Non-adherence to surgical antibiotic prophylaxis guidelines: findings from a mixed-methods study in a developing country

Objectives: To assess adherence to surgical antibiotic prophylaxis (SAP) guidelines in obstetric and gynecologic procedures and identify factors contributing to non-adherence. Design:: A mixed-methods study comprising a cross-sectional survey and qualitative analysis. Setting: Ain Shams University Hospital of Obstetrics and Gynecology, Egypt. Participants The survey included data on all surgical procedures performed from November 1, 2024, to December 31, 2024. Eight healthcare providers participated in the qualitative research. Methods: Trained medical interns collected routine data in real-time in the operative theater and in the wards by observing and documenting three key variables namely the antibiotic prescribed, timing of administration, and the duration of use. The overall adherence rate was calculated as the proportion of cases meeting all three criteria. The survey was followed by qualitative research through a synchronous online focus group of eight healthcare providers. Following the transcription of the audio-recorded discussion, three researchers used a deductive approach to content analysis of the focus group discussion. Results: Two handreds and eighty surgical procedures were analyzed, with cesarean sections accounting for 48.6% (136/280). Full adherence to SAP guidelines was observed in 0% of cases. The appropriate antibiotic was prescribed in 62.5% (175/280) of procedures. Timely administration within the recommended 60-minute pre-incision window occurred in 38.2% (107/280). In contrast, 61.4% (172/280) of procedures had delayed antibiotic administration post-incision. The recommended single-dose or ≤24-hour regimen was administered in only 6.1% (17/280), whereas 93.9% (263/280) had prolonged parenteral antibiotic use beyond 24 hours, with 98.9% (277/280) transitioning to oral antibiotics upon discharge. Key barriers to adherence included knowledge gaps, workflow inefficiencies, inadequate monitoring, limited antibiotic availability, financial constraints, and weak enforcement of SAP guidelines. Conclusions: Non-adherence to SAP guidelines is alarmingly high, particularly regarding timing and duration. Addressing systemic barriers and enforcing guideline compliance is essential to improving antibiotic stewardship in surgical settings.