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

Objectives: The effectiveness of surgical antibiotic prophylaxis in reducing the risk of post-operative infectious morbidity, depends on its appropriate use. We aimed to assess adherence to surgical antibiotic prophylaxis guidelines and to explore the factors contributing to non-adherence. Methods : This mixed-methods study comprised a cross-sectional survey and qualitative analysis. The cross-sectional survey included all surgical procedures performed in Ain Shams University Hospital of Obstetrics and Gynecology from November 1 2024 to December 31 2024. 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 a qualitative research through synchronous online focus group of 12 participants. Following transcription of the audio-recorded discussion, three researchers used a deductive approach to content analysis of the focus group discussion. Results: Two handred 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.