AMS across the surgical pathway in LMICs

Abstract

Optimizing antibiotic prescribing across the surgical pathway (before, during, and after surgery) is a key aspect of tackling important drivers of antimicrobial resistance and simultaneously decreasing the burden of infection at the global level. The overwhelming majority of surgical procedures require effectively limited delivery of antibiotic prophylaxis to prevent infections. Evidence from around the world indicates that antibiotics for surgical prophylaxis are administered ineffectively, or are extended for an inappropriate duration of time postoperatively. Ineffective antibiotic prophylaxis can contribute to the development of surgical site infections (SSIs), which represent a significant global burden of disease. The World Health Organization estimates SSI rates of up to 50% in postoperative surgical patients (depending on the type of surgery), with a particular problem in low- and middle-income countries, where SSIs are the most frequently reported healthcare-associated infections. Much of the scientific research in infection management in surgery is related to infection prevention and control in the operating room, surgical prophylaxis, and the management of SSIs, with many studies focusing on infection within the 30-day postoperative period. However it is important to note that SSIs represent only one of the many types of infection that can occur postoperatively.Surgical patients comprise 35-50% of hospital admissions. Historically, LMICs have sub-optimal investment in surgical services, and existing surgical systems are growing too slowly to meet the increasing demand. The success of interventions such as the WHO checklist targeting surgical safety are highly context-dependent and variable, and are influenced by economic, cultural, and social factors, including role identity and hierarchies within healthcare teams. In particular, LMIC hierarchies have a significantly greater impact on the successful adoption of interventions in surgery. Importantly, leadership, flexibility, and teamwork are required for the implementation of checklists to be effective in any setting. This lesson applies to the successful implementation of any patient safety initiative, including interventions aiming to optimize antibiotic use. Interventions in antibiotic use tend to consider and address only one point at a time on the patient pathway, and in the case of surgical patients, attention has been focused primarily on prophylactic antibiotic use. Identifying and mapping current actors and actions in the surgical specialty in different healthcare settings will inform interventions that are context-specific and relevant to the local patient population. They will also help ensure greater equity in access to safe surgery on a global scale.