Evaluation and optimization of antibiotic selection for surgical prophylaxis in Ahmedabad region

 Corresponding author: Dhanvin Chiragbhai Suthar Copyright © 2025 Author(s) retain the copyright of this article. This article is published under the terms of the Creative Commons Attribution License 4.0. Evaluation and optimization of antibiotic selection for surgical prophylaxis in Ahmedabad region Dhanvin Chiragbhai Suthar *, Rutvika Naranbhai Patel and Jay Narendrakumar Joshi Pharm D Intern at SAL Hospital, SAL Institute of Pharmacy, Ahmedabad, Gujarat, India. World Journal of Biology Pharmacy and Health Sciences, 2025, 23(03), 361-376 Publication history: Received on 05 August 2025; revised on 14 September 2025; accepted on 18 September 2025 Article DOI: https://doi.org/10.30574/wjbphs.2025.23.3.0848 Abstract Objectives: To assess the antibiotic prescribing trends for surgical prophylaxis across selected healthcare centers in Ahmedabad and to evaluate their alignment with standard guidelines. Methods: This retrospective, multi-centric observational study was conducted over 6 months across tertiary care hospitals in Ahmedabad. Patient records from surgical departments were screened to analyses the prophylactic antibiotic choice, dosage forms, frequency, post-operative prescribing patterns, and associated parameters. Surgeries were classified based on wound type (clean, clean-contaminated, contaminated, dirty), and data was compiled on demographics, culture sensitivity tests, and antibiotic cost. Results: Of the included cases, the majority underwent procedures categorized as clean or clean-contaminated. Ceftriaxone and Amikacin were the most frequently prescribed prophylactic antibiotics, often in combination. In certain cases, non-recommended agents such as third-generation cephalosporins were used indiscriminately. Culture sensitivity testing revealed predominant organisms including E. coli and Staphylococcus aureus. Despite available guidance (ICMR, CDC), notable deviations were observed in dosage frequency, timing, and antibiotic coverage, leading to increased costs and suboptimal outcomes. Conclusion: The findings underscore a disconnect between prescribed surgical prophylactic antibiotics and recommended evidence-based guidelines. There is a need for greater awareness, periodic audits, and stricter adherence to antimicrobial prophylaxis protocols to mitigate resistance and improve patient safety. Implementation of stewardship programs and education across surgical departments could significantly enhance rational antibiotic use. Keywords: Surgical Site Infection; Antibiotic Prophylaxis; Drug Utilization Review; Guideline Adherence; Microbial Sensitivity Tests 1. Introduction Surgical site infections (SSIs) are defined as infections that occur at or near the surgical incision site within 30 days of surgery or within one year if implants are involved.1 They are classified into three categories: superficial incisional (involving skin and subcutaneous tissue), deep incisional (affecting deeper soft tissues such as fascia and muscle), and organ/space infections (involving any part of the body other than the incision that was manipulated during surgery). SSIs are among the most common healthcare-associated infections, significantly contributing to patient morbidity, increased healthcare costs, and prolonged hospital stays.1 The pathogenesis involves microbial contamination during surgery, with risk factors including patient comorbidities, surgical duration, and inadequate aseptic techniques. Common pathogens include Staphylococcus aureus (including MRSA) and gram-negative bacteria.1 Preventive World Journal of Biology Pharmacy and Health Sciences, 2025, 23(03), 361-376 362 measures, such as proper hand hygiene, sterilization of surgical instruments, and timely administration of prophylactic antibiotics, are critical to reducing SSI incidence.2 Surgical site infections (SSIs) remain a global health concern, disproportionately affecting lowand middle-income countries, where infection rates can be as high as 20% due to inadequate resources and sterilization practices.3 Even in high-income nations, SSIs contribute significantly to healthcare-associated infections. The global incidence varies widely, influenced by factors such as healthcare infrastructure, regional infection control practices, and the prevalence of antimicrobial resistance.3 Efforts like the WHO’s Clean Care is Safer Care initiative have focused on reducing SSIs through education and evidence-based practices.4 In India, surgical site infections (SSIs) remain a significant challenge, with reported rates ranging from 6% to 38%, particularly in resource-limited healthcare settings.5 Contributing factors include limited adherence to infection control measures, overburdened healthcare systems, and widespread antimicrobial resistance.6 SSIs are among the most common healthcare-associated infections in the country, disproportionately impacting patients in rural areas and those undergoing emergency surgeries.5 Efforts like the National Infection Control Guidelines aim to standardize prevention strategies and improve outcomes. The most common pathogens causing surgical site infections (SSIs) are Staphylococcus aureus, including methicillinresistant strains (MRSA), and Escherichia coli.1 Other notable organisms include coagulase-negative staphylococci, Klebsiella pneumoniae, Pseudomonas aeruginosa, and Enterococcus species.4 The prevalence of these pathogens varies based on surgical type, hospital setting, and geographic region.4 In particular, S. aureus is frequently associated with orthopaedic and cardiovascular surgeries, while gram-negative pathogens like E. coli are common in gastrointestinal procedures.7 The emergence of multidrug-resistant strains further complicates treatment and highlights the need for robust infection control practices. Surgical site infections (SSIs) can lead to significant complications, including prolonged hospitalization, increased healthcare costs, and delayed wound healing.1 Severe infections may result in abscess formation, systemic sepsis, organ dysfunction, or even death, particularly in immunocompromised patients.8 Chronic SSIs can lead to implant-related infections, requiring surgical reintervention or prosthetic removal. Additionally, they contribute to the development of antimicrobial resistance, complicating treatment options. Preventing these complications through effective infection control measures remains critical in improving surgical outcomes. Appropriate use of antibiotics in surgical prophylaxis is pivotal in reducing the incidence of surgical site infections (SSIs).8 Administering antibiotics within the recommended timeframe—typically within 60 minutes prior to incision— ensures adequate tissue concentrations to prevent microbial contamination during surgery.9 Prolonged or inappropriate use of prophylactic antibiotics, however, contributes to antimicrobial resistance and offers no additional benefit in preventing SSIs.8 Studies emphasize the importance of evidence-based guidelines to optimize antibiotic selection, timing, and duration to achieve maximum efficacy while minimizing risks. The selection of antibiotics for surgical prophylaxis largely depends on the type of surgical wound (clean, cleancontaminated, contaminated, or dirty) and the procedure performed.9 Clean surgeries, such as orthopaedic or cardiovascular procedures, typically require coverage against gram-positive organisms like Staphylococcus aureus, often using cefazolin.10 Clean-contaminated and contaminated surgeries, like gastrointestinal or gynaecological procedures, demand broader-spectrum antibiotics to target gram-negative and anaerobic pathogens, such as ceftriaxone or metronidazole.10 Tailored antibiotic regimens based on wound classification and patient-specific factors optimize infection prevention and minimize resistance risks. The inappropriate selection of antibiotics for surgical prophylaxis can result in serious consequences, including treatment failure, higher rates of surgical site infections (SSIs), and increased morbidity.9 For example, inadequate gram-negative or anaerobic coverage in gastrointestinal surgeries may fail to prevent infections.9 Conversely, overuse of broad-spectrum antibiotics fosters the development of multidrug-resistant organisms, complicating future treatments. Additionally, wrong antibiotic choices may lead to adverse effects like allergic reactions or toxicity in patients.11 Evidence underscores the importance of adhering to evidence-based guidelines to avoid these outcomes. A study on the use of antibiotics in surgical prophylaxis is crucial to address the increasing threat of surgical site infections (SSIs) and the emergence of antimicrobial resistance.12 Despite existing guidelines, substantial variability in antibiotic selection, timing, and duration persists, often leading to suboptimal outcomes.9 Research is essential to evaluate adherence to protocols, identify gaps in practice, and optimize antibiotic regimens based on evolving resistance World Journal of Biology Pharmacy and Health Sciences, 2025, 23(03), 361-376 363 patterns and regional needs. So, our aim of the study is to evaluate and optimize the selection of antibiotic for surgical prophylaxis in Ahmedabad region. 2. Materials and Methods • Study Type: This research employed a retrospective study design, conducted across multiple centres to ensure diverse representation and comprehensive data collection. • Study Centres Included: Patient data was collected from several hospitals and clinics located within the Ahmedabad region, enabling an expansive evaluation of antibiotic usage for surgical prophylaxis. [Study centres: SAL Hospital (Thaltej, Ahmedabad); Treya Surgi care (Maninagar, Ahmedabad); Arham Hospital (Jodhpur, Ahmedabad); Param Maternity and Nursing Home (Vastral, Ahmedabad); Swastik Orthopaedic Hospital (Naroda Patiya, Ahmedabad)] • Sample Size: A total of 602 patients were included in the study, selected based on predefined criteria to maintain the reliability and statistical power of the findings. • Inclusion Criteria: Patients undergoing various surgical procedures who had received prophylactic antibiotic therapy were considered eligible for the study. • Exclusion Criteria: Patients with incomplete medical records, missing antibiotic data, or lacking follow-up documentation were excluded to maintain data integrity. • Study Duration: The research was conducted over a six-month period, allowing sufficient time to assess patterns in antibiotic prescribing and surgical outcomes. • Data Collection: Relevant patient information, including demographic details, types of surgeries, antibiotics prescribed, dosage forms, and hospitalization outcomes, was extracted from patient records. Data was then categorized and analysed to evaluate adherence to prophylactic guidelines, antimicrobial trends, and microbial resistance. • Statistical Analysis: As this study was descriptive in nature, data were summarized using basic statistical methods to illustrate prescribing patterns and clinical characteristics. Descriptive statistics, including frequencies and percentages were employed to analyse categorical variables. Tabulated results and graphical representations (bar charts, pie charts) were used to visually convey trends across multiple study centres. No inferential statistical tests were applied, as the primary objective was to observe and report existing prescribing practices rather than establish causal relationships. [Note: Patients receiving multidrug regimens were counted per antibiotic entity. Hence, total antibiotic count exceeds patient count.] 3. Case Report Form • Aim of project: Evaluation and Optimization of Antibiotic Selection for Surgical Prophylaxis in Ahmedabad Region • Investigators: Dhanvin C. Suthar, Rutvika N. Patel, Jay N. Joshi Case no Gender: Male/Female Age group o Less than 20 years o 20-30 years o 30-40 years o 40-50 years o More than 60 years Date of admission: __/__/____ Date of discharge: __/__/____ Length of hospitalization: o Less than 3 days o 3-5 days World Journal of Biology Pharmacy and Health Sciences, 2025, 23(03), 361-376 364 o More than 5 days 3.1. Type of surgical wound o Clean o Clean/Contaminated o Contaminated o Dirty Surgery: __________________ Antibiotic used for surgical prophylaxis: ______________ Antibiotic used for post-operative care: ______________ Culture and sensitivity test done: Yes/No Microorganism detected: _____________ 4. Results Figure 1 Distribution of Patients based on Types of Surgical Wounds Figure 2 Gender Distribution World Journal of Biology Pharmacy and Health Sciences, 2025, 23(03), 361-376 365 Figure 3 Length of Hospitalization Figure 4 Culture and Sensitivity Testing Table 1 Microorganisms Detected in Culture and Sensitivity Tests Microorganism Detected in Culture and Sensitivity Tests No. of cases Percentage (%) Bacteroides fragilis 5 10.41 Clostridium difficile 5 10.41 Enterococcus faecalis 1 2.08 Escherichia coli 4 8.33 Helicobacter pylori 9 18.75 Klebsiella pneumoniae 1 2.08 Pseudomonas aeruginosa 3 6.25 Staphylococcus aureus 16 33.33 Staphylococcus epidermidis 3 6.25 Streptococcus pyogenes 1 2.08 Total 48 100 World Journal of Biology Pharmacy and Health Sciences, 2025, 23(03), 361-376 366 Table 2 Prophylactic Antibiotics Prophylactic Antibiotics Antibiotic Class Antibiotic sub-class Antibiotic name Antibiotic count Beta-lactam 1st Generation Cephalosporin Cefazolin 131 2nd Generation Cephalosporin Cefuroxime 47 2nd Generation Cephalosporin Cefotetan 5 2nd Generation Cephalosporin Cefoxitin 10 3rd Generation Cephalosporin Ceftriaxone 58 3rd Generation Cephalosporin Cefixime 108 3rd Generation Cephalosporin Cefotaxime 5 3rd Generation Cephalosporin Cefoperazone 98 3rd Generation Cephalosporin Cefpodoxime 12 Penicillin Amoxicillin 20 Penicillin Piperacillin 30 Carbapenem Meropenem 5 Total Beta-lactam 529 Tetracycline - Doxycycline 3 Fluoroquinolones 2nd Generation Fluoroquinolone Ciprofloxacin 11 3rd Generation Fluoroquinolone Levofloxacin 22 Total Quinolones 33 Aminoglycoside - Amikacin 2 Glycopeptides - Vancomycin 1 Nitroimidazole - Metronidazole 19 Lincosamide - Clindamycin 19 Total Antibiotics 606 Beta-lactamase inhibitors Clavulanate 8 Tazobactam 30 Sulbactam 98 Total Beta-lactamase inhibitors 136 Table 3 Post operative antibiotics Post operative antibiotics Antibiotic class Antibiotic sub-class Antibiotic name Antibiotic count 3rd Generation Cephalosporin Cefixime 153 Penicillin Amoxicillin 41 Penicillin Piperacillin 62 World Journal of Biology Pharmacy and Health Sciences, 2025, 23(03), 361-376 367 Total Beta-lactam 256 Fluoroquinolones 2nd Generation Fluoroquinolone Ciprofloxacin 6 3rd Generation Fluoroquinolone Levofloxacin 52 Total Fluoroquinolones 58 Nitroimidazole - Metronidazole 79 Oxazolidinone - Linezolid 22 Macrolides - Azithromycin 5 Total Antibiotics 420 Beta-lactamase inhibitors Clavulanate 161 Tazobactam 62 Total Beta-lactamase inhibitors 223 Figure 5 Antibiotics Used for Surgical Prophylaxis in Clean Wounds World Journal of Biology Pharmacy and Health Sciences, 2025, 23(03), 361-376 368 Figure 6 Antibiotics Used for Surgical Prophylaxis in Clean/Contaminated Wounds Figure 7 Antibiotics Used for Surgical Prophylaxis in Contaminated Wounds World Journal of Biology Pharmacy and Health Sciences, 2025, 23(03), 361-376 369 Figure 8 Antibiotics Used for Surgical Prophylaxis in Dirty Wounds Figure 9 Antibiotics Used for Post-operative Care in Clean Wounds World Journal of Biology Pharmacy and Health Sciences, 2025, 23(03), 361-376 376 [27] Badge HM, Churches T, Naylor JM, Xuan W, Armstrong E, et al. 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