Augmenting core strategies of antimicrobial stewardship to improve Surgical Antibiotic Prophylaxis and management of Surgical Site Infections

Context

Kenya’s National Policy and Action Plan (NAP) on the Prevention and Containment of Antimicrobial Resistance was launched in 2017. Its implementation is coordinated through the National Antimicrobial Stewardship Interagency Committee.

As part of the NAP’s strategic objective of promoting appropriate use of antimicrobials, national AMS guidelines were developed and published in 2020. These guidelines focus on optimising the use of antimicrobials in human health through strengthening Medicines and Therapeutics Committees (MTCs) to ensure patient safety, optimal treatment outcomes, and reduced costs of treatment. The implementation of the AMS guidelines on a local level has been slow with less than 30% of the hospitals countrywide having established an AMS programme two years after the launch. The limited implementation of AMS guidelines has partly been caused by difficulties with adapting them to facility and county level, and there is a need to tailor them to the local hospitals’ needs. Up to date national guidelines on Surgical Antibiotic Prophylaxis (SAP) and empiric management guidelines for Surgical Site Infections (SSIs) are currently not available.

Problem

AP is commonly associated with irrational antibiotic use in LMICs. Studies have shown that up to 40% of prescriptions in this situation may be inappropriate or suboptimal. There are multiple complex reasons for this behaviour, including limited diagnostic support and laboratory capacity, mistrust in lab reports, and lack of confidence in the facility’s infection, prevention and control processes- prompting surgeons to fear SSIs and choose to administer broad-spectrum antibiotics.

In surgical settings, AMR can lead to:

• longer hospitalisation periods
• extended duration of antibiotic therapy (often with toxicities associated)
• higher healthcare expenditure
• increased mortality and morbidity
• need for surgical revisions

AMR features prominently in SSIs, which form one of the most common Healthcare Associated Infections (HAIs). In Kenya, the establishment of a national HAI surveillance system, including surveillance for Caesarean Section (CS) SSI, is a key priority in the National IPC Strategic Plan for Healthcare Services. Early implementation findings from HAI surveillance on SSIs post caesarean section in some level 4 hospitals have indicated poor compliance to surgical prophylaxis guidelines.

Project overview

The project aims to play a significant role in optimising SAP and reducing the burden of inappropriate antimicrobial use. This project will also build on the existing HAI surveillance system in Kenya, to further strengthen the quality of healthcare delivery, especially in surgical departments.

The aim of the study is to develop and deploy Guidelines for Surgical Antibiotic Prophylaxis (SAP) and treatment of Surgical Site Infections (SSIs) within health care facilities, to achieve at least 60% compliance and optimize the surveillance and management of SSIs in three counties. One county-level government hospital and one private hospital will be included from each county.

The specific objectives of the project are to:

• Evaluate the bacteriological profile and antibiotic sensitivity of SSIs and map the use of antibiotics as a part of routine SAP, in secondary and tertiary hospitals in three counties of Kenya
• Develop guidelines and information, education and communication (IEC) materials for SAP based on bacteriological and AST profiles, and through standard evidence synthesis processes
• Pilot SAP guidelines and IEC materials to support uptake of guidelines in secondary and tertiary hospitals in three counties in Kenya
• Assess the behavioural and social enablers and barriers to uptake of SAP guidelines by prescribers, including its acceptability, feasibility, and appropriateness
• Conduct an economic evaluation to assess the cost and benefits of the implementation of guidelines, IEC materials and the clinical decision support system (CDSS)
• To support development of national guidelines on management of SSI including surveillance and treatment of SAPs.

Outcomes

• Improved prescription practices of antibiotics for (selected) SAP in 6 secondary and tertiary care facilities of three counties of Kenya
• Improve AMS policies and practices that utilise intervention results to sustain appropriate antibiotic use and use of antibiotics contained in the standard treatment guidelines (STGs) for SAP and SSIs in Kenya supported by facility administration.