervention arms and standard of care. However, given our previous study findings describing the significant patient-incurred financial burden posed by traveling to a health center, we believe this intervention has the potential to reduce this burden by limiting patient travel to the health center when an SSI is ruled out at home. Further studies are needed (1) to determine the acceptability of this intervention by CHWs and patients as a new standard of care after c-section and (2) to assess whether an app supplementing the mHealth screening checklist with image-based machine learning could improve CHW diagnostic accuracy.

A study of clinical and economic burden of surgical site infection in patients undergoing caesarian section at a tertiary care teaching hospital in India

Background
Caesarian section is one of the most commonly performed surgeries in India. Determination of the incidence as well as the clinical and financial burden of post caesarian surgical site infection (SSI) is of critical importance for all the stakeholders for rational and fair allocation of resources.

Methods
This study was a prospective observational case-control study. The mean direct and indirect cost of treatment for the cases were compared with the control patients. An unpaired t-test was used to compare the mean between the two groups.

Results
Out of 2024 patients, who underwent caesarian section during the study period, 114 had acquired incisional surgical site infection (ISSI), with the infection incidence being 5.63%. The total cost of illness due to post caesarian ISSI was almost three times higher compared to the non-infected matched control group. (P<0.0001). An average length of hospital stay in the ISSI patient group was 10 days longer than that in the control group (P<0.0001) and importantly total length of antimicrobial therapy(LOT) in patients with ISSI was also almost three times higher than the control group (P<0.0001).

Conclusion
The development of post caesarian SSI imposes a significant clinical as well as a financial burden. The study highlights the necessity of taking effective preventive measures to decrease the incidence of SSI.