Identifying challenges with antibiotic use in surgical services and implementing evidence-based interventions

Context

An analysis of antibiotic use and resistance in Ghana identified systemic challenges, such as the lack of a national antimicrobial policy, weak regulatory environment and disregard for best practices, including the use of antimicrobials in surgery and Infection Prevention and Control (IPC) practices. A study reported increasing rates of resistance across several isolates to commonly used, affordable and available antimicrobials, such as tetracycline (82%), co-trimoxazole (73%), ampicillin (76%), and chloramphenicol (75%).

Studies in Ghana report higher Surgical site infections (SSI) incidence than the global average, underscoring the need for implementing interventions focusing on improving IPC procedures and the use of antibiotics for Surgical Antibiotic Prophylaxis (SAP). The overuse or prolonged use of antimicrobials in surgeries has been documented as a significant challenge in healthcare facilities. Other challenges include non-compliance with standard guidelines, weak antimicrobial stewardship structures and governance issues, which exacerbate the problem.

Problem

To prevent the development of SSI, SAP before surgery is an evidence-based practice. However, an issue associated with SAP in surgery in Ghana is the high level of non-adherence to national treatment guidelines. For example, antibiotics are prescribed for a longer duration than the recommended one day for caesarean section. Poor IPC measures, such as hand hygiene and facemask use could also contribute to the high SSI incidence in Ghana. Many facilities lack formal Antimicrobial Stewardship programs and IPC structures, which could strengthen antimicrobial use and implementation of IPC protocols. Additionally, data from field surveillance conducted by Ghana’s Food and Drug Authority showed substandard antiseptics and disinfectants on the Ghanaian market which may be accessed in healthcare facilities.  

Project overview

This project’s primary goal is to reduce the incidence of SSIs by improving SAP and IPC practices. The project will develop and implement interventions on rational use of antibiotics for SAP and IPC practices, evaluate their effectiveness and cost-effectiveness, and make recommendations for scaling up, informing policy decisions for broader implementation. This Quality Improvement Study with mixed methods uses an iterative Plan-Do-Study-Act approach across four hospitals (one teaching hospital, one regional hospital and two district hospitals) in Ghana. It will focus on testing and refining facility-specific interventions that have the potential for sustainability and scaling across these different levels of care in the country. The objectives of the project are:

1. Determination of baseline antibiotic prescribing practices in line with the Ghana Standard Treatment Guidelines or other acceptable standard guidelines (e.g. WHO guidelines for surgical prophylaxis) in four hospitals.
2. Assessment of baseline IPC practices in surgical settings of the project sites in line with IPC protocols of Ghana.
3. Assessment of the quality of antiseptics and disinfectants used in surgical units and in particular at the project sites in Ghana.
4. Investigation of individual behavioural drivers of healthcare practitioners in surgical units, challenges and institutional factors affecting appropriate antibiotic use in surgery and IPC practices.
5. Development and implementation of sustainable evidence-based interventions to address the identified challenges with the use of antibiotics in surgery and IPC practices.
6. Evaluation of effectiveness and cost-effectiveness of the interventions addressing antibiotic use in surgery and IPC practices and making recommendations for scale-up.
7. Assessment of likely mechanisms for sustainability and scale-up and dissemination of findings to all stakeholders including policy and decision-makers.

Outcomes

Improving AMU, SAP and IPC for common surgical procedures has the potential to impact emerging AMR patterns in health care facilities but requires that interventions target both prescriber practices as well as the general hygiene conditions to reduce SSIs. Therefore, this study aims to implement an AMS program at four hospitals in Ghana to reduce SSI incidence by 30%, and to develop a blueprint for scaling AMS in surgical contexts. This will address SSI drivers through achieving three outcomes:

• Improved antibiotic use in surgeries,
• Improved adherence to IPC protocols in surgery, and
• Improved AMS functioning in the health facilities to reduce SSI.

Each facility will be supported to develop contextualised and facility-owned AMS interventions with SAP and IPC components using an implementation research approach, where interventions will be tailored and adjusted to specific facility-level challenges and needs.