Open Access Original
Article
DOI: 10.7759/cureus.4776
Compliance Rate of Surgical Antimicrobial
Prophylaxis and its Association with Knowledge
of Guidelines Among Surgical Residents in a
Tertiary Care Public Hospital of a Developing
Country
Muhammad Zubair Satti 1 , Muhammad Hamza 2 , Zaina Sajid 3 , Omaima Asif 4 , Hassaan Ahmed 1 , Syed
Muhammad Jawad Zaidi 1 , Umer Irshad 1
1. General Surgery, Rawalpindi Medical University, Rawalpindi, PAK 2. Internal Medicine, Rawalpindi Medical
University, Rawalpindi, PAK 3. Surgery, Rawalpindi Medical University, Rawalpindi, PAK 4. Miscellaneous, Rawalpindi
Medical University, Rawalpindi, PAK
Corresponding author: Muhammad Zubair Satti, zubairsatti42@gmail.com
Disclosures can be found in Additional Information at the end of the article
Abstract
Introduction
Surgical antimicrobial prophylaxis (SAP) means the administration of antibiotics in surgical practice, and it
reduces the likelihood of surgical site infections (SSIs). Inappropriate SAP practice regarding the
prescription, timing, and duration of antibiotic use prolongs the hospital stay of patients, increases patient
morbidity (by exposing them to the adverse effects of antibiotics), promotes bacterial resistance, and puts an
economic burden on health care.
While developed countries regularly monitor and revise their SAP protocols, there are only a few such
researches in developing countries, which is a major setback to proper surgical care.
Objectives of the study
This study aims to compare the practice of SAP in a tertiary health care hospital of a developing country
Pakistan, with internationally recommended protocols and evaluate the impact of knowledge of
international guidelines on SAP practice. The results of the study will highlight important shortcomings in
prophylactic practice in the hospital and help develop recommendations to improve SAP practice and ensure
better surgical care for patients.
Materials and methods
Received 05/22/2019
Review began 05/23/2019
Review ended 05/26/2019
Published 05/29/2019
© Copyright 2019
Zubair et al. This is an open access article
An observational, cross-sectional study was conducted in the general surgery unit of Holy Family Hospital
(HFH), Rawalpindi, Pakistan, from March 2017 to November 2017 during which antimicrobial prophylaxis of
150 general surgery procedures was documented on the basis of six international SAP criteria, which were
“indication for use of prophylaxis, timing of preoperative dose, choice of drug, route of administration,
duration of postoperative prophylaxis, and the assessment of beta-lactam allergy.” The compliance rate
(number of procedures following all the six criteria) was calculated for each operating surgical resident.
distributed under the terms of the Creative
Commons Attribution License CC-BY 3.0.,
which permits unrestricted use, distribution,
and reproduction in any medium, provided
the original author and source are credited.
A questionnaire was formulated that assessed the knowledge of 33 surgical residents working at that time
regarding the above- mentioned six variables of SAP by six close-ended questions. Their responses were
then compared to their compliance rate by chi-square analysis and binary logistic regression in SPSS version
23 (IBM Corp, Armonk, NY, US). A p-value of less than or equal to 0.05 was considered significant.
The required ethical approval was obtained from the departmental heads as well as institutional research
forum.
Results
Seventy-four of 150 observed procedures followed all the six international criteria of SAP, giving a
compliance rate of 49.33%. Seventeen out of 33 (51%) surgical residents were aware of the guidelines. A chisquare analysis revealed a highly significant association between the awareness of guidelines and the
number of compliant procedures performed by a resident (p<0.000). Forty-five out of 74 compliant
procedures were performed by residents who were aware of the guidelines (61% of compliant procedures).
The odds ratio for awareness and correct prophylaxis was 4.064 (p<0.000).
How to cite this article
Zubair M, Hamza M, Sajid Z, et al. (May 29, 2019) Compliance Rate of Surgical Antimicrobial Prophylaxis
and its Association with Knowledge of Guidelines Among Surgical Residents in a Tertiary Care Public
Hospital of a Developing Country. Cureus 11(5): e4776. DOI 10.7759/cureus.4776
Conclusions
The study indicates an overall low compliance rate of 49.33% regarding surgical antimicrobial prophylaxis
(SAP) practice in a public health care hospital of a developing country. The most common cause of noncompliance was prolonged postoperative prophylaxis. This study also shows that the knowledge of
international guidelines significantly improves the prophylaxis practice by about four times. Hence, proper
SAP compliance rate can be increased by actively educating and monitoring surgical residents.
Categories: Preventive Medicine, General Surgery, Quality Improvement
Keywords: surgical antimicrobial prophylaxis, compliance rate
Introduction
Surgical site infections (SSIs) are defined as infections occurring at the incision site or deep tissue space
within 30 days after surgery [1]. They are among the most common nosocomial infections around the world,
causing pain and discomfort to surgical patients [2]. SSIs are involved in one-third of postoperative
mortalities and are responsible for 8% of all deaths due to nosocomial infections [2]. SSIs are also an
established, yet preventable, cause of prolonged hospital stays and a major economic burden on health care
[3]. Despite the improvements in preventive measures, the rate of surgical infections is feared to increase
because of the advent of more complex and prolonged surgeries and a growing number of elderlies,
diabetics, immunosuppressed, and cancer patients, all of which are risk factors for SSIs [4-5]. In developing
countries like Pakistan, with limited health care and lack of adequate research in the matter, surgical site
infections pose an even greater challenge, as implied by a recent global study that shows that the overall rate
of SSI increases from 7.4% in high-income countries to 20% in low-income countries [2].
Although many factors contribute towards SSIs, contamination of the surgical site by pathogenic microbes
remains the most important [6]. Surgical antimicrobial prophylaxis (SAP) is defined as the administration of
antibiotics in surgical practice, and it reduces the likelihood of surgical site infections by preventing the
growth of such pathogens [1]. Due to proper antimicrobial prophylaxis, the incidence of SSIs has been
reduced by 50% in some procedures and proper SAP is now considered the most important preventive
measure against SSIs [7]. However, the literature suggests inappropriate SAP practice regarding the
prescription, timing, and duration of antibiotic use worldwide, which prolongs the hospital stay of patients,
increases patient morbidity (by exposing them to the adverse effects of antibiotics), promotes bacterial
resistance, and puts an economic burden on health care [5,8-9]. Thus, it is the need of the hour to practice a
rational SAP and minimize the side effects mentioned above.
Proper SAP practice requires good knowledge of international guidelines among the hospital staff and
regular evaluations of prophylaxis protocols. While the developed countries regularly monitor and revise
their SAP protocols, there is a paucity of such researches in developing countries, which is a major setback
to proper surgical care. This study compares the practice of surgical antimicrobial prophylaxis (SAP) in a
tertiary health care public hospital of a developing country, Pakistan, with internationally recommended
protocols and elaborates the impact of the knowledge of international guidelines on SAP practice. The
findings of this study will highlight important shortcomings in prophylactic practice in the hospital and
help develop recommendations to improve SAP practice and ensure better surgical care for the patients.
Materials And Methods
Study design
A descriptive, cross-sectional study was conducted in the general surgery unit of Holy Family Hospital,
Rawalpindi, Pakistan, from March 2017 to November 2017 during which antimicrobial prophylaxis of 223
elective general surgery procedures was observed. Patients with immunodeficiency, cancer, concurrent
infections, and those undergoing contaminated surgical procedures were excluded from the study. Pediatrics
and gynecological surgeries and procedures with a primary indication for prophylaxis (cardiac, valvular, and
orthognathic) were also excluded from the study.
Of the 223 procedures observed, 150 met the criteria and were further documented. Data regarding SAP in
each procedure were collected by the investigators and subsequently entered on a standard data collection
form.
Criteria for comparison
Six common variables of surgical prophylaxis were observed and compared with international guidelines.
These were “indication for use of prophylaxis, the timing of the pre-operative dose, choice of drug, route of
administration, duration of postoperative prophylaxis and the assessment of beta-lactam allergy.” Overall
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compliance was calculated based upon criteria used in previous studies [10-11], and only those procedures
were labeled “compliant” in which all the six variables were individually compliant with the guidelines. A
procedure in which any one or more of the six variables were not practiced according to the guidelines was
labeled non-compliant.
Questionnaire formation
A questionnaire was formulated that assessed the knowledge of the surgical residents regarding the abovementioned six variables of antimicrobial prophylaxis by six close-ended questions. Evidenced-based SAP
guidelines developed by World Health Organization (WHO) [1], National Institute for Health and Care
Excellence (NICE) [9], and Stanford Health Care (SHC) [12] were used as a reference in our study.
Questionnaires (sample shown in the Appendix) were distributed among general surgery residents of the
hospital by convenient sampling. Postgraduate trainees (PGTs) in their second to fourth years of surgical
residency were included in the study, as they performed antimicrobial prophylaxis in the surgical unit.
Grouping of surgical residents
Residents were divided into two groups based on their response to the questions. The criteria for assessing
compliance (mentioned above) was also used to assess the awareness of surgical residents and only those
residents who correctly answered all the questions were labeled “aware of guidelines.” One or more incorrect
answers by the residents marked them as “not being aware of guidelines.”
Statistical techniques
The descriptive analysis was performed using SPSS v23.0 (IBM Corp, Armonk, NY, US) to characterize the
population parameters and study variables.
Chi-squared analysis was then performed between the resident’s awareness of international guidelines and
practice of antimicrobial prophylaxis. A p-value of less than or equal to 0.05 was considered statistically
significant. Binary logistic regression and odds ratio were also calculated for compliant procedures based on
the awareness of guidelines.
Results
Population parameters and the characteristics of procedures studied are provided in Table 1.
Characteristics of Procedures studied
Characteristics of Population Studied
Clean contaminated procedures (n=115)
Clean procedures (n=35)
Laparoscopic cholecystectomy
59
Inguinal hernia repair
12
Total procedures observed=223
Open Cholecystectomy
25
Breast surgery
7
Procedures included in study=150
Appendectomy
20
Umbilical hernia repair
7
Male patients in study=81
Hepatobiliary procedure
7
Incisional hernia repair
5
Female patients in study=69
Small intestine procedure
4
Thyroidectomy
4
Mean age of population=39.3 years
The compliance rate was 56.21%
The compliance rate was 28.57%
TABLE 1: Characteristics of Population and Procedures Studied
n=number
The individual compliance rate of six variables is shown in Table 2.
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Criteria of
prophylaxis
(SAP)
Indication according to
international guidelines
Residents aware of
the guideline (n=33)
Practice observed in the
procedures (n=150)
Compliance
rate (%)
% of nonadherence to
guidelines
Indication for
prophylaxis
Indicated only in 125 of
150 cases of study
29
Given in all 150 cases
83.33%
16.67%
Timing of preoperative dose
Give within 120 minutes
before the procedure
33
Given within 120 minutes in all
150 procedures.
100%
__
Choice of drug
1st choice for all
procedures is Cefazolin
19
Cefazolin administered in only
86 procedures
57.33%
42.67%
Route of
administration
Use Intra-venous (IV)
route
33
Intravenous (IV) route used in all
150 procedures
100%
__
Duration of
postoperative
prophylaxis
Limit the duration to less
than 24 hours
18
The duration was less than 24
hours in only 79 of 150
procedures
52.67%
47.33%
Assessment of
beta-lactam
allergy
Test for beta-lactam
allergy in all patients
20
Beta-lactam allergy was
assessed in only 92 cases
61.33%
38.67%
Number of compliant procedures was 74 (49.33%)
TABLE 2: Compliance Rate of Six Variables of Prophylaxis
n=number
The results of the questionnaire-based study are indicated in Table 3 along with the compliance rate of the
two groups of surgical residents. A chi-squared analysis revealed a highly significant association between
the awareness of guidelines and the number of compliant procedures performed by a resident (p<0.000).
Forty-five out of 74 compliant procedures (63.38%) were performed by residents aware of the guidelines.
Group of
surgical
residents
GROUP A
RESIDENTS
GROUP B
RESIDENTS
Number and
Awareness of
Percentage
guidelines
Procedures
Compliant
performed
procedures
(n=150)
(n=74)
66
84
Non-compliant
Compliance
procedures (n=76)
(%)
45
21
68.18%
29
55
34.52%
Aware of
17 (51.51%)
international
guidelines
Not aware of
16 (48.48%)
international
guidelines
Chi-square shows a significant association between compliant procedures and awareness (p< 0.000)
TABLE 3: Groups of Surgical Residents and Their Compliance Rates
n=number
Table 4 shows the classification table of Block 1 of binary logistic regression, indicating that our model
correctly predicts 66.7% cases as compared to 50.7% cases of Block 0. The odds ratio was 4.064 for the
significance of (p<0.000).
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PREDICTED
OBSERVED
Were they correct
Percentage correct
no
yes
no
55
21
74.4
yes
29
45
60.8
Were they compliant
Overall percentage
66.7
The Odds ratio for compliance based on awareness was 4.064 (p< 0.000).
TABLE 4: Binary Logistic Regression: Classification Table Block 1
Discussion
Implementation of a proper surgical antimicrobial prophylaxis (SAP) is a challenge worldwide [13], as it
requires good knowledge of international recommendations and repeated evaluations of prophylaxis
practice.
In our study, prophylaxis was used in all 150 procedures, whereas it was indicated only in 125 of 150 cases
(83.33% compliant) if NICE guidelines are adhered to, which state that uncomplicated clean surgeries should
be performed without prophylaxis because large clinical trials have shown no benefit of the use of
antibiotics in these procedures [9]. Of the procedures, 16.67% (25 out of 150) in our study were noncomplaint regarding indication for use of prophylaxis. The finding of antibiotic use in all routine surgeries is
consistent with another study conducted in Pakistan, which reports antibiotic use in 99% observed surgeries
[14]. Studies in other developing countries also report non-compliance regarding the indication of
prophylaxis. An Ethiopian study showed 19.6% procedures received antibiotics without indications [15]. The
administration of prophylaxis in clean surgeries is deemed unnecessary and contraindicated by international
guidelines because such unnecessary antibiotic use is the most important factor responsible for the
development of antimicrobial resistance (AMR), a global health crisis as it complicates the treatment of
bacterial infections and leads to the eventual loss of efficacy of that particular drug [16]. AMR is widespread
in developing countries due to the lack of routine checks on antibiotic use, over-the-counter availability of
many broad-spectrum antibiotics, and inappropriate antibiotic prescription in a surgical setting [17].
Moreover, this practice also puts an extra economic burden on health care, a system which already receives a
very low proportion of the budget in developing countries.
The problem of antimicrobial resistance is compounded by another observation in our study. According to
Stanford Health Care (SHC) guidelines, the recommended prophylactic drug in all procedures (except in
patients with a serious beta-lactam allergy) is a first-generation cephalosporin, cefazolin [12]. The goal is to
administer the drug with a moderate spectrum of activity, targeting only the suspected surgical pathogens
so that the development of antimicrobial resistance is prevented [9], and cefazolin fits this criterion. In our
study, 64 procedures (42.67%) used broad-spectrum third-generation cephalosporin ceftriaxone for
prophylaxis instead of cefazolin. This finding is consistent with a previous study conducted across Pakistan,
which reported the use of ceftriaxone in 57.6% procedures [18] and another study reported that 60.7% of
procedures received ceftriaxone [19]. A study in India also reported the use of third-generation
cephalosporins for routine prophylaxis [20] while an Italian study showed a compliance rate of only 9.8%
regarding the choice of drug in the hospital [21]. A study based in Nekemte Hospital reported ceftriaxone use
in 84% procedures [15]. These findings indicate a general trend among the doctors in developing countries
to prefer broad-spectrum drugs in the surgical setting, which aggravates the above-mentioned problem of
antimicrobial resistance. With the routine use of broad-spectrum drugs, multidrug-resistant (MDR) bacteria
are eventually selected, which cause serious postoperative complications [16]. Thus, our study points out
two factors, the widespread use of antibiotics and preference for broad-spectrum drugs, in a surgical setting
that promote antibiotic resistance. The emergence of resistant bacteria has complicated the treatment of
many infections such as pneumonia and tuberculosis, increasing the length of hospital stays, medical costs,
and mortality rates of the affected patients [17]. Fearing the loss of efficacy of antibiotics, the World Health
Organization (WHO) recommends a change in the practice regarding antibiotic use by doctors, prescribing
them only when necessary [14]. This recommendation needs to be transformed into surgical practice to
prevent the emergence of resistant pathogens and their spread to the community.
Regarding the timing of preoperative prophylaxis, the guidelines state that the optimal time for the first dose
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of the prophylactic drug is within 120 minutes before incision [1]. It is important to follow the timing
because administering antibiotics before 120 minutes of incision increases the risk of surgical site infections,
as the concentration of the drug may fall below the adequate levels needed for its effects [1]. All 150 patients
in our study received preoperative prophylaxis in this time frame, giving a 100% compliance rate to this
guideline. A previous study in Pakistan showed that 80% of procedures were compliant regarding the timing
of the preoperative dose and 18% of these procedures received the drug just before incision [22]. A study
conducted in India indicated that the timing of preoperative dose was not according to any guidelines and,
in some cases, started six hours before surgery [20], and a study in Italy also indicated variable adherence
with this guideline [21]. The practice of administering the preoperative dose inside the operation
theater (OT) by the anesthesiologist in charge ensured full compliance with this guideline in our study.
International guidelines recommend the intravenous (IV) administration of prophylactic drugs to ensure
steady and predictable drug levels [1]. The practice of surgical residents in our study followed this guideline,
giving a 100% compliance rate regarding the route of administration of the prophylactic drug. The finding is
consistent with a similar study in the Philippines, which also reports 100% compliance with this guideline
[23].
In 71 of 150 (47.33% non-compliant) observed procedures, postoperative prophylaxis was continued for
more than 24 hours after surgery based on the wrong assumption that such practice may decrease the
infection risk even further, giving a compliance rate of 52.67% to this guideline. A previous study in Pakistan
reported only 26.1% adherence to this guideline [22] and a study in Saudi Arabia indicated 58.2% compliance
regarding the duration of postoperative prophylaxis [23]. The guidelines state, with strong evidence, that in
all surgeries (except cardiac, vascular, and orthognathic procedures), prolonging the prophylaxis for more
than 24 hours after the surgery has no additional benefit [1]. Rather, it has been associated with a prolonged
hospital stay of patients, increased patient morbidity due to the risk of the side effects of antibiotics,
development, and spread of bacterial resistance [1] and as a risk factor for Clostridium difficile infection, the
cause of pseudomembranous colitis [24]. In the current era, much research is focused on reducing patient
recovery time after surgery and a unanimous Enhanced Recovery After Surgery (ERAS) protocol has been
developed to optimize surgical care. A key aspect of ERAS is to minimize fluid administration in surgical
patients [25]. The development of diarrhea either due to Clostridium difficile infection or direct
gastrointestinal distress caused by prolonged antibiotic use requires the use of intravenous (IV) fluids and
contradicts ERAS protocols, increasing the post-operative hospital stay of patients. This also puts an
unnecessary physical, emotional, and economic burden on the patient and consumes hospital resources and
manpower by attending to such patients. Thus, the developing countries need to follow the international
guidelines regarding postoperative prophylaxis to minimize the patient’s exposure to antibiotics and reduce
the average length of hospital stay of surgical patients.
According to the literature, up to 35% percent of surgical patients suffer from beta-lactam allergy, and it may
lead to perioperative anaphylaxis when severe [26], which makes it necessary to assess the patients’ betalactam allergy status before administering the prophylactic cephalosporins. An immunoglobulin E (IgE)mediated allergically reaction exhibited by the patient during the test, contraindicates cephalosporins, and
alternative non-beta-lactam drugs, such as vancomycin or clindamycin, are then administered [26].
Although cephalosporins were administered in all procedures in our study, a beta-lactam allergy was
assessed only in 92 procedures (61.33% compliant). In the remaining 58 procedures (38.67% noncompliant), cephalosporins were administered in the operation theater without knowing the allergy status.
A case of anaphylaxis in a patient undergoing cholecystectomy was observed in the study due to such
practice. The patient was administered ceftriaxone on the operating table just before the incision and
developed hypotension and decreasing oxygen saturation during the surgery, requiring epinephrine
administration to prevent a fatal outcome. This highlights the importance of knowing the beta-lactam
allergy status of surgical patients before administering cephalosporins. Studies in other developing
countries do not include this variable in assessing the prophylactic practice but a rational SAP practice must
tend to the prevention of any drug-related adverse effects that may occur during the surgery, which makes
the assessment of beta-lactam allergy status necessary.
Our study indicates an overall low compliance ratio of 49.33% when all six criteria of antimicrobial
prophylaxis practice are considered. In other words, of 150 procedures in which SAP was analyzed, only 74
were compliant with international guidelines regarding all the six variables and 76 deviated from the
guidelines in one or more of these criteria. The compliance rate was higher in clean-contaminated surgeries
(56.21%) than in clean surgeries (28.57%). This observation contradicts with a similar study conducted in
Qatar in which the compliance rate of clean procedures (66%) was higher than clean-contaminated
procedures (34%) [6]. The markedly low compliance rate in clean surgeries observed in our study was due to
the use of antibiotics in all observed surgeries, whereas uncomplicated clean surgeries do not require
prophylaxis according to the international guidelines.
Other related studies in the literature also report the failure of compliance with international guidelines,
establishing it as a global health care problem. Table 5 shows a comparison of the compliance rate in our
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study with those of similar studies around the world:
The compliance rate of individual criteria of prophylaxis
Country
of study
Overall
Duration of
compliance
rate
Indication
Timing
Chosen drug
post-operative
dose
Qatar [6]
46.5%
___
Low
India [18]
compliance
___
Rate
Philippines
___
68.5%
No
3rd generation
guidelines
cephalosporins used
followed
frequently
Route of drug
administration
Assessment of
beta-lactam
allergy
40.7%
100%
__
__
100%
__
13%
___
45%
44%
67%
100%
__
40%
72.3%
46.6%
40%
40.7%
100%
__
___
48%
91%
3.6%
58.2%
100%
__
Pakistan
Less than
Prophylaxis used in
[20]
50%
99% routine surgeries
26.1%
100%
__
52.67%
100%
61.33%
[21]
Italy [19]
Saudi
Arabia [22]
3rd generation
___
cephalosporins in more than
50 % cases
Present
study
49.33%
83.33%
100%
57.33%
TABLE 5: Comparison of Compliance Rate with Other Studies
While the previous studies only reported the shortcomings in SAP practice, our research also focuses on one
of the factors responsible for the low compliance rate. It was proposed that awareness of guidelines
regarding SAP among surgical residents may have a direct bearing upon the prophylaxis practice. A chisquared analysis revealed that the number of compliant procedures performed by surgical residents is
significantly associated with their awareness of international guidelines (p<0.000). A binary logistic
regression between the independent categorical variable (awareness of guidelines) and the dependent
nominal variable (whether the procedures were compliant or not) in the two groups of surgical residents.
The results were statistically significant and the proposed model correctly classified 66.7% of cases, an
improvement over 50.7% of cases classified by the baseline model. This validates our proposed model that
the awareness of guidelines increases the number of compliant procedures performed by the resident.
The odds ratio calculated for a confidence interval of 95% was 4.064 (with lower and upper limits of 2.047
and 8.070, respectively) and (p<0.000). This means that a surgical resident who is aware of the international
guidelines on SAP is, on average, four times more likely to perform correct prophylaxis and yield a 100%
compliance rate than a resident who is not aware of the guidelines.
Other studies also argued that lack of awareness regarding the guidelines contributes to inappropriate SAP
practice [6] but our study provides statistical evidence of the importance of awareness of international
guidelines in administering the correct prophylaxis. This result is significant because it indicates that a
proper SAP practice can be achieved by imparting proper knowledge regarding SAP guidelines among the
current and future surgical residents. Adherence to evidence-based practice will decrease the rate of surgical
site infections, provide better surgical care to patients, and reduce the cost burden on the health care budget
in developing countries.
To ensure the practice of rational prophylaxis, the authors recommend increasing the awareness of
international guidelines of antimicrobial prophylaxis among doctors and surgical residents by arranging
workshops and teaching courses. Also, repeated evaluations of prophylactic practice must be conducted to
identify the factors responsible for low compliance and develop strategies to counter them. A unanimous
national prophylaxis protocol should be developed to standardize SAP practice in hospitals.
Limitations
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Our study has certain limitations. First, due to the lack of national guidelines, SAP practice may differ among
surgical residents and different compliance rates may be obtained if a different study population is selected.
Second, the observation that surgeons with knowledge of guidelines also perform inappropriate SAP in
some cases (21 such cases in our study) should be further evaluated and the factors for this finding should be
identified and tackled. Third, the study only concerns a tertiary care hospital in Rawalpindi and more
extensive multicenter studies should be conducted to elaborate on the results.
Conclusions
The study indicates an overall low compliance rate of 49.33% regarding surgical antimicrobial prophylaxis
(SAP) practice in a tertiary health care hospital of Rawalpindi, which predisposes the patients to the
unnecessary side effects associated with a non-compliant SAP. The compliance rate was higher in cleancontaminated surgeries than in clean surgeries and the most common cause of non-compliance was postoperative prophylaxis of more than 24 hours. Forty-five of 74 compliant procedures were performed by
residents aware of the guidelines. The study also shows that proper awareness of international guidelines
regarding SAP increases the likelihood of proper prophylaxis by four times. Interventions are needed to
ensure rational antimicrobial prophylaxis practice by implementing the above-mentioned recommendations
so that better surgical care is provided to the patients and the hazards of inappropriate SAP are avoided.
Appendices
The proper prophylaxis
Below are some questions regarding Surgical Antimicrobial Prophylaxis (SAP) in your hospital. Please take
out some of your precious time and answer them to the best of your knowledge.
Name of Resident: ______________
Q1: In your opinion, is SAP needed in all routine surgeries?
a)
Yes
b)
No, some surgeries can be performed without SAP
Q2: What is the optimal time for administering prophylactic drug?
a)
A day before surgery
b)
3 hours before surgery
c)
Within 120 minutes of surgery
d)
4 hours before surgery
Q3: Which is the preferred drug for routine prophylaxis?
a)
Cefazolin
b)
Ceftriaxone
c)
Any other drug (please mention _____________)
Q4: What is the preferred route for administering the prophylactic drug?
a)
IV route
b)
Oral route to minimize side effects
c)
IM injection
Q5: What is your routine duration for postoperative prophylaxis?
a)
Less than 24 hours after surgery
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b)
2 days after surgery
c)
3 days after surgery
Q6: In your practice, do you take the patient’s history of beta-lactam allergy before administering
prophylactic drugs?
a)
Yes
b)
No
AWARENESS STATUS: ___________________
Additional Information
Disclosures
Human subjects: Consent was obtained by all participants in this study. Animal subjects: All authors have
confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance
with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All
authors have declared that no financial support was received from any organization for the submitted work.
Financial relationships: All authors have declared that they have no financial relationships at present or
within the previous three years with any organizations that might have an interest in the submitted work.
Other relationships: All authors have declared that there are no other relationships or activities that could
appear to have influenced the submitted work.
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