Clinical Audit for Antibiotic Usage in Surgical Prophylaxis

This article presents a clinical audit conducted to evaluate the correct usage of antibiotics in surgical prophylaxis in a hospital setting in the United Arab Emirates. The aim of the audit was to investigate whether the correct antibiotic usage is conducted in surgical prophylaxis for caesarean sections according to standard guidelines. The study design involved the use of a clinical audit tool for data collection and a mixed method (qualitative and quantitative) analysis. The main findings revealed that some of the prescribed medicines for operative prophylaxis, including dose, duration, and incision timing, did not comply with standard medication guidelines. The article concludes with recommendations for improving preoperative antibiotic use.

Running head: ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
CLINICAL AUDIT FOR THE CORRECT USAGE OF ANTIBIOTIC IN SURGICAL
PROPHYLAXIS IN A HOSPITAL SETTING IN UNITED ARAB EMIRATES
A thesis presented by
Name of the Student
2019
Affiliation of author
Research for this project was carried out by me during the period of registration on
the MSc in Advanced Clinical Pharmacy Practice (or Clinical Pharmacy) with
Queen’s University Belfast.
This thesis is submitted in part fulfilment of the requirements of
Queen’s University Belfast for the degree of
MSc in Advanced Clinical Pharmacy Practice (or Clinical Pharmacy).
Signed......................................................... Date.......................................

1ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
Acknowledgement
It has been a fascinating and very rewarding experience to write this thesis.
To begin with, I want to thank a few individuals who made a contribution to the final
outcomes in distinct respects. I express my sincere and profound thanks to my
Supervisor Dr _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _, who has made
critical proposals and asked questions on several of my text's preliminary works.My
experience was substantially complemented by his/ her skills, invaluable guidance,
continuous encouragement, affection, knowledge, patience, and good criticism. It
would not have been possible to complete this study without his/ her continuous
inspiration.
I sincerely thank all medical professionals, administrative officials from the heart for
helping me complete the clinical audit and for their written consent with complete
patience. I would like to take this chance to thank my University, _ _ _ _ _ _ _ _ _ _
_ _ _ _, for letting me use its facilities and library.
A special thanks to my family. Words are not capable of expressing my appreciation
of the sacrifices given by my mother and my father, family and
friends. Your prayer for me which was supported me so far.
Finally, I praise GOD, the Almighty, who gave me excellent health, bravery,
motivation, enthusiasm, and light. Your guidance I've encountered every day. You're
the one who allowed me to graduate. For my future, I will continue to trust you.
Thank you, Lord.

2ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
Abstract
Title: Clinical audit for the correct usage of antibiotic in surgical prophylaxis in a
hospital setting in United Arab Emirates.
Background: The clinical audit includes the measurement of a clinical results or
process against well-defined norms established on the ideology of evidence - based
practice to establish the modifications necessary to enhance care quality. The
ultimate objective of the clinical audit is always to improve health care provided to
the patients. Caesarean delivery is one of the most significant risk factor for post-
partum maternal infection. An important and significant cause of maternal morbidity
is infectious complications after caesarean births which have been associated with
significant growth in hospital stays. The audit was therefore performed to evaluate
the use of prophylactic medicines in caesarean females and to evaluate the
compliance with solid proof required for antibiotic prophylaxis in caesarean areas.
Aim and Objectives: To investigate whether correct antibiotic usage is conducted
in surgical prophylaxis with regard to the caesarean section according to the
standard guidelines.
Study design: Clinical Audit Tool was used for the collection of data and mixed
method (both qualitative and quantitative) was implemented for analysis.
Setting: A hospital in United Arab Emirates was selected for this clinical Audit.
Sample size: Total 240 surgeries were inspected in span of six months.
Main Findings: This research showed that the some of the medicines prescribed for
operative prophylaxis, correct dose, correct duration, and incision timing do not
comply with the standard medication guidelines. To improve the excellence of
preoperative antibiotic use, a preface of a local prescription guideline and
appropriate instructional intervention are needed.
Conclusion: This research showed that the some of the medicines prescribed for
operative prophylaxis, correct dose, correct duration, and incision timing do not
comply with the standard medication guidelines. To improve the excellence of
preoperative antibiotic use, a preface of a local prescription guideline and
appropriate instructional intervention are needed.

3ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
Table of Contents
Chapter 1.................................................................................................................. 9
1.0 Introduction......................................................................................................9
1.1 Introduction to Clinical Audit.........................................................................9
1.2 Introduction to Antibiotic prophylaxis for caesarean section.......................15
1.3 Rationale behind the project.......................................................................22
1.4 Ethical consideration..................................................................................27
Chapter 2................................................................................................................ 30
2.0 Aims and Objectives......................................................................................30
2.1 Aims........................................................................................................... 30
2.2 Objectives..................................................................................................30
Chapter 3................................................................................................................ 32
3.0 Clinical standards...........................................................................................32
Chapter 4................................................................................................................ 42
4.0 Methodology..................................................................................................42
4.1 Study design..............................................................................................42
4.2 Survey Instruments....................................................................................44
4.3 Sample setting...........................................................................................45
4.4 Sample Size...............................................................................................45
4.5 Data Collection...........................................................................................45

4ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
4.6 Inclusion and Exclusion Criteria.................................................................46
4.7 Data and Statistical analysis.......................................................................46
Chapter 5................................................................................................................ 48
5.0 Results...........................................................................................................48
Chapter 6................................................................................................................ 71
6.0 Discussions....................................................................................................71
Chapter 7................................................................................................................ 74
7.0 Conclusions...................................................................................................74
7.1 Summary....................................................................................................74
7.2 Limitations..................................................................................................75
7.3 Recommendations.....................................................................................75
References.............................................................................................................. 77
Appendices............................................................................................................. 83
Appendix 1...........................................................................................................83

5ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
List of Tables and Figures
Table 1: Stratification of total surgery according to the Nationality of the patients...48
Fig 1: Graphical presentation of stratification of total surgery according to the
Nationality of the patients........................................................................................49
Table 2: Stratification of total surgery according to the Age.....................................50
Fig 2: Graphical presentation of stratification of total surgery according to the
Nationality of the patients........................................................................................50
Table 3: Stratification of total surgery according to the Primigravida of the patients 50
Fig 3: Graphical presentation of stratification of total surgery according to the
Primigravida of the patients.....................................................................................51
Table 4: Stratification of total surgery according to the type of surgery of the patients
................................................................................................................................ 52
Fig 4: Graphical presentation of stratification of total surgery according to the
Nationality of the patients........................................................................................52
Table 5 a.: Stratification of total surgery according to the Nationality with respect to
the age of the patients.............................................................................................53
Table 5 b.: Stratification of total surgery according to the Primigravida with respect to
the age of the patients.............................................................................................53
Table 5 c.: Stratification of total surgery according to the Type of Surgery with
respect to the age of the patients............................................................................53
Table 6 a.: Stratification of total surgery according to the Nationality with respect to
the age of the patients.............................................................................................54
Table 6 b.: Stratification of total surgery according to the Primigravida with respect to
the age of the patients.............................................................................................54

6ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
Table 6 c.: Stratification of total surgery according to the Type of Surgery with
respect to the age of the patients............................................................................55
Table 7 a.: Stratification of total surgery according to the Nationality with respect to
the age of the patients.............................................................................................55
Table 7 b.: Stratification of total surgery according to the Primigravida with respect to
the age of the patients.............................................................................................56
Table 7 c.: Stratification of total surgery according to the Type of Surgery with
respect to the age of the patients............................................................................56
Table 8: Stratification of total surgery according to the Surgeon who conducted the
surgery.................................................................................................................... 57
Table 9: Stratification of total surgery according to the administration of Correct
Dose of Antibiotic to the patient...............................................................................57
Fig 5: Graphical presentation of Stratification of total surgery according to the
administration of Correct Dose of Antibiotic to the patient.......................................58
Table 10: Stratification of total surgery according to the administration of Correct
Drug of Antibiotic to the patient...............................................................................58
Fig 6: Graphical representation of Stratification of total surgery according to the
administration of Correct Drug of Antibiotic to the patient........................................59
Table 11: Stratification of total surgery according to the antibiotic used to the patient
after surgery............................................................................................................ 59
Fig 7: Stratification of total surgery according to the antibiotic used to the patient
after surgery............................................................................................................ 60
Table 12: Stratification of total surgery according to the correct usage of Incision
time of Antibiotic to the patient................................................................................60

7ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
Fig 8: Graphical representation of Stratification of total surgery according to the
correct usage of Incision time of Antibiotic to the patient.........................................61
Table 13: Stratification of total surgery according to the correct usage of Antibiotic
Duration to the patient.............................................................................................61
Fig 9: Graphical representation of Stratification of total surgery according to the
correct usage of Antibiotic Duration to the patient...................................................62
Table 14 a.: Stratification of total surgery according to the Correct Dose with respect
to the Surgeon.........................................................................................................62
Table 14 b: Stratification of total surgery according to the Incision time with respect
to the Surgeon.........................................................................................................63
Table 14 c.: Stratification of total surgery according to the Antibiotic Duration with
respect to the Surgeon............................................................................................63
Table 15 a.: Stratification of total surgery according to the Correct Dose with respect
to the Surgeon.........................................................................................................64
Table 15 b.: Stratification of total surgery according to the Incision Time with respect
to the Surgeon.........................................................................................................64
Table 15 c.: Stratification of total surgery according to the Antibiotic Duration with
respect to the Surgeon............................................................................................64
Table 16 a.: Stratification of total surgery according to the Correct Dose with respect
to the Surgeon.........................................................................................................65
Table 16 b.: Stratification of total surgery according to the Incision Time with respect
to the Surgeon.........................................................................................................65
Table 16 c.: Stratification of total surgery according to the Antibiotic Duration with
respect to the Surgeon............................................................................................66

8ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
Table 17 a.: Stratification of total surgery according to the Correct Dose with respect
to the Surgeon.........................................................................................................66
Table 17 b.: Stratification of total surgery according to the Incision Time with respect
to the Surgeon.........................................................................................................67
Table 17 c.: Stratification of total surgery according to the Antibiotic Duration with
respect to the Surgeon............................................................................................67
Table 18 a.: Stratification of total surgery according to the Correct Dose with respect
to the Surgeon.........................................................................................................67
Table 18 b.: Stratification of total surgery according to the Incision Time with respect
to the Surgeon.........................................................................................................68
Table 18 c.: Stratification of total surgery according to the Antibiotic Duration with
respect to the Surgeon............................................................................................68
Table 19 a.: Stratification of total surgery according to the Correct Dose with respect
to the Surgeon.........................................................................................................69
Table 19 b.: Stratification of total surgery according to the Incision Time with respect
to the Surgeon.........................................................................................................69
Table 19 c.: Stratification of total surgery according to the Antibiotic Duration with
respect to the Surgeon............................................................................................70

9ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
Chapter 1
1.0Introduction
1.1 Introduction to Clinical Audit
The assessment and improvement of the quality of care provided to patients is
crucial in everyday clinical practice, health policy planning and financing. Various
tools have been developed, such as incident assessment, health technology and
clinical audit (Esposito and Dal Canton 2014). The clinical audit involves measuring
clinical findings or processes against well defined standards laid down on the
principles of evidentiary medicine to determine needed changes for improving the
quality of care. It comprises in evaluating a clinical outcome or process based on
evidence-based medicine values in reaction to well-defined standards. The audit will
highlight the discrepancies between current practice and norms in order to identify
the adjustments needed to enhance the quality of care. The "professionalism" of the
project expressing certain typical components is a special feature of the clinical
audit: clinically particular competence of the respondents, confidentiality of the
outcomes, the object which is closely linked with the "quality" of the experts.
Methodologically, the clinical audit is comprised of a "quality loop." When a subject
is chosen, common criteria and measurable norms will be assessed, in specific, as
regards procedures or outcomes, present clinical practice (Hart 2002). It should not
be confused with information gathering or clinical research: in fact, this audit
attempts to determine characteristics of good practice in an unidentified nation,
compared with existing practice. The audit should not be confused with
benchmarking. The ultimate objective of the clinical audit is always to improve health

10ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
care provided to the patients. The ongoing quality enhancement method involves
the clinical audit. It is to measure a clinical result or procedures based on evidence-
based medicine with some well-defined standards. The comparison of clinical
practice with standards leads to the development of strategies to improve the quality
of daily care.
The first stage in the design of a clinical audit is to define the subject. In clinical
practice, the subject of the audit can be easily recognized and may relate to the
adequacy of a care or the outcomes of a treatment. A subject that is audited should
have particular features: it must be of high clinical significance, be simple to collect
and analyse and cause significant implications (Benjamin 2008). The audit
personnel play a main role in prioritizing the management of clinical issues. Different
aspects should be regarded by selecting an appropriate theme. In addition, the use
of more appropriate methodology, such as complex clinical events or sporadic
adverse events, should be examined in a rare case. Incidents that are rare are an
incorrect matter. The project topic was selected to choose and develop a proper
audit methodology to describe the purpose of the project (Lorenzo and Jackson
2008). The objective of an audit project could include the application of fresh
processes (such as laboratory procedures, operational protocols, etc.). Moreover,
organisations clearly should identify resources for project management help,
including training in Clinic Audit Technique, facilitations, and information
management, before beginning clinical audits (including data collection, hardware
and software needed) as well as preparation of clinical staff. For example, the audit
team should include nephrologists, vascular surgeons and dialysis nurses for the
management of vascular access in haemodialysis patients (de Stampa et al 2009).

11ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
The next step is to set the norms that the present clinical practice compares with
when the preliminary problems of the audit were identified. Some definitions are
essential here: (I) indicator: a variable that enables the description of complicated
events and the measurement, in order to guide the choices to achieve or maintain
improvements in relation to specified criteria. The criterion is definable and
measurable in the quality of health care. This may be defined as an absolute
number, rate, percentage, and/ or average; (II) Criterion: Explicit statement defining
a result to be measured is the audit criteria. In a clinical audit it is a statement of
what should occur in good practice, based on evidence; and Standard: for each
particular criterion, it is the standard of care that needs to be accomplished,
generally expressed as a proportion (Bursgess 2011). The value that defines the
upper or lower limit, that is, reflects the acceptability threshold, so that the care
quality is deemed suitable. In 100 per cent of patients (e.g., using masks in central
venous catheter dressing), there are some indicators which are so important, but
generally, the standard needs to be met in a smaller proportion, for example 80 per
cent. One of the most important points when designing a clinical review is to select
requirements and norms and all participants in an audit must cooperate. In reality,
the quality of care given (this is the final outcome of the audit) requires just a
comparison to those parameters. It may be possible to derive criteria and Standards
from: global guidance, scientific literature, expert opinion, data gathered by other
health institutions and case studies. The more proof is stronger, the more accurate
the comparison findings with daily clinical exercise are. In order to design an
effective clinical audit, however, before checking the information gathered, it is
essential to share the standard and criteria with peers since the audit results

12ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
themselves should not be rearranged or retrospectively altered (Hearnshaw et al
2001). In the event of significant discrepancies between norms and current clinical
practice, the audit team should also determine the intervention policies to be
implemented. These approaches should according to a structured algorithm be
debated, communicated, clear, and easily practicable.
Data may be collected forward or backwards in the clinical audit. The latter
procedure is certainly quicker, taking into account previous clinical documentation,
but often the quality of the information collected is not optimal. Perspective audits
are time-consuming, but enable a more accurate design and provide an actual
clinical practice description. The variables to be carefully recorded must be planed
and the type of analysis carried out in respect of the data collected must be
determined before data collection is performed. These points are important to
ensure that vital data is not collected or not used. A particular form or database
should be developed to collect patient records (Simmons et al 2006). In addition, a
test can be carried out with the confidence that you want to accomplish and
resources (time, money and workforce) also when examining a very big amount of
patients (preferably by randomized techniques). Quantitative or qualitative data,
including medical documents, biochemical and instrumental evaluation results
and/or other archives can be gathered such as interviews, questionnaires or
commentary and data sources. The primary source of data is definitely the medical
record, but it is often incomplete. In this regard, the audit improved the existing flow
of information by highlighting the data management inadequacies already in the
preliminary data collection phase (Layman 2008). Finally, it should be stressed that
the protection of patient data should be protected at any time during data collection

13ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
and analysis, anonymizing the data collected and explaining the reasons for the
data collection, should the patient directly involve himself.
Comparing information collected with norms and developing corrective activities is
the key phase of the clinical audit. An audit team analyzes and compares the
information with default norms in this stage. The critical nature of the moment is that
audit specialists can interpret this audit as a clinical exam and therefore become an
unconscious barrier to an effective information assessment (Sales et al 2006).In
addition, those contents should be shared with the auditors in advance. Different
findings could arise and the standard can be achieved by comparing the real
information with theoretical norms. If the standard is not met, whether or not there is
real chance of improvement should be assessed. Indeed, if the information is not in
line with the norms but near enough, one could decide that any further
improvements are hard to accomplish, and it would therefore be worth investing
resources in evaluating other issues. If the data from clinical records and norms are
significantly distinguished, collegiate discussions should highlight the obstacles to
the accomplishment of this standard. The audit methodology then requires the audit
team to create policy and recommendations for action based on the preliminary
indications (Giguère et al 2012). The advice or recommendations should take
account of organisational variables (financial resources, timing, and employees) and
the audit context. It is therefore essential to have clear, explicit, and shared
suggestions established. Simply distributing instructional material, such as
instructions, has little impact if chosen modalities of execution, such as training
sessions or conversations between peers are not followed. Instead, if the audit
findings are satisfactory, a type of surveillance is similarly essential (Jamtvedt et al

14ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
2006). Finally, in a comprehensive report to be distributed to all of the audit
respondents, the data analysis and subsequent debate, including the implementing
policies, should be recorded as feedback on and a reminder of the work being
completed.
The audit cycle concludes with the checking and tracking phase of the strategy
implemented. In fact, it is vital to plan regular checks on the impacts of modifications
implemented for a correct clinical audit method. The information collection and an
organisational approach similar to the one used for the past assessment should be
used to ensure comparable outcomes (Esposito and Dal Canton 2014). This would
be recommended. If the goals have not been accomplished and the improvement
plan has not been effective or adequate, alterations to the planned strategies might
be necessary. In order to preserve the changes that have been made, however, a
surveillance plan should also be planned for achievement.
There is conflicting evidence of the effectiveness of the clinical audit. A systematic
evaluation by the study group Cochrane has taken 140 studies into account in which
either alone or in comparison with other measures, such as conferences, prints
distribution and so on; the clinical audit and the corresponding feedback are tested.
(Ivers et al 2012). The findings generated by the audit were commonly varying from
adverse to very beneficial in the research included in this review. The impacts
usually ranged from small to moderate when the audit was efficient. The
assessment has shown that the comparative effectiveness of the audit will probably
be improved if baseline adherence to recommended practice is minor and reviews
are carried out with a greater intensity. Scientific evidence therefore does not
presently provide clear support for the real effectiveness of the clinical audit. This

15ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
could form the foundation for the investigation and analysis of clinical audits in
different operating circumstances for validation (Ivers et al 2012).
1.2 Introduction to Antibiotic prophylaxis for caesarean section
The world's leading cause of maternal death, which account for about one third of
the overall maternal death rate, is bacterial infections during labour and puerperium.
Although the amount of fatalities caused by such diseases in high revenues has
decreased substantially, in resource -limited environments the situation has not
enhanced. In low - income countries, the majority of approximately 75,000 maternal
deaths globally occur annually as a consequence of diseases. While there is
comparatively a small incidence (between 0.1 and 0.6 per 1,000 births) in high -
income countries, it is nevertheless a significant immediate cause of maternal
mortality (World Health Organisation 2015).Long - term disabilities like Fallopian
tube blocking, chronic pelvic pain, and secondary infertility also happen in addition
to fatalities and acute morbidity associated with diseases during or after pregnancy.
In fact, infection related morbidity and extended hospitalizations can interfere with
mothers’ and infants’ bonding in the very first few days of birth. Mother infections
around the childbirth also have a substantial effect on the death of new - born and
approximately 1 million new-born are associated with such diseases annually.
Maternal mortality and morbidity may lead after Caesarean delivery (CD) from a
variety of diseases such as endometritis, urinary tract infection (UTI) and SSI
(surgical site infection). In patients with peri - operative antibiotics (within a period of
three hours after skin incision), wound infection happens in 1.4 per cent compared
to 0.6 per cent in those receiving antibiotics in less than a couple of hours after skin
incision(Lamont and Haynes 2008). Prophylactic antibiotics decrease the incidence

16ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
of SSIs and suggest the use of evidence-based instructions prior to or after the
incision. For gynaecologic processes, such as abdominal hysterectomy, antibiotic
prophylaxis is well created. For abdominal and vaginal hysterectomy a single pre-
operative antibiotic is suggested. Cumulative meta-analysis information showed
that, from the moment of the first study in 1972, the advantages of antibiotic
prophylaxis for abdominal hysterectomy were obvious (Lamont et al 2011). Similarly,
the individual advantages of cefazoline, metronidazole, and tinidazole were shown
in 1980, 1984, and 1986 using cumulative meta-analysis information. Here the use
of control in subsequent research that received no therapy would have been
inappropriate had the multiple studies been grouped at a prior date.Infection was
associated with 77 per cent of fatalities in operative patients with nosocomial SSIs.
Although a percentage of SSIs are unavoidable, compliance with evidence, like
prophylactic antibiotics, has shown that the rate of SSIs has been reduced following
optional surgical processes. SSIs are more and more used as performance indices
in accordance with this concept. Postpartum SSIs are most prevalent than after
other surgical procedures, particularly those that follow CD(Fry 2008).This can be
because it requires close contact with lay staff members, e.g. families who are not
aware of hospital antiseptic interventions, and because a large number of experts
from various hospital departments can boost the danger of cross-contamination.
This is often the result of extended intra - partum treatment. The work and
distribution of other body fluids are also connected with contamination and are often
unexpected or in emergencies.
Antimicrobials are often prophylactically prescribed for pre- and post-operative
procedures (episiotomy, caesarean section, medical termination of pregnancy, full

17ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
vaginal hysterectomy or abdominal hystereposis, squirrel-binding, dilation and
curettage and myomectomy) in obstetrics and gynaecology. (Liu et al 2016).
Rational application of antimicrobials in women of the age group is crucial, as both
its kids and its population are affected. In order to create drug resistant organisms,
antibiotics may be used indiscriminately. The WHO defines the use of drugs as' The
social marketing, advertising, prescription and use of medicines with particular
attention which leads to the medical, personal and financial effects.' Thus, a drug
use survey is intended to quantitative and qualitative describe the use of a specified
drug, i.e. drug class, indication, length of therapy, dosage and preceding or related
therapy and compliance. The prevalent complication of obstetrical and
gynaecological processes is surgical site infections. Antimicrobial prophylaxis was
found to be efficient in decreasing post-operative morbidity, price, and hospital
length for caesarean section. Antimicrobial use is inevitable but should be limited in
the above context (Clifford and Daley 2012). The wise use of these medicines can
prevent mother and neonate infections after birth and decrease the occurrence of
negative medication responses.
The post-CD infection risk variables are comprehensive. In the lack of risk variables,
SSI rates of 3.4 per cent for CDs and 8.1 per cent following high - risk CDs, both
greater as those used for non - CD surgery, are recorded by the National
Nosocomial Infections Monitoring scheme. Emergency CD (compared to elective) is
a significant risk factor for post-operative infection. Furthermore, there are significant
risk factors for post - CD diseases which are identified in the elevated maternal
mass index (BMI), the lack of operative drainage with a subcutaneous tissue density
to be 0.03 cm, as well as longer working time and bad surgical technique. Almost 20

18ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
Per Cent of developing world CD prices is already above despite the World Health
Organization's estimates that the CS levels should not exceed 15 Per Cent. In the
USA, the CD level has risen by 50 Per Cent (from 20 percent to 30 percent in the
10-year period from 1996 to 2006), making it now the largest significant operation
performed. In 2006, the US accounted for 31 percent of births by CD, which equates
to 1.3 million annual processes (Brennan et al 2009). CDs in the USA are expected
to achieve 50 per cent by 2020, meaning two million CDs per year if this trend
continues. With rising CD levels the health and financial burden of post - CD
diseases will probably increase and prevention remains a concern for public health.
The enhanced use of main CDs for maternal requests, which varies from 4-15 Per
Cent of all CDs in the US, is part of the reason for the rise in CD prices. 53 per cent
of those interviewed confirmed in their interview with obstetricians that they had
conducted such procedure; 58 per cent noted that the rate had grown over the past
year and 41 percent stated that they had discussed the subject on a routine basis
with patients.Increasing the percentage of females on the CD will have a significant
impact on CD morbidity through SSI reduction policies (Bettes et al 2007). Since CD
has an important infection danger in comparison to vaginal delivery, (primarily
because of WI but also because of UTI after CD) and less than 75 Per Cent SSI
happen after hospital discharge, this should become component of a debate with
patients considering CD at their mother's request. Antibiotic prophylaxis was found
useful for females who have CD, both in high -risk (post membrane -rupture) and
low -risk (non -intact membranes) patients with CD, to decrease post - CD infectious
morbidity. A single dosage of antibiotics is as efficient as multiple dosages given peri
-operatively, and the regular use of prophylactic antibiotics lowers the risk of

19ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
infection by up to 20 -50 percent from a baseline by more than 50 percent (Maharaj
2007). During the systematic assessment of over 80 study projects, the Cochrane
Collaboration has examined the effect of prophylactic drugs on post-partum
maternal fevers, WI, endometritis, UTI, serious infectious disease, infectious
mortality, as well as on maternal and hospital stays. Only maternal side impacts
(although statistically significant) on all CDs (elective and emergency) rose after
prophylactic drugs. The use of antibiotics was connected to a statistically important
decrease with an impact of 40 to 65 percent for all the other results. Following both
elective and emergency CD, endometritis and WI decreased by 60 – 70 per Cent
and 30 – 65 per Cent, respectively. Although antibiotic prophylaxis for elective CDs
has proven cost efficient, both incoherence and inconsistencies have been shown in
applying the suggestions (Lamont et al 2011). Various issues, including
optimization, drugs of choice and medicinal products, have been raised, and
whether all or only those deemed at high danger should be given prophylaxis. The
various variables engaged in the evaluation of post CD antibiotic prophylaxis are
highlighted by these issues.
Currently, a first-generation narrow-range cerebrosphorins, such as cefazoline,
recommended for use after umbilical cord-clamping to prevent infection after post-
CD, are available in the Cochrane database of Systematic Reviews, American
College of Obstetrics and Gynaecologists (ACOG) and CDC. This is because
antibiotics of broad spectrum are deemed equally efficient and less expensive
(Lamont et al 2011). However, 10 percent of CD is still complicated by disease and
15 Per Cent by fever, despite the use of antibiotics. The purpose of antibiotics is not
to decontaminate tissue, but rather to reduce intra -operative microbial stress to a

20ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
level that is managed by host adaptive and innate immune system. At the time of
microbial contamination, the purpose of antibiotics is to achieve sufficient
concentrations of tissue, and the optimum agent should be long-acting, cheap and
with a low side effect profile. Within five minutes of the mother's administration of
ampicillin in Group B Streptococcus (GBS), the bactericidal level is reached and
within 30 minutes of foetal blood administration, cefazoline reaches a minimum
inhibitory GBS concentration. Concern about antibiotic usage with a broad spectrum
antibiotic centre, but unlikely with the use of single-dose prophylaxis, on infection
with resistant bacteria such as Clostridium difficile or methicillin resistant
Staphylococcus aureus (Tita et al 2009b). Furthermore, after antibiotic prophylaxis,
a shorter hospital remainder does not reflect the rise in resistance organism
diseases. Because there is overwhelming proof that prophylactic medicines are
needed and effective in order to avoid infection after CD, the present discussion
focuses on antibiotic selection and timing of administration .As far as timing is
concerned, the discussion lies between pre – incision or post - clamping of the
umbilical cord and antibiotic selection between the narrow range and the broad
spectrum. Both these discussions were affected by the worries about the possibility
that large-scale pre-incision antibiotics could mask neonatal infections or result in an
infection that could not cultivate any organism (Tita et al 2009b). The mistake in the
use of antibiotics may also lead to the exposition of neonates to resistant strains of
bacteria, which may lead to a worse neonatal outcome and/or to the need for costly
neonatal septic screens and workouts with infections.
While regulatory authorities are overwhelmingly advocating for pre-incision
prophylactic antibiotics to avoid SSIs, CD exceptions are created where these

21ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
antimicrobials are recommended to be used after umbilical cord clamping. This
approach has been recently questioned by a systematic literature review83. A total
of 277 possibly appropriate trials have been chosen for meta-analysis from which
two non-randomised tests, two RCTs and two RCTs were chosen. The two non-
randomized studies found no advantage to the general level of infection or
endometritis of pre-incision versus post-clamping antibiotic prophylaxis (Centres for
Medicare & Medicaid Services 2008). The second consisted on two tests, but one
with a narrow range and the other with a large range of antibiotics, with a small,
blindness-free sample size. These are excluded by the majority of meta-analysis or
systemic reviews. The same applies to two retroactive cohort studies using narrow-
range cephalosporin but which have considerably lowered overall rates of infection.
On the contrary, the use of cefazolin in women with optional CD did not reduce pre-
incision antibiotics worldwide infected or endometritis. The use of pre -incision
antibiotics was nevertheless not correlated with an increase of neonatal sepsis,
sepsis work-up, and intravenous treatment or stay duration (Centres for Medicare &
Medicaid Services 2008).
The primary source of the following CD infection is in the reduced genital tube,
particularly when the membranes are broken, but with intact membranes,
particularly after premature birth. The bacteria responsible for causative activity are
poly - microbial, especially those responsible for bacterial vaginoid (BV) diseases,
such as Ureaplasma, Mycoplasma, Anaerobic, and Gardnerella, and are also
frequently isolated at the moment of CD(Titaet al 2008). If identified, the risk of
endometritis or WI after CD is increased by three to eight times, and BV is linked
with a 6-fold rise in post - CD endometritis. The utilization of cephalosporin of first

22ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
generation like cefazolin offers antibiotic activity against ureaplasms and
mycoplasmas. Therefore, the addition of agents like metronidazole, clindamycin, or
azithromycin is recommended for extending the cover. The widely-spectrum
antibiotics assessed are predominantly single-agent penicillin of wide range, or
cephalosporin of second or three generation (β-lactams).Furthermore, research
studies comparing narrow -range prophylaxis medicines with broad -spectrum
regimens that included narrow -range antibiotics with the addition of antibiotics of a
distinct class such as gentamycin or metronidazole, azithromycin and doxycycline
(Tita et al 2008). The statistically important decrease in infection rates, endometritis,
and WI compared with the narrow-range were linked with large-spectrum antibiotics.
When broad - spectrum antibiotics were used, hospital stay was considerably
shorter.
1.3 Rationale behind the project
The greatest risk factor for post - partum maternal disease is caesarean delivery.
Live births per caesarean segment in the western countries amount to
approximately 27 per cent (range of 14.7 per cent to 49 per cent). The overall rates
in developing countries are around 12%, but vary widely by region (0.40 per cent to
40 per cent). In Western countries, the percentage of living birth is around 30
percent or more per caesarean section. An important and significant cause of
maternal morbidity is infectious complications after caesarean births which have
been associated with significant growth in hospital stays. Pelvic bodies, surgical
injury, and urinary tract can be affected by infections. In Cochrane Library, a
systematic analysis has shown that antibiotic prophylaxis has considerably reduced
the incidence of puerperal disease in all instances of caesarean section. During

23ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
other general operations, the time of the administration of medicines was distinct
from that followed due to danger of foetal harm(Smaill and Grivell 2014). The intra -
operative use of a drug soon after cable clamping shall be deemed as effective as
preoperative administration of the drug.The length of antibiotic therapy suggested in
many studies has been decreased to 24 hours from five to three days, and then
from three to one doses. A second study of the Cochrane Library found the same
effectiveness in decreasing puerperal infection with a single dose of ampicillin or
cephalosporin of the first generation. Moreover, the benefit from wide spectrum
cephalosporin is no different(Khanemet al 2012).
Prophylactic medicines have a positive impact in decreasing the presence of
infectious morbidity from caesarean, whether elective or emergent. A single dose is
as efficient as various doses of broad-spectrum agents with cephalosporin of first
generation. Caesarean antibiotics are used globally and, usually following umbilical
cord clamping, one dose is given in most organizations. However, a latest study of
US mother and foetal doctors (released in 2011) shows 84 percent of respondents
(a rate of 25 percent) are taking preoperative medicine.General principles of surgical
infection prevention include sound operating techniques, skin antisepticise and
antimicrobial prophylaxis. Prophylactically administered antibiotics reduce the
bacterial inoculum in the operation and decrease the rate of surgical site bacterial
contamination(Titaet al 2009a). Appropriate tissue antibiotic levels can increase
naturally occurring immune protection systems and kill bacteria invariably inoculated
in the wound during operation.Women undergoing a caesarean section are 5 to 20
times more likely than females who deliver birthvaginally to get an infection. The
organ inside the pelvic, the surgical incision, and sometimes the urine may be

24ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
infected by these diseases. The infections may be severe and can lead to the death
of the mother very occasionally. Possible advantages in decreasing mother
infections are balanced against negative impacts such as nausea, vomiting, skin
rash, and rare allergic responses in the mom and any antibiotic impacts on the child,
including thrush(Kaimalet al 2008).After optional operation, a wound infection
happens in 1.4 per cent compared to 0.6 per cent in those receiving antibiotics
within 2 hours after the skin incision (within three hours of skin incision). The
incidence of SSIs is reduced, particularly before incision rather than during or after
surgery, by prophylactic antibiotics. Single -dose antibiotic prophylaxis is well
established for abdominal and vaginal hysterectomy and cumulative meta-analysis
information suggest that the use of controls would have been unnecessary in later
tests, if the multiple studies had been combined at a previous date.SSIs are not life
threatening for most pregnant females, but have a major impact on the duration of
stay in the hospital, the cost of hospital and the social impacts for parents and new–
born(Dinsmooret al 2009). The most significant factor connected with postpartum
infection is caesarean delivery, which carries a five to 20 times higher risk of
infection relative to vaginal delivery, although this differs by definition, classification,
and time of monitoring.In relation to antibiotic prophylaxis, all factors that influence
the decrease in infectious danger in obstetric care must also be examined. Suitable
skin preparation, including hair cutting, and efficient antiseptic treatment of both the
patient and personnel are necessary. It is necessary to ensure sterile surgical areas,
and continuous quality assurance of sterilization, air ventilation, and post-surgery
wound treatment. Consistent control of infections monitors the capacity to minimize

25ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
these morbidities and to recognize infection clusters and the development of
antibiotic resistant bacteria to monitor and report infectious problems.
The following caesarean section may be present: entomyometry; urinary tract
infection; wound infection; and sepsis. Several stories examined the use in
emergency Caesarean, either with or without the presence of maternal fever and/or
chorioamnionitis of prophylactic antibiotic products, to decrease these problems,
which are all greater in prices. There is also controversy about whether prophylactic
antibiotics should be administered before skin or at umbilical cord clamping in the
segment Caesarean(Witt et al 2011). Prophylaxis has traditionally been postponed
so as to prevent neonatal infections from being masked and unnecessary septic
work-up.The application of prophylactic antibiotics for a number of obstetrics and
gynaecology processes has demonstrated a secure and cost -effective reduction in
infectious morbidity. Many processes stay in place where the usefulness of
prophylactic antibiotics is either uncertain or not well researched. Adequate
antibiotics are used to reduce infective postoperative complications at the
appropriate dose, dose, and frequency and minimize the development of antibiotic-
resistant organisms.
Traditionally, after cord sealing antibiotics are given owing to a number of possible
issues; 1) foetal exposure to antibiotics could mask newborn beneficial bacterial
cultivation outcomes; 2) foetal exposure to antibiotics may lead to increased
colonization or infections of antibiotic species; and 3) the risk of serious foetal
compromises in rare animals(Costantineet al 2008). The powerful proof that
antibiotics provided before skin incision decrease the risk of post - surgery and
surgeon infection by roughly 50 percent must be weighed against these future

26ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
issues.No caesarean segment is a specific problem (i.e., unplanned surgery during
work, following membrane break-down or in maternal or foetal cases). Despite
conventional prophylaxis, there are postoperative infections in up to 12 per cent of
these patients. Previous studies indicate greater levels of postpartum endometrial in
those with genital or placental urealytic colonization, and single-centre research
suggests that in relation to conventional prophylaxis, a single dose of intravenous
azithromycin can decrease the chance of infection after surgery.An extra coverage
of azithromycin ureaplasma species is an assumption in an organization but the role
of ureaplasma in endometritis pathogenesis is discussed. The association's function
is discussed(Baaqeel and Baaqeel 2013).
Operational site infections, endometritic and Urinary Tract Infections commonly
complicate the delivery of caesarean. After the hospital is discharged, the most
surgical site infections are used as indicators of efficiency. Globally, the rate of
shipment of caesareans is rising. Evidence-based guidelines have suggested
preoperative use of prophylactic antibiotics. Derogation is produced for caesarean
delivery where narrow -range antibiotics are given because of putative neonatal
advantage after umbilical cord clamping(Young et al 2012). Nevertheless, latest
proof promotes the use of antibiotics with a broad spectrum of pre-incision that lead
to reduced maternal disease without any negative effects on the neonate.
Caesarean administration is the most prevalent significant operation. Complications
including injury infection and endometritis are 5-10 times higher in caesarean
conditions in comparison to vaginal deliveries. It is suggested that this risk is
reduced peri - procedurally by cefazolin, while there are still infections that
contribute to mammon disease and higher healthcare expenses(Wlochet al 2012).

27ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
Thence, the audit was therefore performed to evaluate the use of prophylactic
medicines in caesarean females and to evaluate the compliance with solid proof
required for antibiotic prophylaxis in caesarean areas.It was also scheduled, based
on the findings from this audit, to implement practical improvements and revise our
practice to evaluate the effects of the modifications.
1.4 Ethical consideration
There is a well -documented gaps between evidence -based practice and real
patient care in healthcare organizations. Professional and organizational healthcare
practitioners have an ethical duty to close the gap in best -known practice and to
address patient quality and security deficiencies. Disciplined and concentrated
attempts to improve healthcare efficiency and security can be seen as an ethical
challenge in healthcare facilities. If the absence of involvement continues unsafe,
unnecessary, or ineffective clinical practices, it may be detrimental to fail to
implement improvements(Brain et al 2009).A large number of operations in
healthcare organizations, such as medical care and research, have widely
recognized ethical norms. However, arrangements are not obviously or thoroughly
described to ensure that IQ and Clinical Audit Projects adhere to suitable ethical
norms. Many individuals feel that only study studies need an ethics evaluation and
that there can be no ethical consequences of a QI project or clinical audit that
involves using earlier collected information for patient care. This assumption cannot,
however, be warranted.Ethical considerations should include a QI project or clinical
review if any activity that presents a danger for psychological or physical damage to
any patient(Brain et al 2009).

28ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
Being conscious of what constitutes ethical research is an important component of
planning for a study project as well as understanding the speech of scholarly
studies. The foundation of this section is this subject of ethical studies. The
investigator should always guarantee that respondents are secure and secure from
unnecessary stress.Almost always unethical study allows respondents and
scientists to feel susceptible, exposed, and unfavourably exposed. Researchers’
unethical behaviour may also affect the validity and confidence of the information
gathered(Cave and Nichols 2007).Achieving overall clinical standards is the role of
clinical audit. Clinical audit ethical problems can have wide-ranging impact on
doctors, patients, health care professionals, and customers. A guiding strategy must
be consistent, so that people engaged in clinical examinations can rely on excellent
practice at any stage. Clinicians and supervisors sometimes believe of best practice
as being a practical matter.
In case of a clinical audit, the primary goal of a project should be that the project will
cause no harm to the patients. In addition to that the clinical audit should be
performed within the frame work of ethical code of conduct(Cowan 2000).
Furthermore, the patient information must be kept confidential while publishing or
utilising the information regarding patients with respect to identifiable information. In
this regard, there are various code of conduct and legislative act such as Data
Protection Act1998 and NHS Confidentiality Code of Practice 2003(Haynes et al
2007). Any research investigation must be in agreement with these act and code of
practice. Moreover, steps need to be taken so that the collected data stay
anonymous with respect to the patient name, personal details, date of birth, address
etc. Special consideration must be allocated to keep the collected data private and

29ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
the collected data should not be kept any longer than necessary for the research
investigation(Courtney and McCutcheon 2010). It should be remembered, too, that
reports and submissions for clinical audits should not recognize clinicians on behalf
of each other without consent. While study is required for ethical approvals to be
presented to REC, clinical audit is not required. However, although clinical audit may
not require, and thus does not require official ethical permission, nothing to be
accomplished beyond their routine clinical leadership, it should still be carried out in
an ethical structure. By authorizing and registering a study as a clinical audit, the
Trust determines that it meets the methodological requirements for accessing and
analysing patient information(Wade 2005).
Therefore, in this research investigation, above guidelines were followed to keep in
line with the above mentioned criteria. Hence, no information were collected
regarding patient name, personal details, date of birth, and address. Only
demographic information like nationality and age were collected. Other information
that was collected was all related to the Clinical Audit Tool(Wade 2005). Before
collecting the data, proper consent was taken from the hospital authority as well as
the respective patients whose information was collected. All the raw data were
recorded in a excel sheet and after analysing the data in IBM SPSS Statistics Tool,
the raw data were deleted.

30ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
Chapter 2
2.0 Aims and Objectives
2.1 Aims
Research aim is important for any research investigation so that the proper research
design can be obtained from the research aims. In order to answer the research
question, the aim is to achieve knowledge and understanding. Well-designed
objectives generate clear connections between the study project and the major,
significant issue that motivates it(Ann 2014). Without a clear and concise research
aim there is a chance that the conducted can be futile due to the ambiguity of the
research aim.
Therefore, the research aim of this clinical audit is:
“To investigate whether correct antibiotic usage is conducted in surgical prophylaxis
with regard to the caesarean section according to the standard guidelines.”
2.2 Objectives
Goals are particular research initiatives planned for the implementation of the
research project. The goals describe the study project framework. This implies that
the study objective will meet the goals identified by the investigation issue, if the
project design has been performed thoroughly(Austin and Sutton 2014). Thence,
research aims of this clinical audit inspection were divided in the smaller objectives
so that the attainment of the research aims becomes clear and easy to achieve.
Thence, the objectives for this clinical audit are mentioned below:

31ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
1. Analyse the demographic of patients with respect to the surgery of caesarean
section.
2. To determine whether correct dose of antibiotic were administered after the
surgical procedure according to the standard guideline.
3. To determine whether correct antibiotics were administered after the surgical
procedure according to the standard guideline.
4. To determine whether correct duration of antibiotic were administered after the
surgical procedure according to the standard guideline.
5. To determine whether correct incision time of antibiotic were administered after
the surgical procedure according to the standard guideline.
6. Analyse the performance of the resident surgeon with respect to the
administration of correct antibiotic usage with regard to the surgical prophylaxis.

32ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
Chapter 3
3.0Clinical standards
In surgical procedures, antibiotic prophylaxis does not aim to sterilize tissues; it aims
instead to reduce microorganisms ' colonization pressure introduced during the
operation to a certain extent that the immune system of the patient can overcome.
No infections induced by postoperative contamination are prevented by prophylaxis.
Prophylactic antibiotic therapy varies from antibiotic treatment by preventing
infection, whereas antibiotic treatment is designed to eliminate an infection that
usually requires more long-term treatment.When the incision is closed in the
operating room, prophylaxis is intended for elective procedures(van Schalkwyket al
2010). There must be proof that it decreases postoperative infection before an agent
can be regarded for use as a prophylactic antibiotic. It must also be secure and
cheap and efficient against bacteria that are likely to be found in the surgery. The
agent has to be administered in such a manner as to ensure an appropriate level of
the serum and tissue before an incision has taken place, while maintaining serum
and tissue therapeutic concentrations during the operation and for a few hours at
most. Wound infection— site-infection surgery — may develop following laparotomy,
in the form of cellulitis, abscess or dehiscence. Infections of pelvic tubes, such as
abscesses or infected blood cells, are a dangerous course of surgery entering the
abdomen. The danger of hysterectomy is Cuff cellulite. A guideline issued in 1999
by the United States Centres for Diseases Control and Prevention lists the particular
and stringent requirements for the diagnosis of an infection at the surgical
site(Bailey et al 2016). Careful monitoring of SSI needs operational monitoring for 30

33ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
days, and monitoring is a challenge due to the trend towards early release from
hospital. Up to 84 per Cent of surgical site infections are projected to happen after
hospital discharge.Caesarean section or surgical abortion may cause endometritis.
Any operation involving the catheterisation of the bladder may lead to urinary tract
infections.The most studies indicate that a single dose is effective, but for long-
lasting procedures (more than 3 hours), it is recommended that the dose be
repeated at intervals 1 - 2 times the half-life of drugs. In addition, the dose is not
administered in any way. It was also suggested that a second dose should be
provided in case of big blood loss (less than 1500 mL).Caesarean, vaginal
operational delivery, manual removal of placenta, repair of perineal laceration in
third and fourth grades, cervical cerclage, and postpartum dilation and curettage are
all methods reviewed in this chapter. There have been recent modifications to the
rules on endocarditis prophylaxis(van Schalkwyket al 2010).
The National Institute for Health and Care Excellence (NICE) has amended its
instruction on how to deliver intravenous prophylactic caesarean-based antibiotics
before skin incision(Leaper et al 2008). This amendment has lately been endorsed
by a Cochrane review which recommends the administration of antibiotics 60
minutes before the incision in order to avoid post-mutual postponement of the skin.
Although it is obviously essential that birth females are protected against infection-
related Caesarean section complications, it is also essential that this guideline affect
close to 25 percent of British births in the Caesarean section, resulting in some 175,
000 children being exposed every year to wide spectrum antibiotics around birth
moment. This suggestion is also concerned. The NICE proposes that females who
suffer from the caesarean segment use prophylactic broad-spectrum antibiotics that

34ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
work effectively against endometritis, urinary tract, and wound-related
microorganisms(Leaper et al 2008). These antibiotics quickly pass the placenta and
reach the baby's circulation before birth. This influences new - born microbial
colonization unavoidably, but not fully. Prior to administering antibiotics to mothers
to avoid such collateral neonatal infections, prior NICE guidance recommended cord
clamping(Leaper et al 2008).
The functional function of intestine microbiota in the growth of immune systems in
neonates is growing and chronic circumstances develop later in life. It was created
that the immune regime is altered by the structure of the first microbial colonization
and by our reaction to pathogens and the mode of delivery of intestinal colonization
by microorganisms(van Schalkwyket al 2010). There is also proof of an enhanced
danger for conditions such as atopic dermatitis, inflammatory bowel disease, and
type 1 diabetes for children with unusual microbiota. As a result, knowledge is
increasing about the significance of microbes and the immune system in human
diseases as aetiological agents.
The Cochrane Review recommends that a 2.8 Per Cent decrease in maternal
infectious morbidity by high-end studies[from 8.5 to 5.7 Per Cent, comparative risk
(RR) 0.57, 95 Per Cent CI 0.45–0.72] when preoperatively compared to antibiotics
after cord tightening(van Schalkwyket al 2010). When this study is performed the
following: This has been due to decreases in the amount of endometritis clinically
diagnosed (28 – 15, 000, RR 0.54, 95 per Cent CI 0.54 – 0.82) and wound diseases,
both of which are sepsis and maternal mortality, (from 41 – 24 out of 1000, RR 0.59
and 95 per Cent CI 0.44 – 0.81), although the bulk of these diseases are mild and
react quickly to therapy.The evaluation, however, does not address the impacts of

35ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
wide spectrum antibiotics on neonatal microbiota and the prospective long-term
health consequences of micro-colonisation interrupted in infants(van Schalkwyket al
2010).
Preoperative-dose timing: In the 60 minutes prior to surgical incision, the optimal
dosing time is required. The timeframe for certain agents, such as fluoroquinolones
and vancomycin, was longer than previously recommended, and should therefore
start administration within 120 minutes of the incision in the event of anaesthesia.
These agents are administered within a period of one to two hours(Bratzleret al
2013).
Selection and dosing: Evidence on weight-based dose strategy in obese patients
and the need for repeat doses in long-term procedures is included. Obesity is
associated with an enhanced danger for SSI(Zelenitskyet al 2002). In obese patients
the pharmacokinetics of pharmaceuticals can be modified, so that body weight
modifications can be warranted. Intra-operative rectification is required for each
patient to guarantee appropriate antimicrobial serum and tissue levels if there is
excessive blood loss during the operation for a period longer than two half-lived of
the drug(Rybaket al 2009).
Duration of prophylaxis: New suggestions are made for shortening antimicrobial
postoperative course with a single dose or a continuation for less than 24 hours.
More clarity is included on the absence of post - operational antimicrobial
prophylaxis based on intra – vascular drains and catheters.The shortest effective
duration of antimicrobial administration is not known to prevent SSI; however,
evidence suggests that the majority of procedures need not have post-operative

36ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
antimicrobial administration. For most processes, antimicrobial prophylaxis should
last less than 24 hours(Bratzleret al 2013). Cardiothoracic processes that have been
approved to promote prophylaxis up to 48 hours without proof are contentious. In
these rules, the length of cardiothoracic prophylaxis is based on specialist
agreement, since the accessible information does not specify the optimum
prophylaxis length. Prophylaxis is suitable in these processes for the period of the
operation and definitely for less than 24 hours.
Common principles: An additional chapter has been added to cover concepts
applicable to all kinds of operations. Extended and new suggestions are being made
for the use of implantable instruments for plastic, urology, the heart, and thoracic
procedure and for clarification of prophylaxis. The choice for a particular patient of a
suitable antimicrobial agent should take into consideration its properties, its relative
effectiveness for the operation, its security profile, and its allergies to the drug.
Cefazolin is the drug of choice for prevention for most processes because it is the
most commonly researched and proven antimicrobial agent. It has a desirable
length of action, a range of activity in surgery, sensible security, and low price
against organisms.There has been little proof of a reduced rate of postoperative SSI
compared with older antimicrobial agents with a smaller range of activity, as
compared with broad-based in vitro antibacterial agents(Bratzleret al 2013). The
antimicrobial choice therefore is based on price, safety profile, ease of
administration, pharmacokinetic profile, and bactericidal activity. Comparative tests
are restricted by tiny sample dimensions resulting in difficulties to detect the
important difference between anti - microbial.

37ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
Spectrum of Activity: These instructions are suggested for antimicrobial agents
with the narrowest activity spectrum needed in order to prevent infection.
Documented effectiveness of alternative antimicrobial agents is also mentioned
here(Bratzleret al 2013). In their adoption of these suggestions, individual health
care systems must consider local organisms ' resistance patterns and general SSI
rates at their sites. Resistance patterns of the bacteria causing SSIs should take
priority over broad antibiograms in the hospital— in some instances procedural
resistance patterns.
Allergy to beta - Lactam Antimicrobials: Antimicrobial allergy to beta-lactam can
be considered for surgical prophylaxis. Beta-lactam antibiotics, including
cephalosporin, are the foundation of surgical antimicrobial prophylaxis and, when
allergic responses happen, are the most frequently used medication(Frumin and
Gallagher 2009). Due to gram-positive incorporation of vancomycin in SSIs after
clean processes, a patient with a life threatening allergy to beta - lactam
antimicrobials may be suitable.
Timing of Initial Dose: Successful prophylaxis needs the anti -microbial to be
delivered to the operating site prior to contamination. The antimicrobial agent should
therefore be administered to provide the most likely organisms connected with the
process at the moment of the incision and for the length of the operation with serum
and tissue levels exceeding the minimum inhibitory concentration (MIC).Overall, the
first antimicrobial start dose should be administered within 60 minutes of an incision.
Vancomycin and fluoroquinolones should start administration with the protracted
infusion times necessary for these medicinal products within 120 minutes of surgical
incision(Weber et al 2008). Due to their lengthy half-life, early administration of this

38ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
drug during most surgical procedures should not compromise the serum
concentrations of these agents.While latest figures suggest that the risk of infection
with antimicrobial administration is smaller within 30 minutes prior to operative
incision, this is not strong enough to recommend that the ideal window be reduced
to 1–30 minutes before surgery. These information, however, indicate that
antimicrobials could be given too near the incision moment. Although several papers
have indicated that the danger of disease has risen too close to administration of the
incision, the information submitted is not convincing(Dellinger 2008). All these
papers actually verify the increase in the antimicrobial SSI ratio provided before the
incision is 60 minutes.
Dosing: In selecting a dose, anti - microbial and pharmaco - dynamic properties and
patient factors should be considered to ensure the adequate serum and tissue
concentrations of antimicrobial agents to prophylaxis of SSI. A reduced infection rate
for patients with detectable serum drugs at final serum levels in one of the earliest
monitored cardiac-operated antimicrobial prophylaxis study was likened to patients
with non- detectable medicinal products(Platt et al 1984).
Weight Based Dosing: In paediatric patients, most antimicrobials are dose-based
by weight, however, the dosage of a large number of anti-microbial in adolescents is
not body weight-based, as standard doses for most adult patients are secure,
efficient, and easy to use. These standardized doses prevent calculations from
being required and decrease the likelihood of medicament mistakes. But obese
patients may vary in their serum and tissue levels from those of normal weight due
to pharmacokinetic modifications, which rely on the lipophilicity of the medicine and
other variables, particularly those who are morbidly obese.On ideal dose of

39ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
antimicrobial agents for obese patients limited information is accessible. In obese
patients, the ideal body weight or total body weight of the patient (i.e., real) has not
been determined when weight-based dosing is warranted(Falagas and
Karageorgopoulos 2010). The optimal weight of the body as the basis for a lipophilic
medication (e.g. vancomycin) can lead to sub - therapeutic levels in the serum and
tissue, and the real body weight can lead to excessive levels in serum and tissue in
dosing a medicine (e.g., aminoglycoside).Definitive guidelines for antimicrobial
prophylaxis dosage in obese patients cannot be made, as there is no publication in
the published literature that shows clinically significant decreases of SSI rates from
the use of these dose strategies in obese patients instead of standard doses(Pai
and Bearden 2007).While the optimum dose of cefazolin is not found in obese
patients, a serum and tissue cefazolin concentrations were investigated by a few
pharmacokinetic studies during operating procedures.
Colonization and Resistance: Surgical antimicrobial prophylaxis can change
bacterial flora in individuals and institutions leading to alterations in colonization
rates or enhanced resistance to bacteria. Clostridium difficile -associated Colitis
patients also may be predisposed to surgical prophylaxis. Development risk factors
for C. difficile associated Colitis with difficulty involves longer prophylaxis or
treatment length and the use of various antimicrobial agents. C. difficile may also be
reduced to a single preoperative injection by restricting the length of antimicrobial
prophylactics(Bratzleret al 2013).
Whilst antimicrobial prophylaxis is a significant part of decreasing SSIs frequency,
there are other considerations such as the attention paid to basic strategy for
infection control, surgical experience, surgeon skin antisepticise (i.e. surgical scrub,

40ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
suitable hair removal), hospital and operating rooms, instrument sterilisation
problems and pre-operative preparation (i.e., surgical scrub). Increased risk of SSI
includes age extremes, dietary status, obesity, diabetes mellitus, the use of tobacco,
co-existing distant diseases, modified immune responses, corticosteroid therapy,
latest surgery, durations of pre-operative hospitalizations and sickle colonization. In
the event of an underlying medical condition with the high level of risk associated
with an SSI or immune - compromised (e.g. malnourished, neutropenic,
immunosuppressive agents) for any procedure, antimicrobial prophylaxis may be
justified. In surgery with an elevated rate of infection (e.g., clean-contaminated or
contaminated processes) and in some cleaning processes, antimicrobial prophylaxis
may benefit even if infection has an unlikely effect (i.e., prosthesis implant)
(Bratzleret al 2013). Although some clean surgical processes do not show
prophylactic antimicrobials, the available information suggests that the comparative
risk decrease of SSI in clean and risky antimicrobial prophylaxis is the same. For
most clean-contaminated processes, antimicrobial prophylaxis is justified. The
therapy of suspected disease and not prophylaxis is classed as the use of antibiotics
in dirty treatments or established diseases. Few pharmaco - economic trials have
included surgical antimicrobial prophylaxis, which has resulted in the development of
these rules using a cost reduction strategy. The suggestions for antimicrobial agents
are mainly based on their effectiveness and safety(Bratzleret al 2013). In the
implementation of these rules, individual organizations shall consider their
procurement expenses. A cooperative leadership by pharmacists and surgeons can
make further cost savings in order to choose the most cost-effective agent and
minimize or eliminate postoperative doses.

41ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
More study on surgical antimicrobial prophylaxis is required in several fields. Further
evaluation of the disadvantages and advantages is needed following the conclusion
of an operative operation of continuous antimicrobial prophylaxis, including dosing
as well as duration. Intra - operative repeat dose, weight dosing in obese patients
and pre-operatory antimicrobial timing, which must be given over a long period,
need to be investigated (e.g. vancomycin, fluoroquinolones). Further clarification is
needed on specific antimicrobial concentrations and on the intra - operative
surveillance of serum and tissue antimicrobial levels in order to optimize effectively.
Additional clarification on targeted antifungal levels and intraoperative monitoring of
serum and tissue antimicrobial levels is required to optimize effectiveness. The role
of topical management of antimicrobial agents should also be evaluated in replacing
or supplementing IV. Further assessment is required of antimicrobial prophylaxis.
For patients with allergies to beta -lactam antimicrobials additional data will be
required to inform the selection of prophylaxis antimicrobials, especially for
combination regimes.The data are also required for the development of antimicrobial
prophylaxis optimisation approaches in patients and equipment at a high danger or
incidence of SSI-implicated resistant bacteria (e.g. MRSA). Optimum S.aureus
screening and decolonization policies should be recognized for certain
processes(Bratzleret al 2013). Finally, results of research are necessary to evaluate
the effect on operating morbidity and mortality by using quality measures and pay-
for-performance incentives.

42ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
Chapter 4
4.0Methodology
As per Birley and Moreland(2014), while conducting research processes it is
important to implement the methodological processes as it helps the research
process by determining the actions which would be required by the researchers to
make the research investigation proper for the completion of the processes. It was
seen that majority of the research process methodology helps to conduct the
research process by identification, selection as well as process that helps in the
analysis of the process (Fassinger and Marrow 2014). With application of the
methodological information, researchers are able to evaluate the reliability as well as
the validity of the critical research process (Punch 2013). Hence, from these
analysis of the methodological section, it could easily mentioned that majority of the
researchers that were associated with the understanding the importance of a proper
methodological section in the research process, found that through the application of
the research methodology, two of the most crucial questions could be answered and
these are the way research questions are determined and the way these research
processes are analysed (Taylor, Bogdanand DeVault 2015). In this situation, it
should be mentioned that the researchers should be able to understand that majority
of methodology should be determined by the researchers as they would be able to
make the proper justification for the chosen methodological aspect (Cronin 2016).
4.1 Study design
As per Birley and Moreland(2014), while implementing the research methodology or
the study design for the research process, it is important to understand that the

43ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
research study design should be inclusive of the abilities so that the design could
answer the research questions. Research methodology is a research process that
helps the researchers to understand the way answers to the research questions
could be obtained and after this it should be mentioned that they should be able to
understand the method such as the qualitative and quantitative as well as the mixed
method (Pattenand Newhart 2017). Quantitative research process includes
numerical data which could be analysed using statistical methods or other online
analysis tools, whereas, qualitative research data includes research methods in
which qualitative responses are evaluated so that individual perception of public
about the method or research process could be identified (Kumar 2019). It should be
mentioned that in this research process, the primary aim of the research is to
investigate whether correct antibiotic usage is conducted in surgical prophylaxis with
regard to the caesarean section according to the standard guidelines and hence,
this requires double analysis of the research processes for cumulative
understanding of the research question (Flick 2015). Hence, the quantitative
research and qualitative research design was implemented forming a mixed method
research so that effective understanding of the research process could be obtained.
Hence, as per Patten and Newhart (2017), application of the research study design
helps the researchers to investigate the proper analysis of any situation which could
not be identified in the process. This further helps the proper understanding of the
existing issues so that primary focus of the future research studies could be
identified (Flick 2015).
In this research process, the researchers conducted a survey among a healthcare
facility in United Arab Emirates and for this process 240 surgeries were assessed for

44ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
the analysis so that the researchers could understand the research process and
question effectively and then uses the SPSS analysis tool so that the statistical
analysis of the research process could be identified. Therefore, as a mixed method
used for the research analysis, it provided an effective way to determine the usage
of the research process effectively (Flick 2015).
4.2 Survey Instruments
A clinical audit is conducted to provide information and feedback on the results of
individual doctors or groups of doctors. Clinical audit activity measures the present
performance against measures established and offers feedback so that fields where
performance meets or exceeds expectations can be easily identified, and where
improvements in patient results are desirable or helpful(Esposito and Dal Canton
2014).In a broad range of subjects, clinical auditing can be used to enhance
elements of care. It can also be used to verify that the present practice meets the
anticipated performance standard in combination with modifications in care
provision. Clinical audit provides a way of evaluating and improving patient care,
maintaining professional norms and doing the correct thing. Healthcare personnel
can recognize and assess risk regions within their services through clinical audits.
Regular auditing enables to build a culture of improving the quality of the clinical
environment(Soltanifar and Russell 2012). For the respondents, clinical audit is
educational. It requires that excellent practice is up to date on proof.To successfully
conduct a clinical audit in the identification of fields of excellence, or improvements,
efficient planning and preparation is necessary. The quantity of planning and
preparation depends on each audit in its particular conditions. Clinical examination
should cover the practice of various clinical and management fields, which add to

45ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
the appropriate audit subject region, since the bulk of clinical practice includes multi-
professional groups. The support team for Clinical Governance (2005) of the
NHS(Som 2005) proposes that 50% of the audits be multi-professional.
Clinical Audit Tool, Surgical Antibiotic Prophylaxis (SAP) Surveillance Tool (Bull et al
2012)are among the few of the survey instruments that were used for collection of
the clinical audit related data in the healthcare facility of United Arab Emirates.
The detail of the Surgical Antibiotic Prophylaxis (SAP) Surveillance Tool Form has
been provided in the Appendix 1 below.
4.3 Sample setting
The sample setting selected for the conduction of the mixed methodological
research includes a healthcare facility in United Arab Emirates in which the clinical
audit was conducted to find out the answers to the selected research questions.
4.4 Sample Size
Total 240 surgeries were selected for the analysis of the clinical audit conducted in
the healthcare facility of United Arab Emirates and all these subjects were subjected
to the clinical audits for this research process.
4.5 Data Collection
As mentioned byHartas (2018), data collection process is a method that helps in
thecollection and measurement of the information collected from the research
methods or study designsthat depends upon the variable of these data. However, in
this prospect, it should be mentioned the data collection method helps the
researchers to find the answers to the entire research question, analysed or
developed test hypothesis as well as outcomes that could be easily evaluated

46ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
through the research process (Creswell and Creswell 2017). Besides this, it should
also be mentioned that the data collection process which is used by the researchers
is an essential section for both qualitative, quantitative and the mixed method
researchesso that the continuity and identity of the research could be assessed and
survived (Nardi 2018). Further, the selection of the proper data collection instrument
as well as clear delineated instructions help in the reducing the probability of
encountering errors in the future (Lampardand Pole 2015). In this research, the data
collection includes Surgical Antibiotic Prophylaxis (SAP) and the Surveillance Tool
form which helps to collect the data for the clinical audit conducted in the healthcare
facility of UAE.
4.6 Inclusion and Exclusion Criteria
Among the selected patients that would be undergoing surgery, the clinical audit
excluded 8 cases due to the penicillin allergy among the subjects and then one
more patient was excluded from the research as the patient showed post - surgical
infection related condition (fever and leukocytosis) and required prolonged antibiotic
treatment
4.7 Data and Statistical analysis
The data were collected from the respondents in the form of raw data in a survey
questionnaire so that those data could be generated in their numeric form
depending upon which the SPSS analysis would be conducted. SPSS software, as
per Lampard and Pole (2015), is a statistical analysis tool which is used by the
researchers that are conducting statistical analysis for their qualitative research
process and then helps to guide the statistical analysis to a direction, from where
analysis becomes easier to conduct or implement. Multiple researchers prefer SPSS

47ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
analysis so that the analysis could be guided to an effective process(Bell et al2018).
In this situation as well SPSS was used for the statistical analysis and through the
analysis of the raw data from the MS Excel, conduction of statistical analysis was
obtained.

48ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
Chapter 5
5.0Results
For this Clinical Audit, a hospital in United Arab Emirates was selected. The Clinical
Audit was conducted for the duration of six months (July, 2018 to December, 2018).
During this six months period a total of 240 surgeries were monitored for this
purpose and 8 surgeries were excluded due to the exclusion criteria set before the
conduction of this Clinical Audit. Total six resident surgeonswere presented in the
hospital during this time and they performed all the surgeries in combined manner.
The Surgical Antibiotic Prophylaxis (SAP) Surveillance Tool was used for the
collection of data and raw data were documented in the MS Excel. The raw data
were then analysed using IBM SPSS Statistical Analysis tool. The analysed data are
presented in the below section.
Table 1: Stratification of total surgery according to the Nationality of the
patients
Nationality
Frequency Percent Valid Percent Cumulative Percent
African 12 5.0 5.0 5.0
Arab 110 45.8 45.8 50.8
Asian 70 29.2 29.2 80.0
Australian 17 7.1 7.1 87.1
European 20 8.3 8.3 95.4
Hispanic 11 4.6 4.6 100.0
Total 240 100.0 100.0

49ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
From the above Table 1 it can be reviewed that the total surgery conducted is 240,
however nationality from the Arab consists of maximum surgery with 110
frequencies which is 50.8 per cent of cumulative percentage. Asian nationality
percentage seems to be securing the 2nd position with 20 frequency and 29.2 per
cent of cumulative percentage. Rest of the surgeries are divided among the
nationalities of the Australia, African, European, and Hispanic. The same findings
has been demonstrated graphically in the in the Figure 1 below.
Fig 1: Graphical presentation of stratification of total surgery according to the
Nationality of the patients
The next part of the findings was observed to determine the age stratification of the
patients whose surgery has been conducted. The Table 2 states 147 numbers of
patients were in between the ages of 20 - 30 with a percentage of 61.3 which is the

50ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
highest among the different age range group.Patients in the age bracket of above 30
belong to 17.1 per cent& below 20 is 21.7 per cent.
Table 2: Stratification of total surgery according to the Age
Age
Frequency Percent Valid Percent Cumulative Percent
20 - 30 147 61.3 61.3 61.3
Above 30 41 17.1 17.1 78.3
Below 20 52 21.7 21.7 100.0
Total 240 100.0 100.0
Fig 2:Graphical presentation of stratification of total surgery according to the
Nationality of the patients
The same findings has been demonstrated graphically in the in the Figure 2 above.
Table 3: Stratification of total surgery according to the Primigravida of the
patients

51ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
Primigravida
Frequency Percent Valid Percent Cumulative Percent
No 174 72.5 72.5 72.5
Yes 66 27.5 27.5 100.0
Total 240 100.0 100.0
According to above mentioned data presented in the Table 3, the percentage of
primigravida among the patients is at around 27.5 per cent and most of the patients
have had an occurrence of pregnancy earlier.
Fig 3:Graphical presentation of stratification of total surgery according to the
Primigravida of the patients
The findings of the primigravida has been demonstrated graphically in the in the
Figure 3 above.

52ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
Table 4: Stratification of total surgery according to the type of surgery of the
patients
Surgery Type
Frequency Percent Valid Percent Cumulative Percent
Elective C- Section 75 31.3 31.3 31.3
Emergency C- Section 165 68.8 68.8 100.0
Total 240 100.0 100.0
Fig 4:Graphical presentation of stratification of total surgery according to the
Nationality of the patients
The above presented data in Table 4 and Figure 4 reflects the percentage of
different type of surgery, the segregation states the emergency C - section is on
higher side with 68.8 per cent whereas the elective C – section is hovering between
31.3 per cent.
After that the nationality, prigravida, and surgery type were analysed with respect to
the age of the patients and the detailed findings is presented in the Table 5 to Table

53ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
7. Three age group mentioned above were selected for this analysis and the
findings were presented in three different tables.
Table 5 a.: Stratification of total surgery according to the Nationality with
respect to the age of the patients
Nationalitya
Frequency Percent Valid Percent Cumulative Percent
Valid African 12 8.2 8.2 8.2
Arab 70 47.6 47.6 55.8
Asian 49 33.3 33.3 89.1
Australian 6 4.1 4.1 93.2
European 3 2.0 2.0 95.2
Hispanic 7 4.8 4.8 100.0
Total 147 100.0 100.0
a. Age = 20 - 30
The above table depicts the data of the age between 20-30 years; Arab is on the
highest with 47.4 % followed by Asia, Africa, Hispanic, Australia, and Europe.
Table 5 b.: Stratification of total surgery according to the Primigravida with
respect to the age of the patients
Primigravidaa
Frequency Percent Valid Percent Cumulative Percent
No 128 87.1 87.1 87.1
Yes 19 12.9 12.9 100.0
Total 147 100.0 100.0
a. Age = 20 - 30
The above data mentions the percentage of primigravida among the patients
between the age of 20 -30 years, is at around of 12.9 per cent.
Table 5 c.: Stratification of total surgery according to the Type of Surgery with
respect to the age of the patients

54ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
Surgery Type a
Frequency Percent Valid Percent
Cumulative
Percent
Valid Elective C- Section 32 21.8 21.8 21.8
Emergency C- Section 115 78.2 78.2 100.0
Total 147 100.0 100.0
a. Age = 20 - 30
The above data states type of surgery along with the age limit between 20-30 years,
the percentage is on higher side of the Emergency C- section (~78 per cent)
compared to Elective C-Section (~ 22 per cent).
Table 6 a.: Stratification of total surgery according to the Nationality with
respect to the age of the patients
Nationality a
Frequency Percent Valid Percent
Cumulative
Percent
Arab 3 7.3 7.3 7.3
Asian 7 17.1 17.1 24.4
Australian 11 26.8 26.8 51.2
European 16 39.0 39.0 90.2
Hispanic 4 9.8 9.8 100.0
Total 41 100.0 100.0
a. Age = Above 30
The above survey states the surgery of the patients across the nation along with the
age parameter between 20-30 years, European patients securing the highest
percentage of 39 per cent followed by Australians, Asians, Hispanic, and Arab.
Table 6 b.: Stratification of total surgery according to the Primigravida with
respect to the age of the patients

55ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
Primigravidaa
Frequency Percent Valid Percent Cumulative Percent
No 35 85.4 85.4 85.4
Yes 6 14.6 14.6 100.0
Total 41 100.0 100.0
a. Age = Above 30
The above data mentions the percentage of primigravida among the patients
between the ages of 20 -30 years, is at around of 14.6 per cent.
Table 6 c.: Stratification of total surgery according to the Type of Surgery with
respect to the age of the patients
Surgery Type a
Frequency Percent Valid Percent Cumulative Percent
Elective C- Section 6 14.6 14.6 14.6
Emergency C- Section 35 85.4 85.4 100.0
Total 41 100.0 100.0
a. Age = Above 30
The above data represents the type of C-section of the patients above the age of 30
years, the percentage of Elective C - section is less compared to the Emergency C -
Section, and the percentage differs with 70.8 per cent.
Table 7 a.: Stratification of total surgery according to the Nationality with
respect to the age of the patients
Nationalitya
Frequency Percent Valid Percent Cumulative Percent
Arab 37 71.2 71.2 71.2
Asian 14 26.9 26.9 98.1
European 1 1.9 1.9 100.0
Total 52 100.0 100.0
a. Age = Below 20

56ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
The above data represents the percentage of surgery below 20years depending
upon the nationality, Arab tops the chart followed by Asian and European.
Table 7 b.: Stratification of total surgery according to the Primigravida with
respect to the age of the patients
Primigravidaa
Frequency Percent Valid Percent Cumulative Percent
No 11 21.2 21.2 21.2
Yes 41 78.8 78.8 100.0
Total 52 100.0 100.0
a. Age = Below 20
The above data mentions the percentage of primigravida among the patients
between the age of 20 -30 years, is at around of 79 per cent.
Table 7 c.: Stratification of total surgery according to the Type of Surgery with
respect to the age of the patients
Surgery Typea
Frequency Percent Valid Percent Cumulative Percent
Elective C- Section 37 71.2 71.2 71.2
Emergency C- Section 15 28.8 28.8 100.0
Total 52 100.0 100.0
a. Age = Below 20
The above data represents the percentage of Elective C- Section and Emergency C-
Section of the patient below 20 years; the percentage is on higher side of Elective
C- Section (~ 71 per cent) compared to Emergency C- Section (~ 29 per cent)

57ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
Table 8: Stratification of total surgery according to the Surgeon who
conducted the surgery
Surgeon
Frequency Percent Valid Percent
Cumulative
Percent
101 40 16.7 16.7 16.7
102 39 16.3 16.3 32.9
103 41 17.1 17.1 50.0
104 39 16.3 16.3 66.3
105 39 16.3 16.3 82.5
106 42 17.5 17.5 100.0
Total 240 100.0 100.0
The presented in the above Table 8 states the number of surgery performed by the
Surgeons, Surgeon 106 is marked with the highest percentage followed by Surgeon
103,104, 102 and 101, total surgery performed is 240.
Table 9: Stratification of total surgery according to the administration of
Correct Dose of Antibiotic to the patient
Correct Dose
Frequency Percent Valid Percent Cumulative Percent
No 33 13.8 13.8 13.8
Yes 207 86.3 86.3 100.0
Total 240 100.0 100.0
The above data states the percentage of correct dose given to the patient, correct
dose consumed is on higher percentage with 86.3 per cent and incorrect with
13.per cent. The same findings have also been illustrated graphically in the Figure 5
below.

58ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
Fig 5: Graphical presentation of Stratification of total surgery according to the
administration of Correct Dose of Antibiotic to the patient
Table 10: Stratification of total surgery according to the administration of
Correct Drug of Antibiotic to the patient
Correct Drug
Frequency Percent Valid Percent Cumulative Percent
No 33 13.8 13.8 13.8
Yes 207 86.3 86.3 100.0
Total 240 100.0 100.0
The above data states the percentage of correct dose given to the patient, correct
dose consumed is on higher percentage with 86.3 per cent and incorrect with 13.8
per cent.

59ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
Fig 6: Graphical representation of Stratification of total surgery according to
the administration of Correct Drug of Antibiotic to the patient
The data presented in the Table 11 states the use of Antibiotic after surgery, the
highest percentage of antibiotic used is Cefazolin + Metronidazole 55% followed by
cefazolin (~ 31 per cent) and combination of the Ceftriaxone / Cefuroxime /
Ceftizoxime.
Table 11: Stratification of total surgery according to the antibiotic used to the
patient after surgery
Antibiotic Used
Frequency Percent Valid Percent Cumulative Percent
cefazolin 74 30.8 30.8 30.8
Cefazolin+Metronidazole 132 55.0 55.0 85.8
Ceftriaxone/Cefuroxime/Ceftizoxime 34 14.2 14.2 100.0
Total 240 100.0 100.0

60ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
Fig 7: Stratification of total surgery according to the antibiotic used to the
patient after surgery
The data presented in the Table 12 below portrays the correct usage of Incision time
of Antibiotic, the highest frequency is 87.5 per cent is noted for administration of less
than 60 minute.
Table 12: Stratification of total surgery according to the correct usage of
Incision time of Antibiotic to the patient
Incision Time
Frequency Percent Valid Percent Cumulative Percent
< 60 mins 210 87.5 87.5 87.5
> 60 mins 30 12.5 12.5 100.0
Total 240 100.0 100.0

61ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
Fig 8: Graphical representation of Stratification of total surgery according to
the correct usage of Incision time of Antibiotic to the patient
The data presented in the Table 13 below demonstrates the correct usage of
Antibiotic duration after the surgery; the highest frequency is 59.6 per cent were
observed for the duration less than 24 hours which is in total 143 cases.
Table 13: Stratification of total surgery according to the correct usage of
Antibiotic Duration to the patient
Antibiotic Duration
Frequency Percent Valid Percent Cumulative Percent
< 24 hours 143 59.6 59.6 59.6
> 24 hours 97 40.4 40.4 100.0
Total 240 100.0 100.0

62ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
Fig 9: Graphical representation of Stratification of total surgery according to
the correct usage of Antibiotic Duration to the patient
In the hospital, all total six surgeons performed the all 240 surgeries. Therefore,
analyses were conducted to study the percentage of correct usage of antibiotic
administration with respect to the correct dose, incision time, and duration of the
administration. Following Table 14 to Table 19 were used to present the data obtain
from this analysis.
Table 14 a.: Stratification of total surgery according to the Correct Dose with
respect to the Surgeon
Correct Dosea
Frequency Percent Valid Percent
Cumulative
Percent
No 8 20.0 20.0 20.0
Yes 32 80.0 80.0 100.0
Total 40 100.0 100.0

63ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
a. Surgeon = 101
The above data mentions the usage of correct dose by Surgeon 101 during the
surgery, its 80 per cent as correct dose,and 20 per cent as incorrect dose.
Table 14 b: Stratification of total surgery according to the Incision time with
respect to the Surgeon
IncisionTimea
Frequency Percent Valid Percent Cumulative Percent
< 60 mins 39 97.5 97.5 97.5
> 60 mins 1 2.5 2.5 100.0
Total 40 100.0 100.0
a. Surgeon = 101
The data presented in the above Table shows that the surgeon 101 has achieved
correct incision time in ~ 98 per cent and wrong incision time has been administered
in only ~ 2 per cent cases.
Table 14 c.: Stratification of total surgery according to the Antibiotic Duration
with respect to the Surgeon
Antibiotic Durationa
Frequency Percent Valid Percent Cumulative Percent
< 24 hours 23 57.5 57.5 57.5
> 24 hours 17 42.5 42.5 100.0
Total 40 100.0 100.0
a. Surgeon = 101
From the data depicted in the above Table, it can be stated that the surgeon 101
has managed to administered correct duration of antibiotic in ~ 58 per cent cases

64ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
whereas ~ 42 per cent cases were wrong administration of antibiotic duration,
similar like surgeon 106 below.
Table 15 a.: Stratification of total surgery according to the Correct Dose with
respect to the Surgeon
Correct Dosea
Frequency Percent Valid Percent Cumulative Percent
No 4 10.3 10.3 10.3
Yes 35 89.7 89.7 100.0
Total 39 100.0 100.0
a. Surgeon = 102
The above data mentions the usage of correct dose by Surgeon 102 during the
surgery, its ~ 90 per cent as correct dose and ~ 10 per cent as incorrect doses.
Table 15 b.: Stratification of total surgery according to the Incision Time with
respect to the Surgeon
Incision Timea
Frequency Percent Valid Percent Cumulative Percent
< 60 mins 35 89.7 89.7 89.7
> 60 mins 4 10.3 10.3 100.0
Total 39 100.0 100.0
a. Surgeon = 102
The data presented in the above Table shows that the surgeon 102 has achieved
correct incision time in ~ 90 per cent and wrong incision time has been administered
in only ~ 10 per cent cases.
Table 15 c.: Stratification of total surgery according to the Antibiotic Duration
with respect to the Surgeon
Antibiotic Durationa

65ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
Frequency Percent Valid Percent Cumulative Percent
< 24 hours 22 56.4 56.4 56.4
> 24 hours 17 43.6 43.6 100.0
Total 39 100.0 100.0
a. Surgeon = 102
From the data depicted in the above Table, it can be stated that the surgeon 102
has managed to administered correct duration of antibiotic in ~ 56 per cent cases
whereas ~ 44 per cent cases were wrong administration of antibiotic duration.
Table 16 a.: Stratification of total surgery according to the Correct Dose with
respect to the Surgeon
Correct Dosea
Frequency Percent Valid Percent
Cumulative
Percent
Valid No 6 14.6 14.6 14.6
Yes 35 85.4 85.4 100.0
Total 41 100.0 100.0
a. Surgeon = 103
The above data mentions the usage of correct dose by Surgeon 103 during the
surgery, its ~ 85 per cent as correct dose and ~ 15 per cent as incorrect doses.
Table 16 b.: Stratification of total surgery according to the Incision Time with
respect to the Surgeon
Incision Timea
Frequency Percent Valid Percent
Cumulative
Percent
Valid < 60 mins 34 82.9 82.9 82.9
> 60 mins 7 17.1 17.1 100.0
Total 41 100.0 100.0
a. Surgeon = 103

66ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
The data presented in the above Table shows that the surgeon 103 has achieved
correct incision time in ~ 83 per cent and wrong incision time has been administered
in only ~ 17 per cent cases.
Table 16 c.: Stratification of total surgery according to the Antibiotic Duration
with respect to the Surgeon
Antibiotic Durationa
Frequency Percent Valid Percent
Cumulative
Percent
Valid < 24 hours 28 68.3 68.3 68.3
> 24 hours 13 31.7 31.7 100.0
Total 41 100.0 100.0
a. Surgeon = 103
From the data depicted in the above Table, it can be stated that the surgeon 103
has managed to administered correct duration of antibiotic in ~ 68 per cent cases
whereas ~ 32 per cent cases were wrong administration of antibiotic duration.
Table 17 a.: Stratification of total surgery according to the Correct Dose with
respect to the Surgeon
Correct Dosea
Frequency Percent Valid Percent
Cumulative
Percent
Valid No 5 12.8 12.8 12.8
Yes 34 87.2 87.2 100.0
Total 39 100.0 100.0
a. Surgeon = 104
The above data mentions the usage of correct dose by Surgeon 104 during the
surgery, its ~ 87 per cent as correct dose and ~ 13 per cent as incorrect doses.

67ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
Table 17 b.: Stratification of total surgery according to the Incision Time with
respect to the Surgeon
Incision Timea
Frequency Percent Valid Percent
Cumulative
Percent
Valid < 60 mins 32 82.1 82.1 82.1
> 60 mins 7 17.9 17.9 100.0
Total 39 100.0 100.0
a. Surgeon = 104
The data presented in the above Table shows that the surgeon 104 has achieved
correct incision time in ~ 82 per cent and wrong incision time has been administered
in only ~ 18 per cent cases.
Table 17 c.: Stratification of total surgery according to the Antibiotic Duration
with respect to the Surgeon
Antibiotic Durationa
Frequency Percent Valid Percent
Cumulative
Percent
Valid < 24 hours 25 64.1 64.1 64.1
> 24 hours 14 35.9 35.9 100.0
Total 39 100.0 100.0
a. Surgeon = 104
From the data depicted in the above Table, it can be stated that the surgeon 104
has managed to administered correct duration of antibiotic in ~ 64 per cent cases
whereas ~ 36 per cent cases were wrong administration of antibiotic duration.
Table 18 a.: Stratification of total surgery according to the Correct Dose with
respect to the Surgeon
Correct Dosea

68ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
Frequency Percent Valid Percent
Cumulative
Percent
Valid No 4 10.3 10.3 10.3
Yes 35 89.7 89.7 100.0
Total 39 100.0 100.0
a. Surgeon = 105
The above data mentions the usage of correct dose by Surgeon 105 during the
surgery, its ~ 90 per cent as correct dose and ~ 10 per cent as incorrect doses,
similar like surgeon 102.
Table 18 b.: Stratification of total surgery according to the Incision Time with
respect to the Surgeon
Incision Timea
Frequency Percent Valid Percent
Cumulative
Percent
Valid < 60 mins 31 79.5 79.5 79.5
> 60 mins 8 20.5 20.5 100.0
Total 39 100.0 100.0
a. Surgeon = 105
The data presented in the above Table shows that the surgeon 105 has achieved
correct incision time in ~ 80 per cent and wrong incision time has been administered
in only ~ 20 per cent cases.
Table 18 c.: Stratification of total surgery according to the Antibiotic Duration
with respect to the Surgeon
Antibiotic Durationa
Frequency Percent Valid Percent
Cumulative
Percent
Valid < 24 hours 21 53.8 53.8 53.8

69ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
> 24 hours 18 46.2 46.2 100.0
Total 39 100.0 100.0
a. Surgeon = 105
From the data depicted in the above Table, it can be stated that the surgeon 105
has managed to administered correct duration of antibiotic in ~ 54 per cent cases
whereas ~ 46 per cent cases were wrong administration of antibiotic duration.
Table 19 a.: Stratification of total surgery according to the Correct Dose with
respect to the Surgeon
Correct Dosea
Frequency Percent Valid Percent
Cumulative
Percent
Valid No 6 14.3 14.3 14.3
Yes 36 85.7 85.7 100.0
Total 42 100.0 100.0
a. Surgeon = 106
The above data mentions the usage of correct dose by Surgeon 106 during the
surgery, its ~ 86 per cent as correct dose and ~ 14 per cent as incorrect doses.
Table 19 b.: Stratification of total surgery according to the Incision Time with
respect to the Surgeon
Incision Timea
Frequency Percent Valid Percent
Cumulative
Percent
Valid < 60 mins 39 92.9 92.9 92.9
> 60 mins 3 7.1 7.1 100.0
Total 42 100.0 100.0
a. Surgeon = 106

70ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
The data presented in the above Table shows that the surgeon 101 has achieved
correct incision time in ~ 93 per cent and wrong incision time has been administered
in only ~ 7 per cent cases.
Table 19 c.: Stratification of total surgery according to the Antibiotic Duration
with respect to the Surgeon
Antibiotic Durationa
Frequency Percent Valid Percent Cumulative Percent
< 24 hours 24 57.1 57.1 57.1
> 24 hours 18 42.9 42.9 100.0
Total 42 100.0 100.0
a. Surgeon = 106
From the data depicted in the above Table, it can be stated that the surgeon 106
has managed to administered correct duration of antibiotic in ~ 57 per cent cases
whereas ~ 43 per cent cases were wrong administration of antibiotic duration.

71ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
Chapter 6
6.0Discussions
Almost three-quarters of the clients were 20 to 30years of age in our research. The
distribution of age refers to the population status of the society, because during this
era the majority of women tend to finish their families. One third of the research
respondents were the elective C-section. It is essential to choose optional processes
as far as possible, as it offers a smooth operational scope. Almost all c section
surgery was done for postoperative morbidity under antibiotic prophylaxis. This
shows that practice in the audit environment is generally based on evidence.
Peri - operative dose- of- skin antibiotic prophylaxis is sufficient for all clean
surgeons, with the added advantage of cost - effectiveness and the possibility of
reducing the risk of developing antibiotic resistance, to prevent infectious morbidity
post - operatively (both optional as an emergency). Almost all the patients have
obtained antibiotic prophylaxis, which is excellent clinical practice and similar to
world-wide evidence norms. The decrease in the amount of days that the patient
has to remain in the hospital reduces, in turn, the postoperative infection related
morbidity. Furthermore, it reduced the incidence of more resistant micro-organism
hospital-acquired infections and diseases.The research showed that most patients
got Cefazolin + Metronidazole, which is one of the antibiotics, suggested when it
covers almost the same microorganism range, in conjunction. However, it currently
works for most infectious species, but extended use will lead to the growth of
resistant bacteria, which will require cephalosporins of third and fourth-generation. It
was intend to develop an antibiotic prophylaxis unit guideline in instances of

72ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
caesarean section to prevent this dilemma and to guarantee consistency of
exercise.
The patients with a single antibiotic were administered in about 45 per cent cases
and patients who got two or more antibiotics were administered 55 per cent cases.
In all 240 processes, approximately 85 per cent administration conformed to the
guideline recommendation with respect to correct dose. Approximately 85 per
cent and 60 per cent of the procedures were given the right dose and dosing
duration. All the antibiotics have been intravenously delivered.
The findings of this research show that surgical prophylaxis for the kind of surgical
intercession is anti-microbial for all patients. In around 85 percent of the processes,
overall consistency with evaluation criteria with respect to correct dose and correct
drug was achieved. These results indicate that the surgical team has been aware of
antibiotic estimates for SSI, and also demonstrate an overall lack of awareness
among human health care suppliers of global norms, reflecting the effect of lack of
clinical guidance.
Antibiotic prophylaxis was launched in 210 patients in 240 patients within 60 minutes
of anaesthesia induction. After 60 minutes after surgery, prophylaxis began in 30
patients. All our patients remain alive and are released from the hospital. Despite
the use of antibiotics for surgical prophylaxis, infection evolved in eight of these
patients. Only the suitable prophylaxis was obtained for one patient.
This research showed that the some of the medicines prescribed for operative
prophylaxis, correct dose, correct duration, and incision timing do not comply with
the standard medication guidelines. To improve the excellence of preoperative

73ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
antibiotic use, a preface of a local prescription guideline and appropriate
instructional intervention are needed(Khanemet al 2012).
The period of prophylaxis was expanded to more than one dose in the majority of
patients. The same issue has been noted in other research. Extensive use of
prophylactic antimicrobials has been related to the development and risk of super
infection and toxicity of the bacterial resistance. In most of our processes,
prophylaxis was initiated at the correct moment. During hospitalization, none of our
patients created an infection because prophylaxis was continued beyond the
recommended period. In general surgery and obstetrics / gynaecology, the
frequency of incorrect indications for antibiotics was high. Possible reasons for
inappropriate use in these areas include characteristics of surgical systems,
complicated operating techniques, and greater rates of surgery. Proper doctors
specialize in the appropriate use of antibiotics together with rigorous oversight of the
surgeon in local clinics may be useful and helpful(Mousaviet al 2017).
The findings of this research show that surgical prophylaxis for the type of surgical
intercession has been anti-microbial to all patients. In around 60 per cent to 85 per
cent of the processes, overall consistency with the evaluation criteria was achieved.
These findings demonstrate that the Surgical Group was familiar with the antibiotic
estimates in the SSI counteraction, shows an overall lack of attention by the human
health care provider to global norms, and reflects the effect of the lack of clinical
instructions.

74ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
Chapter 7
7.0Conclusions
7.1 Summary
The management of Health Care Systems focuses on quality control, and therefore
the proper distribution of funds. Several instruments are used to monitor and
enhance the quality of the care. One of them is the most common, and widely
distributed, clinical audit. However, knowledge of the clinical audit remains to be
broadened and its systemic implementation promoted both nationally and locally, so
that it is a component of each health care provider's know-how alongside other
methods for quality enhancement.
In females who are caesarean, the use of prophylactic antibiotics significantly
decreased the prevalence of fever, endometritis, wound infection, Urinary Tract, and
severe caesarean infection. The objective should be a 100% target which can be
achieved once the clinical practice guideline in our clinic has been enforced to
guarantee uniform treatment, since prophylaxis does not involve extensive therapy
and other variables, such as patient conformity.
This research showed that the some of the medicines prescribed for operative
prophylaxis, correct dose, correct duration, and incision timing do not comply with
the standard medication guidelines. To improve the excellence of preoperative
antibiotic use, a preface of a local prescription guideline and appropriate
instructional intervention are needed.

75ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
7.2 Limitations
There were some limitations to this research. First, microbiology results parameters
and process parameters are not included in the outcomes. Secondly, in some
instances antibiotic timing had not been recorded on the hospital record of a patient,
and thirdly, the cost efficiency and feasibility of the ASHP rules have not been
recorded in our area. ASHP guidelines have been selected as a global and
accessible guideline for this clinical audit.
7.3 Recommendations
According to the Clinical Audit conducted for this research investigation, following
recommendations have been suggested for the future implementation:
 Antibiotic prophylaxis should be given to all females in an elective or
emergency Caesarean section.
 A single dose of cephalosporin of first generation is the option of antibiotic for
Caesarean section. Clindamycin or erythromycin may be used if the person
has a penicillin allergy.
 Time should be between 15 and 60 minutes before the skin is incised for
prophylactic Caesarean antibiotics. There are no recommended further
doses.
 If a long abdominal process (more than 3 hours) is open or the projected
blood loss exceeds 1500 mL, 3 to 4 hours after the original dose may be
taken to add an extra dose of the prophylactic antibiotic.
 For reducing the infectious morbidity of the third and fourth degree perineal
injury repair, prophylactic antibiotics may be considered.

76ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
 Institutionalisation should be administered by a trustees ' board that includes
experts, anaesthesiologists, microbiologists, pharmacists and departments of
infection control. Directives should be based on the particular
epidemiological patterns of the hospital bacteria, finest literature and a
preferred surgeon. In order to reach consensus before implementation, the
standardized protocol should then be given to surgeons.

77ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
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83ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
Appendices
Appendix 1
Surgical Antibiotic Prophylaxis (SAP) Surveillance Tool Month/Year_________

84ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
MR
N
Patie
nt
Nam
e
Age National
ity
Primigr
avida
Admitt
ing
Surge
on
Type of
Surgery
Antibiotic use Guideline
Complian
ce
Correct
drug
Antibiotic
Used
Correct
Dose
Timing to
incision
to
Duration of
antibiotic
* Ye
s
* No
* Electi
ve C-
sectio
n
* Emer
genc
y C-
sectio
n
* Yes
* No
* Cefaz
olin+
Metro
nidaz
ole
* cefaz
olin
* Ceftri
axon
e/
Cefur
oxim
e/
Ceftiz
oxim
e
* Ye
s
* No
* <60
mins
* >60
mins
* After
incisi
on
* <24 hrs
* >24hrs
* Other____
______* Yes* No
Remarks
* Ye
s
* No
* Electi
ve C-
sectio
n
* Emer
genc
y C-
sectio
n
* Yes
* No
* Cefaz
olin+
Metro
nidaz
ole
* cefaz
olin
Ceftriaxon
e/
Cefuroxim
e/
Ceftizoxi
me
* Ye
s
* No
* <60
mins
* >60
mins
* After
incisi
on
* <24 hrs
* >24hrs
* Other____
______* Yes* No
Remarks
* Ye
s * Electi
* Yes * Cefaz
olin+
Metro
* Ye
s
* <60
mins
* <24 hrs * Yes

85ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
* No
ve C-
sectio
n
* Emer
genc
y C-
sectio
n
* No nidaz
ole
* cefaz
olin
Ceftriaxon
e/
Cefuroxim
e/
Ceftizoxi
me
* No * >60
mins
* After
incisi
on
* >24hrs
* Other____
______* No
Remarks
* Ye
s
* No
* Electi
ve C-
sectio
n
* Emer
genc
y C-
sectio
n
* Yes
* No
* Cefaz
olin+
Metro
nidaz
ole
* cefaz
olin
Ceftriaxon
e/
Cefuroxim
e/
Ceftizoxi
me
* Ye
s
* No
* <60
mins
* >60
mins
* After
incisi
on
* <24 hrs
* >24hrs
* Other____
______* Yes* No
Remarks
* Ye
s
* No
* Electi
ve C-
sectio
n
* Emer
genc
y C-
sectio
n
* Yes
* No
* Cefaz
olin+
Metro
nidaz
ole
* cefaz
olin
Ceftriaxon
e/
Cefuroxim
e/
Ceftizoxi
me
* Ye
s
* No
* <60
mins
* >60
mins
* After
incisi
on
* <24 hrs
* >24hrs
* Other____
______* Yes* No
Remarks
* Ye
s * Electi
* Yes * Cefaz
olin+
* Ye
s
* <60
mins
* <24 hrs * Yes

86ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
* No
ve C-
sectio
n
* Emer
genc
y C-
sectio
n
* No Metro
nidaz
ole
* cefaz
olin
Ceftriaxon
e/
Cefuroxim
e/
Ceftizoxi
me
* No * >60
mins
* After
incisi
on
* >24hrs
* Other____
______* No
Remarks
* Ye
s
* No
* Electi
ve C-
sectio
n
* Emer
genc
y C-
sectio
n
* Yes
* No
* Cefaz
olin+
Metro
nidaz
ole
* cefaz
olin
Ceftriaxon
e/
Cefuroxim
e/
Ceftizoxi
me
* Ye
s
* No
* <60
mins
* >60
mins
* After
incisi
on
* <24 hrs
* >24hrs
* Other____
______* Yes* No
Remarks
* Ye
s
* No
* Electi
ve C-
sectio
n
* Emer
genc
y C-
sectio
n
* Yes
* No
* Cefaz
olin+
Metro
nidaz
ole
* cefaz
olin
Ceftriaxon
e/
Cefuroxim
e/
Ceftizoxi
me
* Ye
s
* No
* <60
mins
* >60
mins
* After
incisi
on
* <24 hrs
* >24hrs
* Other____
______* Yes* No
Remarks
* Ye
s * Electi
* Yes * Cefaz
olin+
* Ye
s
* <60
mins
* <24 hrs * Yes

87ANTIBIOTIC USAGE IN SURGICAL PROPHYLAXIS
* No
ve C-
sectio
n
* Emer
genc
y C-
sectio
n
* No Metro
nidaz
ole
* cefaz
olin
Ceftriaxon
e/
Cefuroxim
e/
Ceftizoxi
me
* No * >60
mins
* After
incisi
on
* >24hrs
* Other____
______* No
Remarks
* Ye
s
* No
* Electi
ve C-
sectio
n
* Emer
genc
y C-
sectio
n
* Yes
* No
* Cefaz
olin+
Metro
nidaz
ole
* cefaz
olin
Ceftriaxon
e/
Cefuroxim
e/
Ceftizoxi
me
* Ye
s
* No
* <60
mins
* >60
mins
* After
incisi
on
* <24 hrs
* >24hrs
* Other____
______* Yes* No
Remarks
* Ye
s
* No
* Electi
ve C-
sectio
n
* Emer
genc
y C-
sectio
n
* Yes
* No
* Cefaz
olin+
Metro
nidaz
ole
* cefaz
olin
Ceftriaxon
e/
Cefuroxim
e/
Ceftizoxi
me
* Ye
s
* No
* <60
mins
* >60
mins
* After
incisi
on
* <24 hrs
* >24hrs
* Other____
______* Yes* No
Remarks