International Journal of User-Driven Healthcare, 1(4), 1-14, October-December 2011 1

antibiotic Utilization for surgical

Prophylaxis in a tertiary care
teaching Rural Hospital
Amit Shah, Gujarat Adani Institute of Medical Sciences, India
Bharat Gajjar, Pramukh Swami Medical College, India
Ravi Shankar, KIST Medical College, Nepal

aBstRact
Rational antibiotic prophylaxis reduces the incidence of surgical wound infection. Improper antibiotic pro-
phylaxis leads to excessive surgical wound infection and increased drug resistance. There is an urgent need to
establish and implement antibiotic policy but it cannot be done if baseline data is not available. In this study,
the authors gathered baseline data about the pattern of surgical antibiotic prophylaxis in their institute. They
found that most of the perioperative use of antibiotics was not as per standard guidelines in terms of choice
of antibiotics and total duration of treatment. Interventions are warranted to promote the development, dis-
semination, and adoption of evidence-based guidelines for antibiotic surgical prophylaxis.

Keywords: Antibiotic Policy, Evidence-Based Guidelines, Preoperative Antibiotics, Postoperative

Antibiotics, Surgical Antibiotic Prophylaxis

intRoDUction laxis should be used where efficacy has been

The discovery of antibiotics is a remarkable
achievement of the twentieth century. Prior
to the antibiotic era, patients who contracted
common infectious diseases had significant
morbidity and mortality. The discovery of
penicillin in 1927, followed by subsequent
discovery of other antibiotics, contributed
to a significant decline in infectious disease
mortality (Oliphant & Madaras-Kelly, 2008).
Antibiotics are effective for the control as well
as cure of serious infections. Antibiotic prophy-
DOI: 10.4018/ijudh.2011100101
demonstrated and benefits outweigh the risk.
Antibiotic prophylaxis is divided into surgi-
cal prophylaxis and nonsurgical prophylaxis
(Lampiris & Maddix, 2009).
Surgical antibiotic prophylaxis is defined
as the use of antibiotics to prevent surgical site
infections (Tripathi, 1999). Surgical procedures
can be categorized into four classes (Table
1) with an increasing incidence of bacterial
contamination and subsequent incidence of
postoperative infection (Culver et al., 1991).
Rationally used antibiotic prophylaxis reduces
the incidence of surgical wound infection.
Prophylaxis is uniformly recommended for all

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2 International Journal of User-Driven Healthcare, 1(4), 1-14, October-December 2011

Table 1. Classification of Surgical procedures (adapted from Culver et al., 1991)

Class Definition Antibiotics

Operations in which no inflammation is encountered and the respiratory, ali-
Not indicated
Class I mentary or genitourinary tracts are not entered. There is no break in aseptic
unless high-risk
(Clean) operating theatre technique (herniorrhaphy, mastectomy, cosmetic surgery,
procedure a
insertion of prosthesis or artificial device).
Class II Operations in which the respiratory, alimentary or genitourinary tracts are Prophylactic
(Clean/ entered but without significant spillage (laryngectomy, uncomplicated ap- antibiotics
Contaminated) pendicectomy, cholecystectomy, transurethral resection of prostate gland). indicated
Operations where acute inflammation (without pus) is encountered, or
where there is visible contamination of the wound. Examples include gross Prophylactic
Class III
spillage from a hollow viscus during the operation or compound/ open antibiotics
(Contaminated)
injuries operated on within four hours (large bowel resection, biliary or indicated
genito-urinary tract surgery with infected bile or urine).
Therapeutic
Operations in the presence of pus, where there is a previously perforated
Class IV (Dirty) antibiotics
hollow viscus, or compound/open injuries more than four hours old.
required
a
High-risk procedures include implantation of prosthetic materials and other procedures where surgical site infec-
tion is associated with high morbidity

clean-contaminated, contaminated and dirty
procedures. It is optional for the clean proce-
dures, although it may be indicated for certain
patients and clean procedures that fulfill specific
risk criteria (Henry, 2006). Irrational antibiotic
prophylaxis leads to excessive surgical wound
infection and increase of drug resistance. Com-
mon errors in antibiotic prophylaxis include
selection of the wrong antibiotic, administering
the first dose too early or too late, failure to re-
peat doses during lengthy procedures, prolonged
duration of postoperative prophylaxis, and
injudicious use of broad spectrum antibiotics
(Lampiris & Maddix, 2009).
Many patients undergo operative proce-
dures in our institute but, there is no baseline
data available about the pattern of use of anti-
biotics in these patients. Therefore, this study
was planned to gather baseline data so that
corrective measures can be suggested for ratio-
nal use of antibiotics.
METHODOLOGY
This was a prospective observational study,
undertaken from February to October 2010, in
Shree Krishna Hospital and Medical Research
Centre, a 550 bedded tertiary care rural based,
teaching hospital attached to Pramukh Swami
Medical College, Karamsad, Gujarat, India.
The study was approved by Institutional Hu-
man Research Ethics Committee. Fifty post-
operative patients from all the departments who
perform surgeries as therapeutic intervention,
i.e., departments of Surgery, Obstetrics & Gyne-
cology, Orthopedics and ENT, thus total of 200
patients were included in this study. Department
of Ophthalmology offers day care surgery and
use of only topical antibiotics, therefore it was
not included in the study.
Inclusion criteria: Patients of all ages and either
gender who were admitted and had under-
gone surgical procedure in the Departments
of Surgery, Obstetrics & Gynecology,
Orthopedics or ENT.
Exclusion criteria: Patients unable to commu-
nicate, patients on ventilators, seriously ill
patients requiring admission in Intensive
Care Unit (ICU).
Prospective participants were explained
about the purpose and nature of the study in
the language understood by them and writ-

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 International Journal of User-Driven Healthcare, 1(4), 1-14, October-December 2011 3

Table 2. Age and gender distribution of patients

Departments
Total
Age Groups Surgery O&G Ortho ENT
(years)
Total W Total Total
M W M W Total (%) M W M W
(%) (%) (%) (%)
Children 21
5 1 6 (12) 0 (0) 6 0 6 (12) 5 4 9 (18) 16 5
(0 – 12) (10.5)
Adolescent
1 0 1 (2) 2 (4) 1 0 1 (2) 2 4 6 (12) 4 6 10 (5)
(13 – 18)
Young Adults 33 81
7 4 11 (22) 13 6 19 (38) 13 5 18 (36) 33 48
(19 – 39) (66) (40.5)
Middle Adults 13 53
12 2 14 (28) 8 5 13 (26) 5 8 13 (26) 25 28
(40 – 59) (26) (26.5)
Older 29
15 0 15 (30) 2 (4) 4 4 8 (16) 2 2 4 (8) 21 8
(60 – 74) (14.5)
Old – Old
2 1 3 (6) 0 (0) 3 0 3 (6) 0 0 0 (0) 5 1 6 (3)
(≥75)
50 50 200
Total 42 8 35 15 50 (100) 27 23 50 104 96
(100) (100) (100)

ten informed consent taken. Each patient was
followed up on daily basis till discharge from
ward. Their case record sheets were reviewed
for collecting requisite information, which was
entered in case record form. Appropriateness of
surgical antibiotic prophylaxis was assessed as
per standard guidelines suggested by competent
authorities like Scottish Intercollegiate Guide-
line Network (SIGN) and American Family
Physician Association (AFPA).
RESULTS
Demographic Parameters
Out of total 200 patients, 104 (52%) were men
and 96 (48%) were women. Majority of the
patients (81=40.5%) were young adults in the
age range 19 to 39 years (Table 2).
Types of Surgery according to
Surgical Wound Class
Majority of the patients (91=45.5%) had Class
II (Clean-Contaminated) surgical wounds fol-
lowed by Class I (Clean 52=26%), Class III
(Contaminated, 35=17.5%) and Class IV (Dirty
22=11%). Most of the patients (20=40%) and
26 (52%) had Class I (Clean) surgical wound in
Surgery and Orthopedics, respectively while in
Obstetrics & Gynecology and ENT (43=86%)
and (24=48%), respectively had Class II (Clean-
Contaminated) surgical wounds (Table 3).
Pattern of Preoperative Antibiotic
Use
Preoperative antibiotics were prescribed in 196
patients. Majority (130=65%) were prescribed
single antibiotic. Majority of the patients of
Surgery (31=62%), Orthopedics (46=92%)
and ENT (40=80%) were prescribed one pre-
operative antibiotic while 36 (72%) patients
were prescribed two antibiotics in Obstetrics
& Gynecology (Table 4).
Cephalosporins were the most frequently
prescribed in 176 (88%) patients out of total
200 patients. Same pattern was observed in all
four departments. Third generation Cephalo-
sporins (92=46%) were most commonly pre-
scribed. Third generation Cephalosporins were
the most commonly prescribed in Surgery

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4 International Journal of User-Driven Healthcare, 1(4), 1-14, October-December 2011

Table 3. Surgical class of wounds in patients

Departments
Class Total (%)
Surgery (%) O & G (%) Ortho (%) ENT (%)
I (Clean) 20 (40) 0 (0) 26 (52) 6 (12) 52 (26)
II (Clean-Contaminated) 13 (26) 43 (86) 11 (22) 24 (48) 91 (45.5)
III (Contaminated) 6 (12) 2 (4) 10 (20) 17 (34) 35 (17.5)
IV (Dirty) 11 (22) 5 (10) 3 (6) 3 (6) 22 (11)
Total 50 (100) 50 (100) 50 (100) 50 (100) 200 (100)

Table 4. Number of preoperative antibiotics prescribed

No. of Departments
Total (%)
Antibiotics Surgery (%) O & G (%) Ortho (%) ENT (%)
0 2 (4) 0 (0) 2 (4) 0 (0) 4 (2)
1 31 (62) 13 (26) 46 (92) 40 (80) 130 (65)
2 16 (32) 36 (72) 0 (0) 10 (20) 62 (31)
3 1 (2) 1 (2) 2 (4) 0 (0) 4 (2)
Total 50 (100) 50 (100) 50 (100) 50 (100) 200 (100)

Table 5. Groups of preoperative antibiotic prescribed

Departments
Antibiotic Total (%)
Surgery (%) O & G (%) Ortho (%) ENT (%)
1st Generation 9 (18) 1 (2) 0 (0) 21 (42) 31 (15.5)
2 Generation
nd
3 (6) 0 (0) 44 (88) 0 (0) 47 (23.5)
Cephalosporins
3rd Generation 28 (56) 41 (82) 1 (2) 28 (56) 92 (46)
Total 40 (80) 42 (84) 45 (90) 49 (98) 176 (88)
Nitroimidazoles 13 (26) 37 (74) 2 (4) 10 (20) 62 (31)
Flouroquinolones 8 (16) 8 (16) 1 (2) 0 (0) 17 (8.5)
Penicillins 4 (8) 1 (2) 1 (2) 1 (2) 7 (3.5)
Aminoglycosides 1 (2) 0 (0) 3 (6) 0 (0) 4 (2)

(28=56%), Obstetrics & Gynecology (41=82%) furoxime (47=23.5%), Cefotaxime (36=18%)

and ENT (28= 56%) departments while second
generation Cephalosporins were most com-
monly prescribed in Orthopedics (44= 88%)
(Table 5).
Ceftriaxone was most frequently prescribed
preoperative antibiotic in 59 (29.5%) patients
followed by Metronidazole (53=26.5%), Ce-
and Cefazolin (31=15.5%) (Table 6).
All the patients received preoperative an-
tibiotics intravenous except two patients from
Surgery department, who were given Cipro-
floxacin orally.
Most of the patients (126=63%) had re-
ceived first dose of preoperative antibiotics

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 International Journal of User-Driven Healthcare, 1(4), 1-14, October-December 2011 5

Table 6. Prescribed preoperative antibiotics

Departments
Antibiotic Total (%)
Surgery (%) O & G (%) Ortho (%) ENT (%)
Ceftriaxone 20 (40) 11 (22) 1 (2) 27 (54) 59 (29.5)
Metronidazole 13 (26) 28 (56) 2 (4) 10 (20) 53 (26.5)
Cefuroxime 3 (6) 0 (0) 44 (88) 0 (0) 47 (23.5)
Cefotaxime 8 (16) 28 (56) 0 (0) 0 (0) 36 (18.0)
Cefazolin 9 (18) 1 (2) 0 (0) 21 (42) 31 (15.5)
Ciprofloxacin 6 (12) 8 (16) 1 (2) 0 (0) 15 (07.5)
Other 7 (14) 12 (24) 4 (8) 2 (4) 25 (12.5)

Table 7. Timing of first dose of preoperative antibiotic administration

Timing of Administration Departments

Total (%)
Prior to Surgery Surgery (%) O & G (%) Ortho (%) ENT (%)
Before 3 hours 0 (0) 0 (0) 0 (0) 44 (88) 44 (22)
Before 1 hour 0 (0) 23 (46) 0 (0) 0 (0) 23 (11.5)
Within 30 minutes 47 (94) 26 (52) 47 (94) 6 (12) 126 (63)

30 minutes prior to surgery, 44 (22%) patients
received antibiotics three hours prior and 23
(11.5%) patients received antibiotics one hour
prior to surgery (Table 7).
Pattern of Postoperative Antibiotic
Use
Variation was seen in the number of antibiot-
ics prescribed postoperatively. Overall 81
(40.5%) patients were prescribed two antibi-
otics (Table 8).
Cephalosporin group was most frequently
prescribed in 164 (82%) patients in all four
departments. Third generation Cephalosporins
(109, 54.5%) were most commonly prescribed.
Third generation Cephalosporins were the most
commonly prescribed group is Surgery (22=
44%) and ENT (43=86%) departments, second
generation Cephalosporins were the most com-
monly prescribed group in Orthopedics
(44=88%) while Nitroimidazoles were the most
commonly prescribed in Obstetrics & Gynecol-
ogy (41=82%) (Table 9).
Cefixime was the most frequently pre-
scribed postoperative antibiotic (84=42%)
followed by Metronidazole (63=31.5%), Cef-
triaxone (46=23%), Cefuroxime (46=23%) and
Cefotaxime (27= 13.5%) (Table 10).
As far as route of administration of post-
operative antibiotics is concerned, 49 (24.5%)
patients were given antibiotics thorough intra-
venous, 26 patients received them orally
whereas as majority of the patients (120, 60%)
were given through both intravenous and oral
route, either intravenous preceded by oral or
simultaneously (Table 11).
Average duration of postoperative antibi-
otic administration was 7.13 days (range 1-35
days). Duration of administration of antibiotics
in respective departments were 8.08 days (range
3-11 days) in ENT, 7.60 days (range 3-17 days)

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6 International Journal of User-Driven Healthcare, 1(4), 1-14, October-December 2011

Table 8. Number of postoperative antibiotics prescribed

No. of Departments
Total (%)
Antibiotics Surgery (%) O & G (%) Ortho (%) ENT (%)
0 5 (10) 0 (0) 0 (0) 0 (0) 5 (2.5)
1 14 (28) 3 (6) 34 (68) 10 (20) 61 (30.5)
2 20 (40) 18 (36) 10 (20) 33 (66) 81 (41.5)
3 8 (16) 26 (52) 5 (10) 2 (4) 41 (20.5)
4 2 (4) 3 (6) 1 (2) 5 (10) 11 (5.5)
5 1 (2) 0 (0) 0 (0) 0 (0) 1 (0.5)
Total 50 (100) 50 (100) 50 (100) 50 (100) 200 (100)

Table 9. Groups of postoperative antibiotic prescribed (figures show number of patients)

Departments
Antibiotic Surgery O&G Total (%)
Ortho (%) ENT (%)
(%) (%)
Cephalosporins – 1st Generation 10 (20) 1 (2) 4 (8) 27 (54) 42 (21)
Cephalosporins – 2 Generation
nd
2 (4) 0 (0) 44 (88) 0 (0) 46 (23)
Cephalosporins – 3rd Generation 22 (44) 40 (80) 4 (8) 43 (86) 109 (54.5)
Cephalosporins 31 (62) 41 (82) 46 (92) 48 (96) 164 (82)
Nitroimidazoles 18 (36) 41 (82) 4 (8) 9 (18) 72 (36)
Flouroquinolones 14 (28) 10 (20) 4 (8) 0 (0) 18 (9)
Aminoglycosides 5 (10) 2 (4) 6 (12) 9 (18) 22 (11)
Penicillins 7 (14) 1 (2) 2 (4) 3 (6) 13 (6.5)
Oxazolidinones 2 (4) 0 (0) 1 (2) 0 (0) 3 (1.5)
Tetracyclines 0 (0) 1 (2) 0 (0) 0 (0) 1 (0.5)
Macrolides 1 (2) 0 (0) 0 (0) 0 (0) 1 (0.5)
Lincosamides 1 (2) 0 (0) 0 (0) 0 (0) 1 (0.5)

in Obstetrics & Gynecology, 6.74 days (range
1-18 days) in Surgery and 6.12 days (range 1-35
days) in Orthopedics (Table 12).
DISCUSSION
The efficacy of antibiotics has decreased with
the advent of antibiotic resistance and the drying
up of the pharmaceutical antibiotic development
pipeline (Hsu et al., 2008). Hence prudent and
rational use of antibiotics has to be promoted to
retard the development of resistance and extend
the viability of the existing medicines, which is
only possible if baseline data about antibiotic
utilization is available. This study focused
mainly on studying the pattern of prophylactic
use of antibiotic in the perioperative period in
surgical patients, which is important for the
initiation of the prudent and appropriate use of
antibiotics in the surgical patients.
In our study majority of the patients had
Class II (Clean-Contaminated) surgical wounds.

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 International Journal of User-Driven Healthcare, 1(4), 1-14, October-December 2011 7

Table 10. Prescribed postoperative antibiotics

Departments
Antibiotic Total (%)
Surgery (%) O & G (%) Ortho (%) ENT (%)
Cefixime 12 (24) 36 (72) 3 (6) 33 (66) 84 (42)
Metronidazole 18 (36) 32 (64) 4 (8) 9 (18) 63 (31.5)
Ceftriaxone 14 (28) 10 (20) 1 (2) 21 (42) 46 (23)
Cefuroxime 2 (4) 0 (0) 44 (88) 0 (0) 46 (23)
Cefotaxime 2 (4) 25 (50) 0 (0) 0 (0) 27 (13.5)
Ciprofloxacin 11 (22) 8 (16) 3 (6) 0 (0) 22 (11)
Cefazolin 2 (4) 1 (2) 0 (0) 18 (36) 21 (10.5)
Other 28 (56) 17 (34) 18 (36) 21 (42) 84 (42)

Table 11. Route of administration of postoperative antibiotics

Route of Administra- Departments

Total (%)
tion Surgery (%) O & G (%) Ortho (%) ENT (%)
Intravenous 9 (18) 1 (0) 35 (70) 4 (8) 49 (24.5)
Oral 15 (30) 3 (6) 1 (2) 7 (14) 26 (13)
Intravenous + Oral 21 (42) 46 (92) 14 (28) 39 (78) 120 (60)

Table 12. Duration of postoperative antibiotics administration

DepartmentsSurgery Average Duration (days)6.74 ± 0.54

O&G 7.60 ± 0.32
Ortho 6.12 ± 0.78
ENT 8.08 ± 0.22
Overall 7.13 ± 0.26
Values in Mean ± SE

van Disseldorp, Slingenberg, Matute, Delgado,
Hak, and Hoepelman (2006) from The Neth-
erlands reported that majority of their surgical
patients also had undergone type II surgery.
No guidelines exist in relation to selection of
antibiotics on the basis type of surgery or surgi-
cal wound class as culture sensitivity pattern
of microorganisms is known to be different
according to geographical area. Clean wounds
which are not contaminated are excised using
sterile technique. So chance of the infection
of clean wounds is quite low, and antibiotic
prophylaxis is generally not necessary if the
environment is sterile. Clean-contaminated
wounds comprise dermatologic surgical proce-
dures in contaminated areas. These have more
chances of infection. Antibiotic prophylaxis
should be considered, depending on the surgical
site, length, and nature of the procedure, overall
health of the patient, and level of contamination.
Contaminated wounds have visibly inflamed
tissue or are associated with trauma or major
breaches of sterile surgical technique. Their
infection rates are higher. Infected wounds

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8 International Journal of User-Driven Healthcare, 1(4), 1-14, October-December 2011
like traumatic wounds are heavily laden with
necrotic tissue, foreign bodies and/or pus.
These wounds have the highest rate of infec-
tion. Antibiotic prophylaxis is recommended
for both contaminated and infected wounds
(Nestor, 2005).
In this study, majority (130= 65%) of the
patients were prescribed single preoperative
antibiotic whereas 35% patients received more
than one antibiotic. The study of Shethwala and
Gajjar (2008) shown that majority of the patients
(56%) had received more than one antibiotic.
Single standard therapeutic dose of any single
effective antibiotic is sufficient for prophylaxis
under most circumstances (Scottish Intercol-
legiate Guidelines Network, 2008). So use of
single preoperative antibiotic in this study is ra-
tional. Cephalosporins were the most frequently
prescribed group in 176 (88%) patients in this
study. Other studies done by Kulkarni, Kochhar,
Dargude, Rajadhyakshya, and Thatte (2005) in
Mumbai and Rehan, Kakkar, and Goel (2010)
in New Delhi also showed that Cephalosporins
were the most commonly prescribed antibiotics
in all surgery groups viz. clean, contaminated
and dirty surgeries. Study carried out in the
Czech Republic had shown that Penicillins
and enzyme inhibitor were most frequently
prescribed antibiotic group (Andrajati, Vlcek,
Kolar, & Pípalová, 2005). Third generation
Cephalosporins (92=46%) were most com-
monly prescribed among the Cephalosporins
group in present study. The American Academy
of Family Physician recommended the use of
first generation Cephalosporins like Cefazolin
for prophylaxis in surgeries (Woods & Del-
linger, 1998). Third generation Cephalosporins
were most commonly prescribed in Surgery,
Obstetrics & Gynecology and ENT departments
while 2nd generation Cephalosporins were most
commonly prescribed Orthopedics in the pres-
ent study. This may be because surgeons want
to avoid surgical wound infection by using
broad spectrum antibiotic groups. The unneces-
sary use of extended spectrum antibiotics for
surgical prophylaxis encourages the selection
of resistant microorganisms, ADRs to patients
and wastage of money.
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Ceftriaxone was the most frequently pre-
scribed preoperative antibiotic in the present
study. Similar studies done by Shethwala and
Gajjar (2008), Kulkarni et al. (2005), and al
Harbi in Yambu (1998) had shown that Ceftriax-
one was most frequently prescribed preoperative
antibiotic. While study carried out in the Czech
Republic had shown that Cefazolin was most
frequently prescribed antibiotic (Andrajati et
al., 2005). According to the American Academy
of Family Physician, species of staphylococcus
causing infection in the majority of procedures
do not violate mucosa or a hollow viscus hence
a first generation Cephalosporin (Cefazolin)
is sufficient for prophylaxis in the majority of
procedures (Woods & Dellinger, 1998). In meta
analyses of heterogeneous studies, perioperative
antibiotic prophylaxis with Ceftriaxone showed
a decrease in the relative risk of SSI of 30%
compared to other Cephalosporins (Dietrich,
Bieser, Frank, Schwarzer, & Daschner, 2002).
Selection of antibiotics differs in different
departments as there are no standard treatment
guidelines (STGs) available.
All the patients were given antibiotics
through intravenous route, except two patients in
department of Surgery. Scottish Intercollegiate
Guidelines Network (2008) recommended that
systemic antibiotic prophylaxis, typically given
intravenous, is reliable and effective against SSI
in all types of surgery. So route of administration
of preoperative antibiotic is justifiable here.
Most of the patients (126=63%) had received
first dose of preoperative antibiotics 30 minutes
prior to surgery. Study done by Rehan et al. (2010)
reported that 13% patients received antibiotics
just before incision. In a study examining the tim-
ing of antibiotic administration to 2,847 patients
receiving prophylaxis, Classen, Evans, Pestotnik,
Horn, Menlove, and Burke (1992) evaluated
patients who received prophylaxis early (2–24
hours before surgery), preoperative prophylaxis
(0–2 hours prior to surgery), perioperative pro-
phylaxis (up to 3 hours after first incision), and
postoperative prophylaxis (>3 hours after first
incision). The risk of infection was lowest (0.6%)
for patients who received preoperative prophy-
laxis, moderate (1.4%) for those who received
 International Journal of User-Driven Healthcare, 1(4), 1-14, October-December 2011 9
perioperative antibiotics, and greatest for those
who received postoperative antibiotics (3.3%)
or preoperative antibiotics too early (3.8%).
Correct timing of antibiotic administration is
imperative to preventing SSI. Antibiotics should
be administered with anesthesia just prior to the
initial incision. Administration of antibiotics too
early may result in concentrations below the MIC
toward the end of the operation, and administra-
tion too late leaves the patient unprotected at the
time of initial incision (Kanji & Devlin, 2008).
The variation in timing of first dose preoperative
antibiotic in various departments is due to their
fixed practices. In departments of Surgery and
Orthopedics, antibiotic administration is done
in the recovery room just before the patient is
shifted to operation theatre or at the time of inci-
sion while antibiotic/s is/are administered at 6 am
and 8 am in Obstetrics & Gynecology and ENT
(except in emergency procedures), respectively.
Scenario is different in terms of number
of antibiotics prescribed postoperatively as
compared to preoperatively. Overall 66.5%
patients were prescribed two or more postop-
erative antibiotics either simultaneously or one
after another, 31% patients were prescribed
one antibiotic while no postoperative antibiotic
was prescribed in 2.5% patients. Shethwala
and Gajjar (2008) also showed that 28% pa-
tients received single antibiotic and 71.75%
patients received two or more postoperative
antibiotics. Guidelines available for antibiotic
prophylaxis in surgery suggests that there is no
need of postoperative antibiotic except in type
IV (dirty) surgeries (Scottish Intercollegiate
Guidelines Network, 2008; Mangram, Horan,
Pearson, Silver, & Jarvis, 1999). Hence the use
of postoperative antibiotics is irrational.
Like preoperative choice, Cephalosporins
were the most frequently prescribed group
postoperatively also in all the four depart-
ments. Cephalosporins were also the most
frequent group prescribed postoperatively in
study done by Shethwala and Gajjar (2008).
Third generation Cephalosporins were most
commonly prescribed. Cefixime was most
frequently prescribed postoperative antibiotic
in our study. The study of Shethwala and Gaj-
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jar (2008) reported that Ceftriaxone was most
frequently prescribed postoperative antibiotic.
Majority of the patients were given antibi-
otics through both IV and oral route, either IV
preceded by oral route or simultaneously. Same
pattern was seen in departments of Surgery,
Obstetrics & Gynecology and ENT. It was com-
mon practice to administer antibiotic through
IV route for 2-3 days and then switch over to
oral antibiotics. While in Orthopedics, majority
of patients were given antibiotics IV because
they preferred Cefuroxime IV for 3 to 5 days.
Average duration of postoperative anti-
biotic administration was 7.13 days (range
1-35 days). In another study done by Rehan
et al. (2010), postoperative antibiotics were
administered for a mean duration of 5 days
during hospital stay and another 6 days follow-
ing discharge. A mean duration of 6.4 days of
antibiotic use has been reported in Taiwanese
patients (Chen, Liv, Kunin, Huang, & Tsai,
2002). Even though evidence from literature
fails to support prolonged administration of
antibiotics, usage of postoperative antibiotics
beyond 24 hours is common (Bratzler et al.,
2005). Longer courses of antibiotics are falsely
believed to be a good preventive measure against
surgical site infections.
There is no evidence based standard,
for the use of postoperative prophylactic
antibiotics in surgical patients. There is gen-
eral agreement that antibiotic prophylaxis in
surgery should not be given for longer than
24 hr postoperatively. A number of studies
have compared administration of a single
dose versus 24 hr of administration and found
equal efficacy (Luchette et al., 2000). Despite
the insufficient power of these studies, most
authorities feel that a single dose of an an-
tibiotic will suffice for surgical procedures
that do not exceed 3-4 half lives of the drug,
provided there is no substantial blood loss and
no use of extra corporal circulation. Under the
latter circumstances an extra dose of antibi-
otic shortly before the end of the surgery is
indicated (Luchette et al., 2000). Currently,
the clinicians’ approach to postoperative
antibiotic prophylaxis in patients undergoing
10 International Journal of User-Driven Healthcare, 1(4), 1-14, October-December 2011
surgery varies widely. Reducing the infectious
complications of surgery is an important goal
but it is also important to reduce the use of
unnecessary postoperative antibiotics.
This study shows that the prophylactic
use of antibiotics in surgical patients was inap-
propriate in majority of cases, irrespective of
the specialty department. It also highlights the
challenges of disseminating evidence based
STGs into routine clinical practice.
There are some limitations of this study.
We collected data from only one institute,
hence population is relatively homogenous.
Large multicentric studies involving hetero-
geneous populations are needed. We have
not considered the surgical site infection for
which antibiotics were prescribed. Hence the
studies which compare the use of prophylactic
antibiotics and development of surgical site
infection are needed.
After considering all these factors, it is
evident that there are various measures needed
to improve appropriate use of prophylactic
antibiotics in surgical patients like,
• Development of evidence based guidelines
in collaboration with surgeons
• Increased outcome based research to docu-
ment benefits of appropriate antibiotic use
• Continuing education to disseminate in-
formation to practitioners
• Strengthening of Hospital Acquired Infec-
tion Control Programme to the level of
surgeon’s satisfaction
• Surveys of antibiotic use and reassessment
of prescribing practices over time
• Providing regular feedback and organizing
group education (e.g., Antibiotic Steward-
ship Program) and consensus meetings.
CONCLUSION
Pattern of antibiotic drugs used perioperatively
was not as per guidelines suggested by com-
petent authority like Scottish Intercollegiate
Guideline Network (SIGN) in terms of choice
of antibiotics and total duration of treatment,
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in majority of the cases. Interventions are war-
ranted to promote the development, dissemina-
tion and adoption of evidence based STGs for
antibiotic prophylaxis.
Antibiotic Use for
Surgical Prophylaxis
Invited Commentary by
Ravi Shankar, KIST Medical
College, Nepal
The authors should be commended on address-
ing a very important issue. Antibiotic resistance
is becoming a major challenge the world over
and is the theme of this year’s World Health
day. The World Health Organization (WHO)
in a recent fact sheet states why antimicrobial
resistance (AMR) is an issue of global concern.
AMR can challenge the considerable progress
made in treatment of infectious diseases, in-
crease healthcare costs, compromise healthcare
gains of society and can reduce or even abolish
the power of antibiotics (World Health Orga-
nization, 2011).
Inappropriate Antibiotic Use
of Surgical Prophylaxis
Inappropriate use of antibiotics is a major factor
contributing to resistance. Inappropriate use for
surgical antibiotic prophylaxis (SAP) is a major
area of concern in many developing nations. The
guideline developed by the American Society
of Hospital Pharmacists (ASHP) recommends
the use of a cephalosporin like cefixime given
30 minutes before the first incision for ma-
jority of surgeries and does not recommend
post-operative antibiotics for most surgeries
(American Society of Hospital Pharmacists,
1999). Studies in hospitals in developing na-
tions have shown that use of antibiotics for
SAP is prolonged and often a combination
of antibiotics is used. In a hospital in western
Nepal, antibiotics were used in 367 of the 371
patients who underwent surgeries. Most surger-
ies were clean-contaminated and the fixed-dose
combination (FDC) of ampicillin and cloxacil-
lin, metronidazole, gentamicin, ampicillin and
 International Journal of User-Driven Healthcare, 1(4), 1-14, October-December 2011 11
cefotaxime were most commonly prescribed
(Shankar, Shankar, Subish, Dubey, Mishra, &
Upadhyay, 2007). The use of antibiotics was
according to guidelines in only 21.1% of pa-
tients. Common reasons for inappropriateness
were wrong choice of antibiotic, long duration
of post-operative use, prophylaxis given in
cases where it is not required and inadequate
dose is used for prophylaxis, The mean cost of
antibiotics for prophylaxis was 11.2 US$ while
if guidelines were followed the cost would have
been reduced to 1.6US$.
Promoting More Appropriate Use
of Antibiotics for Prophylaxis
A major reason stated by surgeons for long
duration of prophylaxis is that they are not
confident about the standards of sterility and
asepsis in the operating theaters and recovery
rooms and the prevalence of resistant organisms
in the wards and the hospital environment. Also
the risk of wound infections and prolongation
of hospital stay and cost of treatment is borne
by the patients and indirectly by the operating
surgeon. A Medicine and Therapeutics Commit-
tee (MTC) also called a Drug and Therapeutics
Committee (DTC) is a major initiative at the
hospital level to promote more rational use of
medicines including antibiotics. The hospital
Infection Control Committee can also play an
important role. A major challenge would be
convincing surgeons about shorter and more
appropriate courses of antibiotics for SAP and
investing in improving aseptic techniques and
sterility in operation theaters and recovery
rooms. Also developing systems for surveil-
lance of antimicrobial sensitivity patterns and
communicating the same to clinicians would be
a challenge. Previously at Manipal College of
Medical Sciences (MCOMS), Pokhara, Nepal
we had started drug information center (DIC)
and a DTC. The center used to publish a drug
information bulletin every quarter and we used
to publish the antibiogram of commonly iso-
lated microorganisms in the hospital to guide
antimicrobial prescribing by clinicians.
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Implications for User
Driven Healthcare
Are patients in a position to contribute to how
their doctors (surgeons) should use antibiotics
for surgical prophylaxis? In developing coun-
tries antibiotics are often available over the
counter (OTC) but in case of SAP the choice
of antibiotics is made by the surgeon. Patients
admitted for surgery want the procedure to go as
smoothly as possible with minimum of problems
and go home as early as possible. Patients in de-
veloping nations (often without insurance) also
want to spend the minimum amount possible
on antibiotics and other medicines. Do patients
want to be prescribed expensive antibiotics to
safeguard them from the risk of surgical infec-
tion? Have patients been educated about and
are they aware about the different choices and
regimens available for SAP? Are patients and
the community aware of the risks and harms
of inappropriate SAP in terms of development
of resistance, spread of resistant organisms to
the community and higher costs involved? Have
there been attempts to educate them about how
resistance has the potential to take them back to
a pre-antibiotic era? Can patients be aware and
knowledgeable partners in treatment decisions?
Fixed-Dose Combinations
In the study carried out in a rural teaching
hospital in Gujarat, India cephalosporins were
commonly prescribed. In our study the combina-
tion of ampicillin and cloxacillin was commonly
used. This is a commonly promoted and used
antibiotic combination in South Asia though
doubts have been raised about the rationality
of the combination (Poudel, Palaian, Shankar,
Jayasekara, & Izham, 2008). At KIST Medical
College Teaching hospital, the use of the fixed-
dose combination (FDC) has been restricted and
the combination is not included in the hospital
medicine list (Shankar, Piryani, Thapa, & Jha,
2011). Practitioners can use the individual
drugs separately in the same patient if required.
Promoting proper and rational use of antibiotics
12 International Journal of User-Driven Healthcare, 1(4), 1-14, October-December 2011
for SAP is a challenge and requires close coop-
eration and understanding between surgeons,
microbiologists, pharmacologists, pharmacists
and hospital administrators. The benefits in term
of reduced risk of resistance, less morbidity and
mortality and reduced transmission of resistant
organisms to the community make it worthwhile
for us to address the challenge.
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Amit Shah is assistant professor in pharmacology at Gujarat Adani Institute of Medical Sciences,
Bhuj-Kutch, Gujarat, India. He has just started his career in field of pharmacology. Dr. Shah
has 3 years of teaching experience in medical education. His fields of research interest include
pharmacotherapeutics and pharmacovigilance.

Bharat Gajjar is associate professor in pharmacology at Pramukhswami Medical College,

Karamsad, Dist. Anand, Gujarat, India. Having over 18 years of teaching experience in medical
education, Dr. Gajjar has participated in several workshops and training courses particularly
on Pharmacovigilance and rational drug therapy. He is a peer reviewer of the several journals
related to Pharmacology and coordinator of the peripheral centre of National Pharmacovigi-
lance Programme of India at Pramukhswami Medical College, Karamsad. His fields of research
interest include pharmacovigilance, rational drug therapy, prescription audit and reforms in
medical education.

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14 International Journal of User-Driven Healthcare, 1(4), 1-14, October-December 2011

Ravi Shankar is a clinical pharmacologist and medical educator at KIST Medical College, Lalitpur,
Nepal. He is professor and head of the department of clinical pharmacology and therapeutics,
a professor in the department of medical education and the MBBS Phase I program coordina-
tor. He is the member secretary of the hospital medicine and therapeutics committee. He is a
member of the institutional research committee. He is keenly interested in promoting the more
rational use of medicines and in small group learning methods. Dr. Shankar is a fellow and a
faculty of the PSGFAIMER Regional Institute, Coimbatore, India. Dr. Shankar is a member of
the editorial board of the International Journal of Medical Education. Dr. Shankar has over
370 publications in various journals. His areas of research are pharmacoepidemiology, phar-
macovigilance, medication counseling, teaching students about rational use of medicines and
medical education including medical humanities among others.

Copyright © 2010, IGI Global. Copying or distributing in print or electronic forms without written permission of IGI Global is prohibited.