Antibioprophylaxy by the Surgery Staff in the Teaching Hospital Gabriel Touré in Mali

This prospective survey was conducted from February to December 2014 about the use ceftriaxone (ceftriaz) for antibioprophylaxy concerning 300 patients by the surgery staff in the Gabriel Touré Teaching Hospital in Mali. The quantity of drug used was based on the weight of the patient. One dose was administrated in intravenous at the anesthesiology induction time. For more than 2 hours of intervention time, 4 (1.3%) patients received a second dose. The majority of cases (189, 63%) were out of emergency (emergency cases—111, 37%). The mean age was 41.6 years (range: 3 95 years). The patients were classed Altmeir II 203 (67.7%) and Altmeir I 97 (32.3%). The NNISS score 0 concerned 101 (33.6%) and NNISS 1 in 180 (60%) patients. The factors of risky were anemia (38; 12.7%), diabetes (6; 2%), and HIV (3; 1%). The mean of intervention duration was 56.8 ± 27.5 minutes. Four cases of intervention site infection were encountered caused by Pseudomonas aeruginosa in 2 patients; Escherichia coli (1 case), and Staphylococcus aureus (1 case). Conclusion: Antibioprohylaxy is not the only way to prevent infections but it stays necessary. The respect of hygien and aseptic measures should be used to reduce the rate of intervention site infection.


Introduction
Antibiotic prophylaxis is antibiotic administration before the potential bacterial contamination due to a danger-ous situation during a surgical procedure [1].The sole fact of breaking the skin barrier suggests a risk of infection to the ill.The first job of the surgeon is asepsis, and this one may be insufficient.That is the reason why the support of an antibioprophylaxy should be questioned [2].Many studies have been conducted to make this antibiotic indisputable today.In 1984, Vachon [3] enunciated practical methodologies of antibiotic prophylaxis.
In 1992, Classen [4] found that ever risky factors were associated with clean or clean-contaminated surgery; the incidence of postoperative infections was 3.8% when the antibiotic was administered 2 hours before the incision, and this increased incidence when it was administered over 2 hours before the incision (4%) or after the incision (6%).A Nigerian study on attitudes and practical knowledge on perioperative use of antibiotics showed a confusing situation between anesthetists and surgeons [5].
Our objectives were to determine the prevalence of antibiotic prophylaxis after surgical site infection (SSI), to assess the effect of antibiotic prophylaxis on the reduction of surgical site infection, to identify the causative organisms of SSI after antibiotic, to analyze the consequences of the SSI over the duration of post-operative care of the sick, and to assess the cost of the treatment after antibiotic prophylaxis.

Methods
Our prospective study conducted over a period of 11 months from February 2014 to December 2014 included patients operated in the general surgery service and care of emergency February 2014 to December 2014 and who received ceftriaz (ceftriaxone) at the time of anesthesia induction.Patients in Class I Altemeier (clean surgery) with an infectious risk estimated by the score of 2 NNISS [6].Patients in Class II Altemeier (clean-contaminated surgery) [6].
As we used the antibiotic ceftriaxone belonging to the beta-lactam, its half life is 7 hours.This antibiotic was chosen taking into account its spectrum of activity on causative of surgical site infection in our service.The dose was dependent on the weight of our patients; a single dose was given at the time of induction of anesthesia, a feedback was carried out for a duration of response was greater than 2 hours.
The dose of the antibiotic used was the weight of the patient; with an administration intravenously; this had the effect of achieving the highest tissue levels as quickly as possible, the single dose was used with a feedback in the case of higher response time to 2 hours.
The operated patients had a clinical and laboratory monitoring, the temperature was regularly taken.Asepsis was advised in bandages.
In case of fever (temperature above 38˚C), etiologic research was undertaken.
If parietal suppuration, a sample was taken and sent to the laboratory of CHU Gabriel Toure for bacteriological analysis and sensitivity.

Results
Indeed, we have compiled 300 cases, 111 (37%) cases of emergency, and 189 (63%) cold; the average age was 41.6 years, ranging from 3 to 95 years, and sex ratio of 0.8.
The mean duration of preoperative stay was 1.3 days, with a range from 0 to 13 days.We made 4 cases of reinjections (or 1.3%) for the duration of these interventions was over 2 hours.
We recorded 4 (1.3%) cases of surgical site infection.These infections surgical site through, there were 1 diabetes, 1 case of biological anemia, 3 emergency, 2 cases score NNISS 2.
Germs found in these 4 cases of infection were Escherichia coli (1 case), Staphylococcus aureus (1 case) and Pseudomonas aeruginosa (2 cases).The average length of postoperative hospital stay of patients who presented a surgical site infection was 13 days ± 10.3; and that of non-infected patients was 7.2 ± 6.4 hours.

Discussion
Our SSI rate of 1.3% after antibiotic prophylaxis remains high, it is similar to that of German S [5] (P = 0.49).It is statistically higher than those in developed countries: Kernodle DS; German S and Yamamoto S [7]- [9] (respectively P = 0.02; 0.034; 0.036) is multifactorial.SSI can be related to lack of means; the precarious facilities block; the lack of rigor in the apepsie, antiseptics because we unique.Mazaki months use hardware et al. [10] had found 2% on SSI hernia prosthesis with antibiotic prophylaxis.Our average age of 41.6 years infected patients is not different from that of uninfected patients equal to 40.2 (with P = 0.73).No link was found between SSI and sex in our study (with P = 0.25).We believe as others [11] [12] that sex is not a factor in the development of SSI.As against others consider the importance of subcutaneous fat in women as a factor that may influence the occurrence of surgical site infection [13].Our average length uninfected patients in 1.5 days is not different from that of infected patients is 1.4 days (P = 0.85).
It is generally accepted that preoperative hospital stay negatively influences the rate of SSI [14] [15].Indeed, during preoperative hospitalization, and digestive microbial skin flora is modified at the 3rd and 4th day of hospitalization; Our mean operating time uninfected patients 56.8 mn 04 s is not statistically different from that of patients infected 60 mn 10 s (P = 0.70).It is generally accepted that the rate of SSI is influenced by the duration of the intervention [16] [17] difference in our series could.The lack of difference in our series could be related to the fact that in 98.6% of cases, our response time was less than 2 hours.
Our results are in the intervals of the CDC [6] when antibiotic prophylaxis is practiced, i.e. <1% for class I and at 7% for class II Alteimeier.No SSI was registered in class I; this result was found by other authors [18] [19] that were antibiotic prophylaxis.Statistically, our rate is lower than those of the authors who did not antibiotic prophylaxis [20] (with P = 10 -6).For class II Alteimeier our results are statistically higher than those of the French and American series (P = 0.036 and 0.034).Strict compliance with asepsis and antisepsis, equipment and behavioral point of view may be the cause of this difference.
As against our rate is statistically lower than for series in which antibiotic prophylaxis was not performed [20] (P = 0.04).We are seeing an increase in SSI rates in connection with the score NNISS in our series.Like other authors [8] [18] [20] we have not recorded score of 3.For patient scores 0 and 1 we found no statistically significant difference with the literature [8] [18] [21] [22] (with P varying between 0.05 and 0.81).Against by the score 2 for our SSI rate is statistically higher than in literature [18] [20]- [22] (with P varying between 10 -6 and 10 -3).Score NNISS being multifactorial comparison seems difficult but it is a better indicator of risk of infection compared to the one taken Alteimeier classification.We noted a higher SSI levels in diabetics (40%) against 1.7%.The difference was significant (P = 0.008).
In all series hyperglycemia has been recognized as a risk factor for SSI [11] [23].Diabetes increases the rate of SSI because of the complications it causes.The vaso-occlusive disorders, immunological failure and malfunction of neutrophils [24] [25].SSI rates in patients underwent emergency surgery was statistically different from that of patients operated cold (P = 0.03).This could be related to the context of the emergency or the patient is not adequately prepared [26].Other authors consider that against by the urgency has no influence on the SSI [27] [28].In the literature [26] urgency is recognized as a risk factor SSI where it is difficult to put the patient in optimal physiological conditions before surgery.
In many studies [29]- [31], Escherichia coli was the most frequently isolated (42.9% in our series).For other Staphylococcus aureus is the most germ found on the operative site [32].Both in Europe [33], the USA [34] and Africa [35], Escherichia coli, Staphylococcus aureus, Proteus mirabilis, Pseudomonas aeruginosa, Klebsiella pneumoniae were the germs problem in our hospitals.
The duration of postoperative hospitalization of our infected patients has been increased significantly (P = 0.002.).This extension was 15 days or 2 times more than non-infected.Some authors have found as our series, an extended hospital stay of infected patients 2 to 2.5 times higher than uninfected [20] [21].Bush according to [26], SSI increases postoperative hospital for 5 to 10 days.

Conclusion
Antibiotic prophylaxis should be integral with the strict respect of hygiene and aseptic technique in the operating room at the sterilization and in the halls of hospitalizations for an effective fight against post-operative infections.