An Observational Study of Antibiotic Prophylaxis in Surgical Inpatients at a Tertiary Care Hospital

Abstract

Background: The study aimed to assess antibiotic prophylaxis in surgery by observing the prescribing pattern, analysing the time of administration in relation to surgery incision, categorising the types of surgery, evaluating the incidence of surgical site infection, and comparing the prescribed prophylaxis with hospital policy. Methods: In our study, 120 patients admitted to the general ward for surgery were included. The data was collected in a predesigned Profoma from surgery booklets and medication charts. The collected data included demographics, pre- and post-antibiotics, incision time, duration of surgery, and category of surgery. The data was compiled and entered in the excel. Results: In this study, we evaluated 120 patients; among them, 68.33% received prophylaxis according to hospital guidelines, where beta-lactam (63.91%) was the most commonly prescribed antibiotic, followed by metronidazole (25.55%). SSI was observed in 12% of patients. The rate of SSI was higher in prolonged surgeries and when the prophylactic antibiotic was administered more than 30 minutes before surgery. Non-adherence to guidelines had a higher risk of infection, highlighting the importance of timing and adherence to guidelines for preventing infections. Conclusions: According to our study, the most commonly prescribed antibiotics were beta-lactams, followed by metronidazole. The administration timing of the antibiotic is important because early or delayed administration of the antibiotic increases the incidence of SSI. This study highlights the importance of strategic antibiotic prophylaxis to minimise the risk of SSIs and the need to improve adherence to guidelines for better patient outcomes in surgical settings.

Keywords

Introduction

In 1992, the medical community used the term "Surgical Site Infection" (SSI) by replacing "surgical wound infection." Even with efforts to prevent SSIs, it remains a common problem and a significant source of illness and death. Patients with SSIs are more likely to die because they frequently need more surgeries, hospital readmissions, or stays in intensive care units. ^1,2,3,4 Antibiotics are often used in hospital settings; data show that over half of all patients admitted to acute care facilities are administered antibiotics. These drugs are used to treat different types of infections, both hospital-acquired and community-acquired. Additionally, before invasive procedures like surgery, antibiotics are administered as a prophylactic measure. Studies revealed that up to 50% of cases may include the unnecessary or inappropriate use of antibiotics. This highlights how important it is to adhere to the hospital guidelines for proper prescribing of antibiotics to ensure that patients receive the best care possible and lower the misuse. ^{3,5 To} reduce the incidence of surgical site infections (SSIs), antibiotic prophylaxis during surgery is essential. SSIs can result in higher morbidity, longer hospital stays, and increased healthcare costs, highlighting the importance of preventive measures.⁶ By concentrating on potential pathogens during the perioperative phase, prophylactic antibiotics can dramatically lower the risk of infection when taken effectively. According to guidelines, prophylactic antibiotics should be administered 60 minutes before surgical incision in order to guarantee enough tissue concentration at the moment of possible contamination.⁷ Several studies have shown that appropriate selection and proper administration of antibiotics can reduce the occurrence of Surgical Site Infections (SSIs) by up to 75%. However, a number of factors, including the exact timing of administration, the careful selection of the best antibiotic for the particular surgery, and the length of therapy, affect how effective antibiotic prophylaxis is.⁸ The inappropriate use of antibiotic prophylaxis may contribute to antimicrobial resistance. Antibiotic overuse or misuse, such as administering them for longer than recommended or picking broad-spectrum antibiotics prematurely, can contribute to the global rise of antibiotic-resistant organisms.⁸ As a result, antibiotic stewardship strategies are now required in surgical settings to ensure patients receive the appropriate medication, dose, and duration to prevent infections. Although there are standard guidelines for antibiotic prophylaxis, different surgeons and healthcare facilities administer it in very different ways. This variation is influenced by factors such as local infection rates, institutional protocols, surgeon preferences, and patient-specific characteristics.⁹ In low-resource settings, it can be challenging to adhere to the preventive guidelines, increasing the incidence of infection. For a better outcome, there is a need to assess current antibiotic prophylactic procedures, identify areas for improvement, and promote adherence. The aim of this observational study is to evaluate the effectiveness of antibiotic prophylaxis in surgical procedures. We observed different prophylaxis regimens and their impact on postoperative infection rates and patient outcomes.

METHODS

A hospital-based prospective observational study was conducted in the inpatient surgery department. The patients who were selected for the study were those who met the inclusion criteria fully. The first step in the study was the data collection, which mainly included the patient’s details such as age, weight, gender, date of admission, and when the drug was started. The treatment details are collected from the medication chart, which includes the type of drug used, route of administration, frequency, dose, and the time of administration, were noted in the data collection form same applies to the necessary lab parameters. The efficacy of the various antibiotics in patients was determined based on the data gathered at the end of the study.

Study procedure:

Prescriptions and treatment charts of inpatients were reviewed prospectively for prescribed patterns of antibiotics. The hospital policy, therapeutic guidelines, Medscape, Lexicomp, and reference books were used as tools to review the prescription and case chart. The case sheet, treatment chart, and physician notes were subjected to capturing any information related to the study. All medically relevant information, like demographic details, diagnosis, and type of surgery, was noted in a predefined data collection form. Patients of both genders who were admitted into the inpatient wards in the Hospital, aged >18 years group were included in the study. Detailed information, such as drug selection, brand name, dosage, frequency, route, indication, and any other relevant information, was retrieved and entered into the data collection form.

RESULTS

This study involved 120 surgical inpatients and observed the frequency of surgical site infections (SSI), hospital policy compliance, and patterns of antibiotic prophylaxis. The baseline demographic and clinical characteristics of the study population are summarised in [Table 1]. Among the 120 patients, the majority belonged to the 21–40 years age group (42.5%), followed by 41–60 years (32.5%) and patients aged more than 60 years (22.5%). The majority of patients were male (55.83%), followed by female (44.17%). The general surgery department conducted the majority of surgeries (47.5%), with orthopaedic surgery coming in second at 17.5% and ENT at 9.16%. 19.2% of instances were emergency treatments, while 47.5% involved elective surgery. With respect to operative duration, 38.33% of surgeries lasted between 1–2 hours, and 17.5% exceeded 3 hours. Clean-contaminated wounds were the most common wound classification (42.5%), followed by clean wounds (40.83%) [Table 1]. The pattern of antibiotic prophylaxis administered to surgical inpatients is presented in [Table 2]. As multiple antibiotics were prescribed to some patients, the total number of antibiotics administered exceeded the total number of study participants. The most frequently used antibiotic class was beta-lactam, accounting for 63.91% of prescriptions, followed by nitroimidazoles (25.55%). The most commonly administered antibiotic agents were metronidazole (25.55%), piperacillin/tazobactam (18.89%), amoxicillin/clavulanate (16.67%), and cefuroxime (10%). The IV route (97.89%) was used most of the time, unlike the oral route (2.10%). While most of the time these medications were given BD (43.75%), followed by TID (32.29%). Prophylactic antibiotics were administered within 30 minutes prior to surgical incision in 48.25% of cases, while 27.09% received antibiotics between 31–60 minutes before incision [Table 2]. Compliance with the hospital antibiotic prophylaxis policy is shown in [Table 3]. Of the 120 patients, 82 (68.33%) received antibiotic prophylaxis in accordance with hospital guidelines, whereas 38 patients (31.67%) demonstrated non-compliance in terms of antibiotic selection, timing, or duration. A total of 12% of patients had surgical site infections (SSIs), and the characteristics of patients who experienced SSI are summarised in [Table 4]. The majority of SSI occurred in patients undergoing procedures that lasted more than an hour, and prophylactic antibiotics were routinely supplied more than 30 minutes before incision. The culture report revealed Enterobacter species (n = 3), Klebsiella species (n = 2), Staphylococcus aureus (n = 4), and Escherichia coli (n = 5) were the most frequently isolated organisms.

DISCUSSION

This study aimed to evaluate antibiotic prophylaxis in surgery. It involved assessing prescription patterns, analysing antibiotic administration timing in relation to surgery incision, categorizing surgery types by department, assessing SSI incidence, and comparing prescribed antibiotics with hospital policy. In a similar study conducted by Belayneh Kefale et.al¹, antibiotics were used preoperatively and postoperatively, and the incidence of SSIs was assessed in 281 patients. This present study shows similar results in a total of 120 study participants, with 67(55.83%) male patients and 53(44.17%) female patients. Among 120 subjects, the highest number of patients were found in the age group of (21-40) years [Table 1]. In our study of 120 cases, 57 were from General Surgery, with 34 elective and 23 emergency surgeries. There were 21 orthopaedic cases, 11 ENT, 9 urology, 7 GI and neurosurgery, and 2 vascular and cardiothoracic cases. This aligns with Kefale et al's study¹, showing a higher percentage of general surgeries (39.1%) and mostly elective procedures (53.4%). Of the 120 patients, 51 (42.5%) underwent clean-contaminated surgeries, 49 (40.83%) underwent clean surgeries, and 10 (8.33%) were involved in dirty or contaminated procedures. The higher number of patients undergoing clean surgery is similar to the study by Kefale et.al¹. [Table 1] In our study, 83 patients received antibiotic prophylaxis 30 minutes before surgery, 48 patients between 31 minutes and 1 hour before surgery, 19 patients between 1 and 2 hours before surgery, and 22 patients 2 hours prior to surgery [Table 2]. Among 120 patients, 35 had surgeries lasting less than an hour, 46 between 1 and 2 hours, 18 between 2 and 3 hours, and 21 over 3 hours [Table 1]. This differs from Kefale et al.'s study, which showed that 71.2% of surgeries took 1–2 hours, possibly due to differences in the type of surgery.

Out of all antibiotic classes prescribed, beta-lactams were the most common (63.91%). Whereas Metronidazole (25.55%) was the most commonly prescribed antibiotic agent, followed by Piperacillin/Tazobactam (18.89%). This is similar to a study by Nehad Ahmed et al.¹¹, which found ceftriaxone (28.44%) and metronidazole (26.36%) to be the most prescribed antibiotics.  [Table 2] The study indicates a correlation between the incidence of surgical site infections (SSI), the duration of surgery, and the timing of prophylactic antibiotics. Among the 120 patients included, 14 were affected by SSI, resulting in an overall incidence rate of 12%. This result coincides with other studies conducted by 35 Fisha et al (9.9%).¹⁵ It was also found that patients with a surgery duration of more than 1 hour and a prophylaxis time of over 30 minutes in 6 out of 14 cases were more likely to experience SSI [Table 4]. This suggests that both the duration of surgery and the timing of prophylactic antibiotics may contribute to the development of SSI, which coincides with the report given by Phan Van Tuong et al. ¹⁰ The study identified various types of organisms in surgical site infections (SSI) within the population. The most commonly isolated organism was E. coli, accounting for 5 cases, followed by Staphylococcus aureus in 4 cases, Enterobacter species in 3 cases, and Klebsiella species in 2 cases [Table 4]. In this study, out of 120 patients, 82 (68.33%) complied with the hospital's prescribed guidelines for antibiotic prophylaxis, while 38 (31.67%) did not adhere to the stipulated policy. Non-adherence to hospital antibiotic prophylaxis guidelines was significantly associated with an increased incidence of surgical site infections among the study population.

DECLARATIONS

Funding: None

Ethical approval: This is an observational study, and it did not involve direct patient intervention. As per the institutional policy, formal ethical committee approval was not required.

Abbreviation:

SSI – surgical site infection; IV – intravenous; PO – per oral; OD – once daily; BD – twice daily; TID – three times daily; QID – four times daily; GI – gastrointestinal.

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