1. Surgical antibiotic prophylaxis at Moi Teaching & Referral Hospital Rose Kakai 1, Barrack Ayumba 2, Damaris Lagat 2, Eveline Wesangula 3, Sam Kariuki 4 1 Maseno University, 2 Moi University, 3 Ministry of Health 4 Kenya Medical Research Institute

2. Introduction Worldwide, over 230m operations performed annually SSIs one of the most important causes of healthcare associated infections SSI is an infection occurring at the operation site within 30 dys of the procedure In GARP-Kenya situation analysis (2011), hospital antibiotic use was one of the critically important areas of policy action Rationale is, in order to control AMR in hospitals, the most important steps are to reduce and rationalize hospital prescribing

3. Introduction -------- Why give pre-operative antibiotics? The operation is the major period of bacterial contamination of the site There is a strong evidence base for single dose from – Experimental (animal) studies – Clinical research in East Africa – International research + recommendations National Clinical Guidelines recommend it

4. Introduction -------- Potential benefits of single dose regimen Reduce rate of wound infections Reduce costs to pts + hospital Reduce overall usage of antibiotics cf. R Better injection safety Less nursing time giving antibiotics in wards

5. Introduction -------- Statement of the problem: Surgical prophylaxis is beneficial in prevention of SSIs identified as one of the areas where antibiotics are often overused Objective: To rationalize use of surgical AP at MTRH Specific objectives: Determine: Use of antibiotics in surgical pts Rate of SSI Pathogens AMR in pts with SSI Outcome measure: Proportion of pts receiving rational (correctly timed and dosed) AP

6. Methods Study site: MTRH surgical patients Design: Longitudinal observational study Inclusion criteria: Surgical wound class I (clean) and II (clean/contaminated) Dependent variable: Pre-operative single dose regimen Independent variables: Use of antibiotics in surgical pts, Rate of SSI, Pathogens and AMR in pts with SSI Limitation: Failure to follow up and detect post operative infections after pts were discharged Ethical consideration: Approval obtained from IREC

7. Methods -- Data collection procedure First seminar for planning Immediately after ethical and other relevant approvals Review of: – research findings – Kenya national clinical guidelines (2009) – Kenya national IPC guidelines (2010) – Experiences of other hospitals e.g. Thika Level 5 (June 2010 – Feb 2011) Show strong evidence to support pre-operative single-dose (AP), using similar antibiotics Agreed that there was need for locally appropriate AP policy at MTRH, hence develop a process chart and drug regime for the proposed policy Process chart describes; rresponsibilities’ for different hospital staff, materials needed and sequence of events Collection of lab and bio data from date of 1 st seminar to end of study is ongoing to monitor antibiotic use, changes in SSIs, pathogens and resistance rates

10. Methods -- Data collection procedure Second seminar for Planning 2 months after 1 st seminar Process chart and drug regime drafts presented and discussed Main drug for AP is Ampicillin because it – Has good bacterial coverage – Is (relatively) cheap – Has no major side-effects or interactions – Is safe in high doses Formal application to Hospital Director requesting approval to implement use of the proposed process chart and drug regime Approval granted to proceed with the implementation and it is ongoing

11. Methods -- Data collection procedure Third seminar for Monitoring and Evaluation Expected to be held 11 months after implementation of proposed surgical AP policy To evaluate effects of the change in the policy with regard to; – Use of antibiotics in surgical pts – Rate of SSI – Pathogens – AMR in pts with SSI

12. Methods -- Data collection procedure Fourth final seminar for Sustainability 3 months write up Discuss: – Final results and challenges – Hence long term sustainability of the policy

13. Preliminary results Total of 446 surgical pts sampled 160 (58.35) females 193 (43%) aged 40 – 65 yrs old Most common surgeries were 164 (36.8%) general and 147 (32.9%) CS SSI reported in 8 (1.8%) pts Post operative AP prescribed for 136 (30.5%) pts ranging from 3 – 5 days duration Inconsistent access to ampicillin

14. Conclusion Pre-operative single dose beneficial Main challenges – Drug stock outs – Prescription of post-operative antibiotics

15. Recommendation Measures e.g. CME on AMR aimed at rational use of surgical prophylactic drugs is necessary to strengthen sustainable practices regarding AP

16. Acknowledgement Ramanan Laxminarayan, CDDEP Thank you