This mixed-methods study assessed adherence to surgical antibiotic prophylaxis guidelines in one of the largest tertiary university hospitals of obstetrics and gynecology in Egypt. We sought to identify gaps in practice and potential areas for improvement. The findings revealed that while the recommended antibiotic selection was usually implemented, substantial deviations from standard guidelines were observed in the timing and duration of antibiotic administration. Adherence to all three SAP parameters was never attained in any of the included procedures. Key barriers to adherence included knowledge gaps, workflow inefficiencies, inadequate monitoring, limited antibiotic availability, financial constraints, and weak enforcement of SAP guidelines.

Our comprehensive literature search clearly showed the paucity of data from Egypt. Our data showed that the most common deviation from evidence-based recommendations was the prolonged antibiotic use beyond 24 hours. In almost all procedures, we observed a switch to oral antibiotics for up to seven days after discharge from hospital. The current status is probably worse than previously reported one decade ago. [20,21] This overuse of antibiotics in developing countries has been recently documented in a rigorous scoping review. [22] Extending antibiotic use beyond 24 hours does not reduce the risk of postoperative infectious morbidity but increases the likelihood of antimicrobial resistance and adverse events [5]. The fear of infections, fear of litigation, misconceptions regarding antibiotic prophylaxis, the culture of blame, and the practice of defensive medicine contributed to this disturbing practice.

Timely administration of prophylactic antibiotics within the recommended 60-minute window before surgical incision is crucial for optimal efficacy. [5,7] In our survey, only 38.2% of patients received antibiotics at the appropriate time. The limited literature from developing countries on adherence to this 60-minute window suggests the same poor practice. [20,21] Administration timing (0–60 minutes before incision) is the most problematic indicator even in developed countries. [23] We observed lapses in timing as a result of workflow inefficiencies, anesthesia- related delays, and inadequate awareness among healthcare providers.

Studies have shown variability in compliance with SAP protocols, influenced by factors such as institutional policies, healthcare provider knowledge, and resource availability. [24] An audit of antibiotic prophylaxis in the Eastern Mediterranean Region revealed that many hospitals lack standardized SAP protocols or fail to enforce existing ones. The same audit indicated that surgeons and other healthcare providers may not always be fully aware of or adhere to updated SAP guidelines, leading to inconsistent practices. [25]

A recent qualitative study from a high-income country demonstrated that a lack of structured workflow was the main factor contributing to non-adherence to antibiotic guidelines in the peri-operative settings. [26] We believe that in LMICs, the main factors have a different profile. Our study indicates that weak enforcement of the guidelines, occasional unavailability of recommended antibiotics, lack of audits or regular feedback, and a lack of fidelity for implementing the guidelines were the main barriers to adherence to SAP guidelines. Some clinicians resist adopting guidelines, especially if previous practices were perceived as effective. Providers expressed their belief that guidelines do not fit the nature of a public hospital serving poor patients with inadequate self-hygiene and poor living conditions at home. Providers extended antibiotic duration beyond guidelines as a precautionary measure, despite their knowledge of the evidence against it. Fear of infections and litigation and consequently the practice of defensive medicine probably contributed to the overuse of antibiotics as a safety measure.

While the overall compliance with guidelines is around 64% in developed countries [23], the picture is different in developing countries, as shown by our data. We understand the numerous challenges for implementing effective and sustainable antibiotic stewardship programs in developing countries. [27] The implementation of effective and sustainable antibiotic stewardship programs in developing countries is not impossible. A recent systematic review assessed the potential for a successful implementation of such programs in African countries, including Egypt. The successes reported in some countries may give us some hope that other developing countries can implement these programs. [28]