Overuse of prophylactic antibiotics for elective caesarean delivery in Medani Hospital, Sudan

Antibiotic prophylaxis for caesarean delivery

The main finding of the current study was that multiple regimens for antibiotic prophylaxis were being administered to women undergoing elective CD at the Medani Maternal Hospital. The use of antibiotic prophylaxis for CD has been shown to be effective in reducing postoperative morbidity, cost and duration of hospitalization (Clifford & Daley, 2012; Smaill & Grivell, 2014; Tita et al., 2009).

Duration of antibiotic prophylaxis for caesarean delivery

The duration of prophylactic treatment administered to the women at Medani Maternal Hospital was extended to an average of 6.4 days. This is inconsistent with international guidelines, where as a short duration of prophylaxis (usually < 24 hours) is recommended, and it gives the benefit of minimal toxicity and decreases the risk of antibiotic resistance (Dellinger et al., 1994; Giuliani et al., 1999). A number of studies have concluded that a single dose regime was equally as effective as multiple dose regimes. (Bhattachan et al., 2013; Westen et al., 2015b; Ziogos et al., 2010)

International and global clinical guidelines have been prepared by a number of advisory committees on the use of antibiotic prophylaxis for women undergoing CDs. Evidence-based recommendations for the prevention of surgical site infections (Berríos-Torres et al., 2017; Review, 2017) state that antibiotic prophylaxis should be administered before skin incision, and no additional doses should have to be administered after the surgical incision is closed (Bhattachan et al., 2013; Ziogos et al., 2010). The guidelines from the American Society of Health-System Pharmacists (ASHP), recommend the use of a single dose of cefazolin administered before surgical incision (Bratzler et al., 2013). Clinical Practice Guidelines approved by the Executive and Council of the Society of Obstetricians and Gynaecologists of Canada recommends the use of a single dose of a first-generation cephalosporin, 15 to 60 minutes prior to skin incision, with no additional doses (van Schalkwyk et al., 2010). A national clinical guideline developed by the Scottish Intercollegiate Guidelines Network for antibiotic prophylaxis in surgery recommends the use of a single standard dose of narrow-spectrum, more affordable antibiotics for prophylaxis (Scottish Intercollegiate Guidelines Network, 2008).

Although many national and international guidelines recommend the use of a single dose of antibiotic for prophylaxis, in our study the average duration of prophylaxis is extended to five-seven days, which is of concern. Antibiotic prophylaxis in surgery is used for prevention of surgical site infections, with optimal use involving the use of the antibiotic agent at a dosage that ensures adequate serum and tissue concentrations during the period of potential contamination (Burke, 2001). The antibiotic should be administered for the shortest feasible period to minimize the risk of adverse effects, development of resistance, and costs. Therefore, there is no need for an extended duration for antibiotic use, as observed in this study.

Gurusamy and his collegues have demonstrated that multiple prophylactic antibiotics or an increased duration of antibiotic prophylaxis is of no advantage to surgical patients with respect of reduction of MRSA infection (Gurusamy et al., 2013). The administration of single dose antibiotic prophylaxis also reduces the load on the staff and decreased the costs, which is a good for low-resource settings. and should be adopted if the cost has to be reduced (Gidiri & Ziruma, 2014; Ijarotimi et al., 2013; Westen et al., 2015a).

The prolonged use of prophylactic antibiotics can lead to emergence of resistant bacterial strains (Harbarth et al., 2000). The indiscriminate use of antibiotic prophylaxis coupled with the great capacity of adaptation of microorganisms, enables the emergence of resistant strains, which requires, synthesis of increasingly expensive drugs, resulting in significant increases in healthcare costs.

Injectable ceftizoxime in combination with gentamicin and metronidazole after cord clamping was the most commonly prescribed regime in our study. The second-generation cephalosporin cefuroxime in combination with metronidazole was used as the second most common regime. In a similar study, Elbur and colleagues found great variation in prescribing patterns between different obstetrics units in Khartoum (Elbur et al., 2014).

The use of third generation cephalosporins, imidazole derivatives and second generation cephalosporins resemble the patterns seen in Asian countries where broad spectrum cephalosporin use is predominant (Al-Momany et al., 2009; Mahdaviazad et al., 2011) Inappropriate use of both prophylactic and therapeutic antibiotics in surgical procedures was observed in Malaysia (Lim et al., 2015). John J et al., also demonstrated inappropriate use of antibiotics in patients undergoing gynaecologic surgery in Texas (Joyce et al., 2017). In spite of this, many developed countries prefer the use of first generation cephalosporins or a combination of penicillin and betalactamase-inhibitors (Durando et al., 2012; Hosoglu et al., 2009). The inappropriate use of antibiotics may result in the development of drug-resistant organisms, which is concerning. (Dancer, 2004).The overuse of third-generation cephalosporin leads to the development of new strains of extended spectrum beta-lactamases (ESBLs), MRSA, vancomycin-resistant enterococci (VRE), and Clostridium difficile (Dancer, 2001).

Time of administration of antibiotic prophylaxis for caesarean delivery

Our study revealed that the majority (91.1%) of women received antibiotic prophylaxis after clamping of the cord. However, less surgical wound infections have been observed when antibiotics were administered prior to skin incision, and there was no increase in the adverse effects on the neonates. (Dlamini et al., 2015; Lamont & Joergensen, 2014; Tita et al., 2009).