Action needed in Global South hospitals on surgical infection and antimicrobial resistance risk

More targeted antibiotic use and proper testing for surgical site infections (SSI) are needed in hospitals across the Global South to help control the spread of antimicrobial resistance (AMR), a new study reveals.

Studying practices in 54 hospitals across Benin, Ghana, India, Mexico, Nigeria, Rwanda, and South Africa, researchers discovered that SSIs and MDR are major problems due to limited testing and inappropriate antibiotic use.

Backed by funding from the UK’s National Institute for Health and Care Research (NIHR), experts at the University of Birmingham led an international research team which studied 5,788 patients undergoing abdominal surgery.

The NIHR Global Health Research Unit on Global Surgery team discovered that 1,163 (22%) developed SSIs, however 80.4% of patients with SSIs did not have a wound swab taken to enable targeted antibiotic treatment.

Among the swabs taken, E-coli was the most common microorganism found, with many of the microorganisms resistant to antibiotics given before surgery. Multidrug resistance was found in 69.4% of cases where data was available.

The study sets out several key steps needed to tackle the problem, including:

• Reducing overall antibiotic consumption through effective, targeted antibiotics use;
• Mapping of local microorganism patterns through a responsive surveillance network;
• Implementing evidence-based best practice on the front line, coupled with communication between departments, education of staff and behavioural change;
• Exploring the effectiveness of a dedicated infection control team;
• Creating capacity for microorganism testing using effective, rapid, low-cost diagnostic tools; and
• Using evidence-based prescribing on local microbial and resistance patterns.

Co-author Dr Elizabeth Li, from the University of Birmingham, commented: “Multidrug resistance in SSI, despite limited microbial capacity, is a substantial problem in Global South countries – an issue likely to affect most hospitals where surgery is performed.

“There is a lack of targeted antibiotic use and proper testing for SSIs. Improving testing capacity, creating local guidelines, and having infection control teams could help to prevent SSIs and reduce MDR."

Systematic weaknesses

Co-author Professor Shereen Varghese, from Christian Medical College & Hospital, Ludhiana, India, commented: “We identified systemic weaknesses in testing capacity and prevention of MDR. This is associated with non-targeted antibiotic use with high levels of AMR.

“When infections do occur, testing capacity is low, turnaround time is long, and drug resistance is high. Undirected and ineffective use of antibiotics before surgery is, therefore, common. Targeted antibiotic prevention of SSIs is vital to improved patient care and will have positive knock-on effects beyond surgery alone.”

SSI is one of the most common healthcare-associated infections globally and the most frequent postoperative complication affecting 15-25% of all patients undergoing abdominal surgery. Patients from low-income countries are disproportionally affected (23.2%) compared to middle- (14.0%) and high-income countries (9.4%).

As SSIs typically require antibiotic treatment, the development of SSIs increases the need for additional antibiotic use. Guidelines by the World Health Organization, ‘strongly’ recommend prophylactic antibiotics to prevent SSI, but inappropriate use of undirected broadspectrum antibiotics is common.

Although the development of AMR is a natural phenomenon, the inappropriate use of antimicrobial drugs, and poor infection prevention and control practices contribute to the emergence of and further spread of AMR alongside an accelerated progression into MDR.