Gaps between antibiotic prescribing practices and international guidelines for women undergoing caesarean deliveries in rural Rwanda: A retrospective cohort study

Objective: Antibiotic stewardship remains a significant challenge in sub-Saharan Africa, with paucity of systematic data on antimicrobial use in surgical care. We characterise antibiotic prescribing practices for women who delivered via caesarean section (c-section) in rural Rwanda. Design: Nested retrospective cohort study. Setting: Kirehe District, rural Eastern Rwanda. Population: All women aged > 18 years who delivered by c-section between November 2017 and February 2018. Methods: Data on antibiotic use, including name, indication, dose/frequency/route, time, and duration of administration were extracted from patient charts. Prescribing practices statistics were summarised by the timing and type. Main Outcome Measures: Pre-operative and post-operative antibiotic prescriptions, by time, name and dose. Results: A total of 506 patients were enrolled. 80.8% received a pre-operative antibiotic, with 67.4% receiving an antibiotic within one hour of incision. The most prevalent pre-operative antibiotics prescribed were Ceftriaxone (83.3%) and Ampicillin (15.0%). Post-operatively during hospitalisation, 95.7% of patients received two antibiotics, most commonly Ampicillin (99.2%) in combination with Gentamicin (98.5%). For all but one, antibiotics were prescribed without indication of infection. At discharge, while 27.8% of patients were not prescribed any additional antibiotics, 72.2% were prescribed at least one antibiotic. Conclusions: Large deviations in antibiotic prescribing practices as compared to international prophylaxis guidelines were observed. Further studies to understand the rationale for these deviations and the effects of over-prescription on infection prevention and antibiotic resistance are needed to support context-appropriate guidelines in Rwanda and in comparable settings.