Antimicrobial stewardship helps reduce postelective caesarean antibiotic use

An intervention with antimicrobial stewardship programs (ASPs) can prevent the unnecessary use of antibiotic prophylaxis in women following elective lower section caesarean section (eLSCS) with no adverse effects, according to a Singapore study.

“Most ASPs are focused on medical specialties, with few in surgical and specialized populations such as obstetrics,” the researchers said. “Our study advocated a multifaceted, collaborative ASP to improve antibiotic prescribing practices in our OBGYN department.”

A total of 1,751 women (mean age 33.6 years) admitted for eLSCS at KK Women’s and Children’s Hospital (KKH) in Singapore were reviewed in this pre-post quasi-experimental study conducted over 18 months (2 months pre- and 16 months postintervention).

The interventions consisted of eLSCS surgical prophylaxis guideline dissemination, and post-eLSCS oral antibiotics was discouraged in participants without risk factors for surgical site infection (SSI). This was followed by ASP intervention notes (phase 1) for 3 months, contacting the ward team for the next 7 months (phase 2) and the primary obstetrics attending in the next 6 months (phase 3).

Some 699 (39.9 percent) women presented with SSI risk factors. The overall rate of appropriate preoperative antibiotics was 99.0 percent. Of the participants, 244 (13.9 percent) were included in the preintervention phase and 1,507 (86.1 percent) in the postintervention phase. [Proc Singap Healthc 2025;doi:10.1177/20101058251318754]

Post-eLSCS antibiotic prescribing rates dropped significantly following the intervention (82 percent vs 46.8 percent; p<0.001). No significant difference was seen in SSI rates pre-post intervention (0.8 percent vs 1.9 percent). Likewise, SSI rates among women who received postoperative oral antibiotics relative to those without did not differ significantly (1.9 percent vs 1.5 percent; p=0.582).

International guidelines

For most procedures, international guidelines do not recommend further antibiotics after incision, but there remain high rates of prolonged prophylaxis. In an Australian review, the most common reason for inappropriateness (54 percent) was duration, which is similar to that of KKH (postoperative antibiotic rate, 82 percent). [Am J Health Syst Pharm 2013;70:195-283; JAMA Netw Open 2019;2:e1915003]

“As many studies have demonstrated effectiveness of collaborative strategies, ASP measures to reduce unnecessary antibiotics use were introduced in our institution,” the researchers said. [Antimicrob Resist Infect Control 2020;9:69; J Glob Antimicrob Resist 2020;20:105-109; PLoS One 2019;14:e0213395; Int J Clin Pharmacol Ther 2015;53:605-615]

Context

“Understanding the contextual and cultural determinants of infection management and antibiotic prescribing is critical to the development of context-specific interventions,” the researchers said. [JAMA Netw Open 2019;2:e1915003; PLoS One 2019;14:e0225011; Clin Microbiol Infect 2017;23:752-760]

“Clinical autonomy of individual prescribers and existing hierarchies within teams require consideration, together with a certain flexibility in implementation of measures,” they added.

In addition, some reasons prevent prescribers from changing their practice, such as lack of knowledge and confidence, innate reluctance for change, fear of “rocking the boat,” and failure to communicate. [Clin Infect Dis 2016;63:532-538]

“Building a culture of appropriate antibiotic prescribing will require more effort and time as compared to approaches such as formulary restriction or guidelines,” the researchers said. “However, the impact could be far-reaching and sustainable and should be further explored.”