Antibiotic prescribing in surgery and orthopedics : evolving practices, perceptions, and resistance in Central India

Background

India has one of the world's highest burdens of antimicrobial resistance (AMR), largely driven by inappropriate antibiotic use. In surgical and orthopedic departments, broad-spectrum antibiotics are routinely used for perioperative antibiotic prophylaxis (PAP) and infection treatment, further contributing to AMR. Although surgical site infections (SSIs) pose a significant risk in surgical and orthopedic departments, there is a lack of surveillance systems and long-term studies on antibiotic prescribing practices and the factors influencing antibiotic use in Central India.

Aim

To increase knowledge about antibiotic prescribing practices, SSIs, and perceptions of AMR in surgical and orthopedic departments in Central India.

Methods

Research was conducted in the orthopedic and surgical departments of three private-sector hospitals in the Ujjain district, Madhya Pradesh. Studies I-III are cross-sectional, involving prospective data collection, while Study IV is a qualitative study based on the integrated Capability, Opportunity, Motivation- Behavior model and the Theoretical Domains Framework. In Studies I and III, data were collected from the orthopedic (Study I) and surgical departments (Study III) of the teaching hospital (TH) and the non-teaching hospital (NTH-1) between 2008 and 2017. Antibiotic prescribing patterns were analyzed at the group level based on diagnoses. Total antibiotic use was measured in Defined Daily Doses (DDDs) per 1000 patient-days. Additionally, in Study III, antibiotics were categorized by Access Watch Reserve classification. Time trends in antibiotic use were analyzed using linear regression (Studies I and III) and polynomial regression (Study III). In Study II, data were collected from 2013 to 2016 in the orthopedic department of the TH. SSIs were identified based on the Centers for Disease Control and Prevention National Healthcare Safety Network criteria. Pathogens causing SSIs were identified according to Clinical and Laboratory Standards Institute guidelines. The American Society for Anesthesiologists classification system was used to assess patients' operative risk. Risk factors for orthopedic SSI development were analyzed using univariable and multivariable backward stepwise logistic regression. In Study IV, semi-structured interviews were conducted in 2023 with 15 general and orthopedic surgeons at the TH, the NTH-1, and the NTH-2. The questions were designed to explore factors influencing antibiotic prescribing decisions, as well as surgeons' perceptions of antibiotic use, AMR, and potential solutions. Manifest and latent content analysis was applied.

Results

Antibiotic prescribing was rarely guided by culture and susceptibility testing, and no context-specific antibiotic prescribing guidelines were in place. In orthopedic departments, third-generation cephalosporins were the most used antibiotics, with fractures of the spine and limbs being the most prevalent indications. In surgical departments, fluoroquinolones and third-generation cephalosporins were the most commonly prescribed antibiotics, with inguinal hernia and calculus of kidney and ureter being the most common diagnoses. In orthopedic departments, total antibiotic use significantly increased over a 10-year period, whereas in surgical departments, it slightly decreased in the last three years (NTH-1) to five years (TH). Additionally, the proportion of prescribed Watch antibiotics significantly increased in surgical departments over the same period. Over a three-year period, the incidence of orthopedic SSIs was 7.6%. Risk factors for orthopedic SSI development included male sex (OR = 2.64, 95% CI 1.32-5.30), previous hospitalization (OR = 2.15, 95% CI 1.25-3.69), antibiotic use during hospitalization before PAP (OR = 4.19, 95% CI 2.51-7.00), postoperative length of stay longer than 15 days (OR = 3.30, 95% CI 1.83-5.95), and preoperative showering (OR = 4.73, 95% CI 2.72-8.22). The most used PAP in orthopedic surgery was a combination of a third-generation cephalosporin and a B-lactamase inhibitor with amikacin. The most common pathogen causing orthopedic SSIs was Staphylococcus aureus, which exhibited 100% resistance to penicillinase-labile penicillins. Various factors were found to influence the decision-making process for antibiotic prescribing among general and orthopedic surgeons, including environmental factors (e.g., dry and dusty rural setting); sociocultural factors (e.g., patients' socioeconomic status and beliefs); and the prescriber's experience, personal preferences, and seniority level. General and orthopedic surgeons largely perceived AMR as a social problem that requires a collective effort.

Conclusion

In orthopedic departments, total antibiotic use significantly increased over 10 years, whereas in surgical departments, it slightly decreased over the last three to five years of the same period. Antibiotic prescribing was predominantly empirical and strongly influenced by environmental and sociocultural factors. A considerable proportion of patients in orthopedic and surgical departments received antibiotics without clear indications, and PAP selection deviated from internationally recommended standards. The incidence of orthopedic SSIs was 7.6% over three years, which is relatively high for orthopedic surgeries but low compared to reported SSI incidences in India. Preoperative showering was identified as a significant risk factor for orthopedic SSIs, a finding not previously reported in the literature. This research emphasized the need to develop hospital antimicrobial stewardship programs, strengthen infection prevention and control measures and diagnostic practices, develop and implement context-specific antibiotic prescribing guidelines, and foster regular interdisciplinary collaboration. AMR was recognized as a complex social issue that requires a collective, multisectoral effort.

List of scientific papers

I. Skender K, Singh V, Stålsby Lundborg C, Sharma M. Trends and patterns of antibiotic prescribing at orthopedic inpatient departments of two private-sector hospitals in Central India: A 10- year observational study. PLoS ONE. 2021 Jan 27;16(1):e0245902. https://doi.org/10.1371/journal.pone.0245902

II. Skender K, Machowska A, Singh V, Goel V, Marothi Y, Stålsby Lundborg C, Sharma M. Antibiotic Use, Incidence and Risk Factors for Orthopedic Surgical Site Infections in a Teaching Hospital in Madhya Pradesh, India. Antibiotics. 2022 May 31;11(6):748. https://doi.org/10.3390/antibiotics11060748

III. Skender K, Machowska A, Dhakaita SK, Stålsby Lundborg C, Sharma M. Ten-year trends of antibiotic prescribing in surgery departments of two private sector hospitals in Central India: a prospective observational study. BMC Public Health. 2024 Jan 27;24(1):310. https://doi.org/10.1186/s12889-024-17817-2

IV. Skender K, Machowska A, Khare S, Singh V, Stålsby Lundborg C, Sharma M. "Our hands are tied": A qualitative exploration of antibiotic prescribing practices and perceptions of antimicrobial resistance among general and orthopedic surgeons in Central India. [Submitted]