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Audit of prophylactic antibiotic use in orthopaedic surgery in Mulago Hospital

Kigera JWM1 MBChB, MMed (Ortho), Turyakira C2 Dip(Orthopaedic Clinical Medicine) 1. Department of Orthopaedics, College of Health Sciences, Makerere University, Kampala, Uganda/Orthopaedic Rehabilitation Unit, PCEA Kikuyu Hospital, Kenya. 2. Mulago Paramedical Schools, Kampala, Uganda Correspondence to Kigera JWM Keywords – Antibiotics, Orthopaedic, Surgery


Background: Prophylactic antibiotics are entrenched in implant orthopaedic surgery. We conducted a study to determine the use of prophylactic antibiotics in clean implant orthopaedic surgery in Mulago hospital.


Methods: We prospectively recruited patients undergoing ORIF, Athroplasty and Foot and Ankle surgery. We obtained information on antibiotic use and observed surgeries to determine the timing of administration.


Results: Antibiotics were not used in 17.3% of patients and over half of the patients received the antibiotic after the skin incision had been made. The antibiotics were administered about 11 minutes from incision.


Conclusion: Majority of patients either did not receive antibiotics or received them after the skin incision had been made. The use of a third generation cephalosporin may be associated with increased complications and drug resistance. Antibiotic prophylaxis is in vari-ance with literature and may result in adverse outcomes.


The risk of infection after Implant orthopaedic surgery has reduced because of the use of antibiotic prophylaxis and is hence established in practice(1). It is however known that compliance to the use and timing of anti-biotics for prophylaxis is poor(2). Though the use and timing of antibiotics is well established, the compliance in the East African setting has not been documented. We conducted a study to determine the patterns of antibiot-ic prophylaxis in implant orthopaedic surgery in a large teaching hospital in East Africa.



A prospective study was conducted in the orthopaedic unit of the Mulago Hospital between February and April 2011. Mulago hospital is the national referral hospital in Uganda and the teaching hospital for Makerere Univer-sity School of Medicine. Patients undergoing implant or-thopaedic surgery were included. We excluded patients with open fractures and patients undergoing implant surgery in the presence of infection. Data concerning the indications for surgery, procedure done and antibiotics used were obtained from the patient charts. The opera-tive procedure was observed and the times of adminis-tration of antibiotics if any and skin incision were ob-served and recorded. Though the surgical team was not formally informed of the study, they were not blinded to its conduct. The study was approved by the institution ethics board who waived the need for informed consent from the patients.


Data was collected by a questionnaire and entered into Epidata program and exported to SPSS v 11.5 (SPSS Inc., Chicago, Illinois).



We included a total of 52 patients of whom 35 were males with a mean age of 36 years (SD 15.53). The pro-cedures done were 47 Open reduction and internal fixa-tion, 4 athroplasties and 1 foot and ankle surgery (Table 1). In 43 patients (82.7%) prophylactic antibiotics were used. In the four cases where tourniquets were used (2 forearm, 1 tibia, 1 foot) the antibiotic was administered 10 minutes prior to tourniquet application. The only drug administered was intravenous ceftriaxone either as 1000, 1500 or 2000mg. The antibiotic was administered before the skin incision in only 20 of the 43 patients who receive antibiotics (46.5%) at an average of 11.3 minutes before incision (range 1-33). In 23 patients (53.5%) the antibiotic was administered after the skin incision had been made at an average of 11.35 minutes after skin incision (range 1-26). In all cases the use of the antibiotic was initiated by the anaes-thesia provider.



Our results show that over 17% of patients did not re-ceive prophylactic antibiotics. It may be that these pa-tients are at an increased risk for complications though it is unclear if these patients suffered worse outcomes. The use of antibiotics in orthopaedic trauma and athro-plasty is an established practice and this is supported by literature (3-7). Less than half of patients received antibiotics prior to surgical incision. However in those receiving antibiot-ics prior to skin incision the timing was good averaging 11.3 minutes from incision time which is in line with recommendations that antibiotics should be admin-istered as close as possible to incision time within the hour preceding surgery and that the timing of antibiotic administration is the most important factor in prevent-ing infection(8-11).


Our study found that ceftriaxone, a third generation cephalosporin, was the only drug used in surgical pro-phylaxis. Though first generation cephalosporins are the recommended antibiotics for surgical prophylaxis in orthopaedics, the use of ceftriaxone in our setting may be due to its wide availability and the reduced cost of generic ceftriaxone in the local market (12). Cost is an issue to consider in the choice of antibiotic for surgical prophylaxis. A systematic review of literature found that a single dose of ceftriaxone may be a cost effective strat-egy(1).


Our study found that in all cases, the anaesthesia pro-vider initiated the administration of antibiotics. Sur-geons undertaking implant surgery should implement a mechanism to ensure that patients receive prophylactic antibiotics on time. Anaesthesia providers and all other surgical staff should also be involved in strategies to remedy the situation. The use of a simple surgical check list has been shown to increase compliance to timely an-tibiotic prescription and reduce the incidence of surgical site infections(2, 13). The rational use of antibiotics has been found that to result in decreased costs which would be a great motivation for many hospital managers (14). A weakness of the study is the fact that outcome data on infection was not retrieved mainly because of difficulties in follow-up. This study however, was aimed at compar-ing practices in the region in comparison to those estab-lished in literature.



The prophylactic antibiotics use in Mulago Hospital is in

Click to view table 1



variance with literature which may compromise results.




Efforts should be made to ensure better compliance with accepted standards.




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