Rational use of antibiotics for major elective gynaecological and obstetrical surgical procedures: quality improvement journey from a tertiary care public facility

Abstract

BackgroundAntibiotic resistance is a global problem. Irrational use of antibiotics is rampant. Guidelines recommend administration of single dose of antibiotic for surgical antimicrobial prophylaxis (SSAP) for elective obstetrical and gynaecological surgeries. However, it is not usually adhered to in practice. Majority of women undergoing elective major gynaecological surgeries and caesarean sections in the department of obstetrics and gynaecology of our tertiary level heavy case load public health facility were receiving therapeutic antibiotics (for 7–10 days) instead of recommended SSAP. Our aim was to increase the SSAP in our setting from a baseline 2.1% to more than 60% within 6 months.MethodsAfter root cause analysis, we formulated the departmental antimicrobial policy, spread awareness and sensitised doctors and nursing officers regarding antimicrobial resistance and asepsis through lectures, group discussions and workshops. We initiated SSAP policy for elective major surgeries and formed an antimicrobial stewardship team to ensure adherence to policy and follow processes and outcomes. The point of care quality improvement (QI) methodology was used. Percentage of patients receiving SSAP out of all low-risk women undergoing elective surgery was the process indicator and percentage of patients developing surgical site infection (SSI) of all patients receiving SSAP was the outcome indicator. The impact of various interventions on these indicators was followed over time with run charts.ResultsSSAP increased from a baseline 2.1%–67.7% within 6 months of initiation of this QI initiative and has since been sustained at 80%–90% for more than 2 years without any increase in SSI rate.ConclusionQI methods can rapidly improve the acceptance and adherence to evidence-based guidelines in a busy public healthcare setting to prevent injudicious use of antibiotics.

Compliance with Antibiotic Prophylaxis in Obstetric and Gynecological Surgeries in Two Peruvian Hospitals

“…It has been shown that the publication and follow-up of clinical practice guidelines improve the proper prescription of antimicrobial prophylaxis in surgery in hospitals where they have been implemented [22][23][24]. A study evaluating surgeons' surgical prophylaxis practices found that gynecologists administered antimicrobial prophylaxis at the correct time only 51.5% of the time, and up to 35.5% administered it together with the incision [25].…”

The impact of antimicrobial management by clinical pharmacists in obstetrics and gynecology on antimicrobial indicators, bacterial resistance and drug costs from 2011 to 2021 in China

“…AMS, such as audit, feedback, education, implementation of a protocol, and a computer-assisted decision support methodology, appear to be effective in promoting adherence to surgical antibiotic prophylaxis protocols, reducing surgical site infection rate with a positive economic impact [ 52 ]. Similar management techniques in China have also been successful in other countries and regions, such as in Nigeria [ 24 ], in Italy [ 53 ], in Britain [ 54 ], in Greece [ 55 ], in Australia [ 56 ], in South Africa [ 57 ], in Pakistan [ 58 ], in Spain [ 59 ], in Iran [ 60 ], in India [ 61 ], to name but a few.…”

Addressing the high prevalence of uterine fundal pressure in low‐middle income country during vaginal delivery through a quality improvement initiative: Road to respectful maternity care

“…A QI initiative which aimed at appropriate use of antibiotics for major elective obstetrical and gynecological procedures concluded that QI initiative is effective in improving the adherence to the standard guidelines. 17 With this evidence, the current QI initiative was implemented with the goal to reduce the prevalence of UFPM. We performed the root cause analysis for the high prevalence of UFPM in the department and multiple plan-dostudy-act (PDSA) cycle was done to achieve the goal.…”

“…Use of flowcharts in the designated labor wards and discussion in the WhatsApp groups would aid in the dissemination of knowledge, especially in the low‐middle income countries (LMICs) with heavy patient load. A QI initiative which aimed at appropriate use of antibiotics for major elective obstetrical and gynecological procedures concluded that QI initiative is effective in improving the adherence to the standard guidelines 17 . With this evidence, the current QI initiative was implemented with the goal to reduce the prevalence of UFPM.…”