Strengthening surgical antibiotic stewardship in low-resource settings: a multicentre, prospective, quality improvement study - Report - MDSpire

Strengthening surgical antibiotic stewardship in low-resource settings: a multicentre, prospective, quality improvement study

  • By

  • Clean Cut Investigators Group

  • John Ibyishaka

  • Yvonne Uwabagira

  • Mediatrice Cyuzuzo

  • Celine Tuyishime

  • Florentine Uwingabire

  • Pierre Celestin Ukobizaba

  • Jean Paul Niyigena

  • Jean Yves Shyrirakera

  • Marie Chantal Umurerwa

  • Gaudence Kabagwira

  • Vestine Musabende

  • Abraham Kwizera

  • Innocent Byamungu

  • Deborah Mukantibaziyaremye

  • Leontine Neema

  • Pierrine Nyirangeri

  • Valens Majyambere

  • Emmanuel Nsengimana

  • Andrew Oryono

  • Fabrice Habarugira

  • Valens Dusabimana

  • Diane Senga

  • Gerard Harerimana

  • Aloys Hakizimana

  • Yves Berard Niyomugabo

  • Senait Bitew Alemu

  • Sara Taye Hale

  • Barnabas Alayende

  • Maia R Nofal

  • Alype Rwamatwara

  • Roda Uwayesu

  • David Tuyisenge

  • Justin Bayisenga

  • Ronald Tubasiime

  • Febronie Muhorakeye

  • Assefa Tesfaye

  • Samantha Steeman

  • Hillena Kebede

  • Natnael Gebeyehu

  • Abebe Bekele

  • Tihitena Negussie Mammo

  • Thomas G Weiser

  • December 10, 2025

  • 0 min

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Reducing Prolonged Antibiotic Prophylaxis in Surgery via Integrated Stewardship in Rwanda

Overview

A multicenter quality improvement initiative in Rwanda significantly reduced prolonged postoperative antibiotic prophylaxis from 40.7% to 14.1% by integrating antimicrobial stewardship with enhanced infection prevention and control (IPC) practices. This reduction did not increase surgical site infection (SSI) rates, demonstrating that improved IPC compliance supports safe antibiotic stewardship in resource-limited settings.

Background

Surgical site infections (SSIs) are a major burden in low-income countries, often linked to overuse of prolonged antibiotic prophylaxis, which contributes to antimicrobial resistance (AMR). The World Health Organization recommends limiting prophylaxis duration, but poor IPC practices lead surgeons to extend antibiotic use. Previous work showed prolonged prophylaxis does not reduce SSIs even when IPC is suboptimal. Addressing both IPC and antibiotic stewardship simultaneously may reduce unnecessary antibiotic use without increasing infection risk.

Data Highlights

MeasurePre-InterventionPost-InterventionP Value
Prolonged antibiotic prophylaxis (>24h)40.7% (95% CI: 35-46%)14.1% (95% CI: 12-16%)<0.001
IPC compliance (mean of 6 standards)2.6 (95% CI: 2.5-2.7)5.0 (95% CI: 4.9-5.1)<0.001
SSI rate with early antibiotic cessation8.9%
SSI rate with prolonged prophylaxis17.2%
Risk-adjusted SSI rate difference (RR)1.37 (95% CI: 0.94-2.00)0.107

Key Findings

  • The integrated quality improvement program reduced prolonged postoperative antibiotic prophylaxis from 40.7% to 14.1% (P < 0.001).
  • Compliance with six key intraoperative IPC standards improved significantly from a mean of 2.6 to 5.0 (P < 0.001).
  • Patients with early cessation of antibiotics had lower unadjusted SSI rates (8.9%) compared to those with prolonged prophylaxis (17.2%).
  • After risk adjustment, no significant difference in SSI rates was observed between early cessation and prolonged prophylaxis groups (RR 1.37, P = 0.107).
  • Higher IPC compliance was associated with appropriate antibiotic use regardless of intervention phase.
  • The program demonstrated feasibility and effectiveness of antimicrobial stewardship integrated with IPC improvements in resource-limited surgical settings.

Clinical Implications

This study supports that reducing prolonged postoperative antibiotic prophylaxis is safe when combined with strengthened IPC practices, even in low-resource environments. Clinicians should prioritize adherence to IPC standards and limit antibiotic duration to prevent antimicrobial resistance without increasing SSI risk. Implementing multidisciplinary stewardship programs with antibiotic timeouts can facilitate guideline adherence and improve surgical outcomes.

Conclusion

Integrating antimicrobial stewardship with enhanced IPC measures effectively reduces unnecessary prolonged antibiotic use without increasing SSIs in resource-limited surgical settings. This approach offers a scalable model to improve surgical safety and combat antimicrobial resistance in low-income countries.

References

  1. WHO 2019 -- Antimicrobial resistance global report
  2. WHO 2016 -- Surgical antibiotic prophylaxis guidelines
  3. Prior study 2023 -- Prolonged prophylaxis ineffective despite poor IPC
  4. Clean Cut program 2019-2023 -- SSI prevention standards

Original Source(s)

Strengthening surgical antibiotic stewardship in low-resource settings: a multicentre, prospective, quality improvement study

  • by Clean Cut Investigators Group, John Ibyishaka, Yvonne Uwabagira, Mediatrice Cyuzuzo, Celine Tuyishime, Florentine Uwingabire, Pierre Celestin Ukobizaba, Jean Paul Niyigena, Jean Yves Shyrirakera, Marie Chantal Umurerwa, Gaudence Kabagwira, Vestine Musabende, Abraham Kwizera, Innocent Byamungu, Deborah Mukantibaziyaremye, Leontine Neema, Pierrine Nyirangeri, Valens Majyambere, Emmanuel Nsengimana, Andrew Oryono, Fabrice Habarugira, Valens Dusabimana, Diane Senga, Gerard Harerimana, Aloys Hakizimana, Yves Berard Niyomugabo, Senait Bitew Alemu, Sara Taye Hale, Barnabas Alayende, Maia R Nofal, Alype Rwamatwara, Roda Uwayesu, David Tuyisenge, Justin Bayisenga, Ronald Tubasiime, Febronie Muhorakeye, Assefa Tesfaye, Samantha Steeman, Hillena Kebede, Natnael Gebeyehu, Abebe Bekele, Tihitena Negussie Mammo, Thomas G Weiser

  • December 10, 2025

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