Antibiotic management of surgical patients with peritonitis at a tertiary referral hospital in Rwanda

Jennifer Rickard; Christian Ngarambe; Leonard Ndayizeye; Blair Smart; Robert Riviello; Jean Paul Majyambere; Stephen Rulisa; Rahel Ghebre

Antibiotic usage and antimicrobial resistance impact surgical patient outcomes and there is growing recognition of the worsening problem of antibiotic resistance and need for antibiotic stewardship in low resource settings. We report results of antibiotic usage in patients undergoing surgery for peritonitis at a tertiary referral hospital in Rwanda.

We hypothesize that there is a substantial number of patients at high risk for treatment failure and current antimicrobial therapy is inadequate.

Patients undergoing surgery for the indication of peritonitis at a tertiary referral hospital in Rwanda were included in this study. Post Caesarean section peritonitis was excluded. Prospective data were collected on epidemiology, clinical features, operative procedure and outcomes. Antibiotics were prescribed and intraoperative cultures were collected according to surgeon discretion. We compared antibiotic usage with current Surgical Infection Society (SIS) guidelines.

Over a 6-month period, 280 patients underwent a laparotomy for peritonitis. Data on antibiotic usage was available for 244 patients. The most common diagnoses were intestinal obstruction (N=97), appendicitis (N=36) and trauma (N=35).

229 (93.9%) patients received antibiotics with the most common antibiotics being third-generation cephalosporins (N=215, 88.1%) and metronidazole (N=188, 77.1%). The mean duration of antibiotics was 4.5 days (range: 0, 14) with longer mean duration seen in patients with typhoid intestinal perforation (7.8 days) and cholecystitis (7.0 days) compared with liver abscess (3 days), tumor (3.4 days) and intestinal obstruction (3.6 days). Based on SIS guidelines, 94 (38%) patients were a high-risk for treatment failure and 113 (46%) patients received the proper initial antibiotic.

Surgical specimens were collected on 33 (12%) patients and 7 (21%) patients had an organism isolated. The most common organism isolated was Escherichia coli, identified in 5 surgical specimens, 1 urine culture and 1 blood culture.

Broad antibiotic coverage with third-generation cephalosporins and metronidazole is common in Rwandan surgical patients with peritonitis. Areas for improvement should focus on choice of and duration of antibiotics, tailored to underlying diagnosis and risk factors for treatment failure. Given the number of patients at high-risk for treatment failure, more data is needed on antibiotic resistance patterns to guide antimicrobial therapy.