Etiquette of the antibiotic decision-making process for surgical prophylaxis in Ethiopia: a triangulated ethnographic study

BackgroundProphylactic antibiotics reduce surgery-associated infections and healthcare costs. While quantitative methods have been widely used to evaluate antibiotic use practices in surgical wards, they fall short of fully capturing the intricacies of antibiotic decision-making in these settings. Qualitative methods can bridge this gap by delving into the often-overlooked healthcare customs that shape antibiotic prescribing practices.AimThis study aimed to explore the etiquette of the antibiotic decision-making process of surgical prophylaxis antibiotic use at Tikur Anbessa Specialized Hospital (TASH).MethodsThe observational study was carried out at TASH, a teaching and referral hospital in Addis Ababa, Ethiopia, from 26 August 2021 to 1 January 2022. Overall, 21 business ward rounds, 30 medical record reviews, and 11 face-to-face interviews were performed sequentially to triangulate and cross-validate the qualitative observation. The data were collected until saturation. The data were cleaned, coded, summarized, and analyzed using the thematic analysis approach.ResultSurgical antibiotic prophylaxis (SAP) discussions were infrequent during surgical ward rounds in TASH, leading to practices that deviated from established recommendations. Clear documentation differentiating SAP from other antibiotic uses was also lacking, which contributed to unjustified extended SAP use in the postoperative period. Missed SAP documentation was common for emergency surgeries, as well as initial dose timing and pre-operative metronidazole administration. Importantly, there was no standardized facility guideline or clinical protocol for SAP use. Furthermore, SAP prescriptions were often signed by junior residents and medical interns, and administration was typically handled by anesthesiologists/anesthetists at the operating theater and by nurses in the wards. This suggests a delegation of SAP decision-making from surgeons to senior residents, then to junior residents, and finally to medical interns. Moreover, there was no adequate representation from pharmacy, nursing, and other staff during ward rounds.ConclusionDeeply ingrained customs hinder evidence-based SAP decisions, leading to suboptimal practices and increased surgical site infection risks. Engaging SAP care services and implementing antimicrobial stewardship practices could optimize SAP usage and mitigate SSI risks

Multicentre point-prevalence survey of antibiotic use and healthcare-associated infections in Ethiopian hospitals

Objective: Effective antimicrobial containment strategies such as Antimicrobial Stewardship Programs (ASPs) require comprehensive data on antibiotics use which are scarce in Ethiopia. This study sought to assess antibiotics use and healthcare-associated infections (HCAIs) in Ethiopian public hospitals. Design: We conducted a cross-sectional study using the WHO point-prevalence survey protocol for systemic antibiotics use and HCAIs for low/middle-income countries. Setting: The study was conducted among 10 public hospitals in 2021. Participants: All patients admitted to adult and paediatric inpatient and emergency wards before or at 08:00 on the survey date were enrolled. Outcome measure: The primary outcome measures were the prevalence of antibiotic use, HCAIs and the hospitals' readiness to implement ASP. Results: Data were collected from 1820 patient records. None of the surveyed hospitals had functional ASP. The common indication for antibiotics was for HCAIs (40.3%). Pneumonia was the most common bacterial infection (28.6%) followed by clinical sepsis (17.8%). Most treatments were empiric (96.7%) and the overall prevalence of antibiotic use was 63.8% with antibiotics prescription per patient ratio of 1.77. Ceftriaxone was the most commonly prescribed antibiotic (30.4%) followed by metronidazole (15.4%). Age, having HIV infection, ward type, type of hospital, catheterisation and intubation history had significant association with antibiotic use. Patients who were treated in paediatric surgical wards were about four times more likely to be on antibiotics compared with patients treated at an adult emergency ward. Patients on urinary catheter (adjusted OR (AOR)=2.74, 95% CI: 2.04 to 3.68) and intubation device (AOR=2.62, 95% CI: 1.02 to 6.76) were more likely to be on antibiotics than their non-intubated/non-catheterised counterparts. Patients treated at secondary-level hospitals had 0.34 times lower odds of being on antibiotics compared with those in tertiary hospitals. Conclusions: Antibiotic use across the surveyed hospitals was common and most were empiric which has both practical and policy implications for strengthening ASP and promoting rational antibiotics use