Medical Journal أُغِٚ اُطجٚ٤ اُغٞداٚ٤ٗ Sudan Med J 2017 August;53(2):76-83 Original Article

Antibiotics use in Inguinal hernia repair: a cross-sectional survey of participants at the 2014 West Africa College of Surgeon’s Conference in

Amarachukwu C Etonyeaku, FWACS *, Elugbraonu A Agbakwuru, FMCS FWACS*, Olalekan Olasehinde, FWACS FMCS*, Ademola O Talabi, FMCS FWAC*, Oladapo A Kolawole, FWACS**, Akinbolaji A Akinkuolie, FWACS*, Julius G Olaogun FWACS***

Department of Surgery, Obafemi Awolowo University, Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Osun State *, Department of Surgery, Ladoke Akintola University of Technology Teaching Hospital Osogbo, Osun State Nigeria**, Ekiti State University Ado-Ekiti, Ekiti State Nigeria

اطرخذاِاٌّضاداذاٌسُىَحفُئصالزاٌفرماإلرتٍ :ِظسشاٍٍِعذجلطاعاذٍٍّشاروُٕفُّؤذّزوٍُحغزتأفزَمُاٌٍدزازٍُٕعاَ 2014 فُغأا.

آشارشٌٞ ا٣ز٤ٗٞبًٞ, ا٣ِـجشاٞٗٝ اؿجوٞسٝ, اٝال٤ٌُٖ اٝالع٤ٜ٘ذ١, ادٞٔ٣ال رالث٢, ا٤ً٘جٞالع٢ ا٢ٌُٞ٘٤ً, هغٔبُغشاؽخ،عبؼٓخأٝثبك٤ٔ٤ؤُٝٞٝ،عبؼٓخأٝثبك٤ٔ٤ؤُٝٞٝٓغؼٔبُٔغزشل٤بربُز٤ٔ٤ِؼخ،ا٣َ-ا٣ق،ٝال٣خأٝع٤٘ٗٞغ٤ش٣ب. اٝالدٝثًٞ ٞال٢ُٝٝ, هغٔبُغشاؽخ،عبؼٓخالدًٝؤ٤ً٘زٞالُِزٌُٞٞ٘ع٤بٓغزشلىبُز٤ِؼٔؤٝعؿٞجٝ،ٞال٣خأٝع٤٘ٗٞغ٤ش٣ب.

أتظرزاوراٌخٍفُح:ٛ٘بًآساءٓزجب٣٘خٞؽالعزخذآبُٔعبدارب٣ٞ٤ؾُخك٤غشاؽخاُلزوبإلسث٤ـ٤شؼٓوذح )اٛظ(. ك٤ؾ٤٘شأىجؼعبُغشا٤ؽ٘ؤٗبُٔعبدارب٣ٞ٤ؾُخ٤ُغزعشٝس٣خ،ٝدػبآخشٝٗالعزخذآٜبك٤بصالؽبرشجٌخكوػ . هٔ٘بثزو٤٤ٔٔٔبسعخاعزخذآبُٔعبدارب٣ٞ٤ؾُخك٤بٛغج٤٘بُٔشبس٤ً٘ل٤ٔئرٔشاُغشا٤ؽ٘ل٤ـشثؤكش٣و٤ب . اٌّىادواٌطزق:رٔزوذ٣ٔبعزج٤بٗزذاسرار٤باُىبُٔشبس٤ً٘بُز٣٘شبسًٞاك٤ٔئرٔش٤ًِخؿشثؤكش٣و٤بُِغشاؼِ٘٤ؽبّ 2014 كٌٞ٤ٓبع٢،ؿبٗب. كوطؤُٝئٌبُز٣٘ؤعشٝااٛغزٔبُ٘ظشكٜ٤ب. إٌرائح:أًَٔ 67 اعزج٤بٗباالعزج٤بٕ. ًبٗٔزٞعػ ٓذحأُٔبسعخاُغشا٤ؽخ 16.61 )± 9.96( ع٘خ. ًٝبٗبُٔغ٤ج٤٘٘ٔٗٞغ٤ش٣ب )ؿٝ )51بٗب )ٝ )10ثٖ٘ )2( ٝٝاؽذٌِٓ٘ٔ٘ـبٓج٤بٝع٤شا٤ُٞٗٞ٤ُجش٣بًٞٝرذ٣لٞاس. أٓباألؿِج٤خاُز٤زٔبسعل٤ٔغزشل٤بربُز٤ِؼٔبؼُب٢ُ )54( 80.6 ك٤بُٔبئخٝرئد١>5 اٛغشٜش٣ب 58.2 ك٤بُٔبئخ. اعزخذٓغؼ٤ٔبُٔغ٤ج٤٘ؤًضشٓ٘طش٣وخُإلصالػ. ثبع٢٘٤ )ٕ = ٝ )34اُ٘بِٞ٣ٗبُشٕ )ٕ = 32( رو٤٘بربصالؽٌبٗزؤًضششؼج٤خ. ؼٓظٔبُٔغ٤ج٤ٖ )48( ٪71.6 رذاسأُعبدارب٣ٞ٤ؾُخك٤بٛغـ٤شؼٓوذح. ًٝبٜٗزاأعبعبداخال٤ِٔؼُخ )ٝ ٪75 )36روزصش٠ِػ 24 عبػخٓ٘بُغشاؽخ )20( 41.7٪. ًبٗبالخزشاهبُٔشزجٜجٜل٤زؼو٤ْ )20( ٝ ٪41.7أُطِٞثؼِ٘ٔبؼُذٝىبُٞٔهؼبُغشا٢ؽ )18( 37.5٪ ًبٗزبألعجبثبُشئ٤غ٤خالعزخذآبُٔعبدارب٣ٞ٤ؾُخ. اخز٤بساُغشاٞؽٓذحاعزخذآبُٔعبدارب٣ٞ٤ؾُخًبٗزٔغزوِخػ٘ٔذحأُٔبسعخ،ٝاُٞٔهؼؤٝغجؼ٤خأُٔبسعخ،ٝر٤شحاٛغؤٝغش٣وخاصالؽبؼُٔزٔذح . ؼٓٝزُي،كبٗٔذحاعزخذآبُٔعبدارب٣ٞ٤ؾُخرؼزٔذػِىٞٔهؼبُٔٔبسعخ. االطرٕراج: اعزخذآبُٔعبدارب٣ٞ٤ؾُخك٤بٛغـ٤شؼٓوذحٞٛشبئؼغذاثـعبُ٘ظشػ٘زو٤٘خاصالػ،اُخجشحك٤بٝ،َٔؼُاُٞٔهٞؼغجؼ٤خأُٔبسعخ . اُٞهب٣خٓ٘بؼُذٝىبُٞٔهؼبُغشاٜٞ٤ؽاُغججبُشئ٤غ٤العزخذاٚٓ.

Abstract Background: There are divergent Materials & Methods: A self-administered opinions on the use of antibiotics in questionnaire was given to respondents who uncomplicated inguinal hernia surgery (IHS). were participants at the 2014 West African While some surgeons opined that antibiotics College of Surgeons‘ conference in Kumasi, are not necessary, others advocated its use in Ghana. Only those who performed IHS were meshbased repairs only. We evaluated the considered. practice of antibiotic use in IHS among Results: Sixty-seven respondents completed participants at a surgeons‘ conference in West the questionnaire. The mean duration of Africa. surgical practice was 16.61 (±9.96) years. ______Respondents were from Nigeria (51), Ghana Corresponding author (10), Benin (2) and one each from the Amarachukwu Chiduziem Etonyeaku Gambia, Sierra-Leone, Liberia, and Cote Tel: +234 8036369808 D‘Ivoire. Majority practiced at tertiary Email:[email protected] hospitals (54) 80.6% and performed <5 IHS Sudan Med J 2017 August;53(2) 76

Original Article Antibiotics use in Inguinal hernia repair Amarachukwu C Etonyeaku monthly 58.2%. All respondents used more infection in situations where chances of than one method of repair. Bassini (n=34) and infection occurring are high or the effect of its Nylon darn (n=32) repair techniques were occurrence is grave. In surgery, patients with more popular. Most respondents (48) 71.6% contaminated and dirty wounds are placed on administered antibiotics in uncomplicated therapeutic course of antibiotics. Those with IHS. This was mainly intra-operative (36) clean contaminated wound are offered 75% and limited to within 24hours of surgery prophylactic antibiotics; while clean (20) 41.7%. Suspected breach in asepsis (20) procedures generally do not require antibiotics 41.7% and desire to prevent surgical site administration. However, some otherwise infection (18) 37.5% were the major reasons clean procedures of the heart, brain and for antibiotics use. The surgeon‘s choice and surgeries involving insertion of implants duration of use of antibiotics were require antibiotics as any infection arising independent of the duration of practice, from these procedures may portend dare location or nature of practice, the frequency of consequences. IHS or repair method adopted. However, the In hernia surgery, presence of gangrenous duration of use of antibiotics was dependent contents of the hernia sac, obstructed viscus or on the location of practice. gut perforation necessitates the use of Conclusion: Antibiotics use in uncomplicated therapeutic doses of antibiotics. For IHS is very common irrespective of repair uncomplicated inguinal hernia repair technique, work experience, location and antibiotics are not generally required.(6) nature of practice. Prevention of surgical site However, some surgeons argue that in infection is the major reason for its use. meshbased repair, which is akin to implant Keywords: Hernia, antibiotics surgery, prophylactic antibiotics should be Introduction given to prevent infections.(7) Similarly, The surgeon through the years had to contend certain high risk patients for hernia repair are with three major challenges in the course of given antibiotic prophylaxis. These include: his/her duties. These challenges are: best the aged, immune-suppressed, obese, diabetic anaesthesia appropriate for a procedure and patients and those with recurrent disease and patient, best fit wound healing (scar less hypoproteinaemia.(8) When antibiotics are surgery) and prevention of surgical infections used, there would be need to determine the especially surgical site infections (SSI). There drug(s) of choice and duration of use. This had been steady advances in these frontiers study sought to evaluate the practice of over the years. Groin hernia surgery antibiotics use in groin hernia surgery epitomizes these advancements. Inguinal amongst surgeons who were participants at hernia repair has moved from a general the 2014 West African College of Surgeons‘ anaesthesia procedure through regional conference in Ghana, and to ascertain any anaesthesia and lately to local anaesthesia on a determinant that may influence the decision to day case basis.(1) Also with knowledge of skin use it. lines of tension,(2,3) better cosmesis is Materials & Methods achievable with appropriately placed incisions A confidential, self-administered and finesse in tissue dissection. Defective questionnaire on the use of antibiotics during wound healing, as may occur with surgical inguinal hernia repair was given to surgeons site infection, may herald recurrence,(4) while practicing in West Africa who attended the exuberant healing may lead to abnormal 2014 WACS conference in Kumasi, Ghana. scars.(5) Only questionnaires from those who perform Antibiotics use in clinical practice could either IHS were evaluated. be therapeutic or prophylactic. Therapeutic Respondents were given a single page use of antibiotics entails its use in the questionnaire containing 3 open ended treatment of established infections. questions (Location of practice, duration Prophylactic use connotes its use to prevent surgical practice and preferred antibiotics) and Sudan Med J 2017 August;53(2) 77

Original Article Antibiotics use in Inguinal hernia repair Amarachukwu C Etonyeaku

9 closed ended questions (Nature/type of and 71 were returned for review giving a practice, highest educational qualification; response rate of 97.3%. Of the 71 returned whether or not respondent perform inguinal questionnaires, 4 of them were from hernia surgery IHS, how frequent and type of respondents who did not undertake groin repair done, whether they would give hernia repair; and thus were excluded from antibiotics, and when it would be commenced further analysis. Thus 67 respondents were and for how long, and reasons for giving). considered eligible for further review, and Information obtained was then entered into a these comprised sixty-two consultant surgeons spread sheet and was analyzed using the (92.5%), one consultant family physician statistical package for the social sciences (1.5%), and four surgical residents (6%); one (SPSS) version 20 for frequencies, from Nigeria and three from Ghana. The mean percentages and statistical relationships using duration of surgical practice was 16.61 the chi square test; p values <0.05 were taken (±9.96) years (Range = 2−40 years). Their as significant. location and nature of practice are as shown in Results Table 1. Seventy-three questionnaires were administered,

Table 1: Location and nature of practice of respondents. Nature of practice

Location of Tertiary General / Primary Healthcare/ Private Public & Total (%) practice Hospital Specialist District Hospital Hospital Private (only) Hospital (only) (only) (only) Practice) Nigeria 40 5 0 4 2 51 Ghana 9 0 1 0 0 10 Gambia 1 0 0 0 0 1 1 0 0 0 0 1 Liberia 1 0 0 0 0 1 Cote D‘ivoire 1 0 0 0 0 1 Benin 1 0 1 0 0 2 TOTAL 54 5 2 4 2 67 (100)

Thirty-nine (58.2%) respondents did an or in combination with metronidazole (n=11; average of less than five inguinal hernia 22.9%), or gentamicin (2; 4.1%). surgeries every month, while 19 (28.4%) and 9 (13.4%), others operated between five and Herniotomy (only) 4 ten, and greater than 10 patients per month 14 respectively. Most respondents still practice suture based groin hernia repair techniques: with Nylon darn (32; 47.8%) and Bassini (34; 50.7%) being the most preferred (Fig. 1), 12 while mesh-based technique (24; 35.8%) a 5 distant third. More than a quarter of the 3 respondents (35.8%) used more than one 4 repair technique for IHS. Majority of the 5 respondents (n= 48; 71.6%) would administer antibiotics in the perioperative period. Of 20 those that would give antibiotics, their preferences were for the penicillin group (n=15; 31.3%), cephalosporins (n=10; 20.8%), and ciprofloxacin (n=23; 47.9%). The latter Figure 1: Inguinal hernia repair techniques was either administered alone (n=10, 20.8%), used by respondents.

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Original Article Antibiotics use in Inguinal hernia repair Amarachukwu C Etonyeaku

Furthermore, majority of those who used population. Most respondents had substantial antibiotics did so intra-operatively before years of practice and were engaged at tertiary incision was made (36; 75%), while others centres which served as training and research would either commence the drugs pre- hubs. Thus what they practice is expected to operatively within two hours of surgery (4; cascade through generations of their trainees, 8.3%), or did so post-operatively (8; 16.7%). and may become dogma. Similarly, duration of use of antibiotics varied Simple (uncomplicated) inguinal hernias are from ≤24hours in 20 (41.7%) respondents, expected to be managed at the secondary level >24hours but ≤72hours in 15 (31.3%) of health care delivery system (District/ respondents and >72hours in 13 (27%) General ± Specialist hospital). These middle respondents. For those who commenced level centers often do not enjoy the services of antibiotics after surgery (n=12; 17.9%), the full time specialists(9-11) who tend to duration of use of the drugs was > 72hours in preferentially practice at major cities and all but one (p<0.05). Perceived breech in tertiary (reference) centers. In this study, we aseptic protocol (20, 41.7%), desire to prevent noted that 80.6% of the respondents practice surgical site infection (18; 37.5%), and a in tertiary hospitals. This could explain the combination of both (8; 16.7%) were the relatively fewer patients managed (≤60 per major reasons for use of antibiotics. Twenty- year) by majority of the respondents. It is also three of thirty-six respondents (63.9%) who assumed that the longer the duration of would give intra-operative (on-table) practice, and the more hernia repairs a surgeon antibiotics did so because of perceived breech does the more proficient he/she would be. in aseptic process while seven out of nine However, we observed that these did not (77.8%) who would do so post-operatively influence the practice of antibiotics use in aimed to prevent SSI. Remarkably, two hernia repair. respondents routinely used antibiotics for no Inguinal hernia is a common affliction in the special reasons (4.2%) and usually gave the sub-region, thus it is safe to conclude that drugs intra-operatively. most repairs are done outside tertiary centers The practice of use of antibiotics and the by non-specialist surgeons. It is trite to note duration of its use, for elective uncomplicated that medical education occurs at tertiary groin hernia were independent of the years of centres for both basic and postgraduate experience of surgeon, the location of his programmes. Hence the non-specialist practice, the nature of his practice, the surgeons would have had some training at frequency of inguinal hernia surgery or repair these tertiary centres. Thus if most trainers method deployed (p>0.05). However, the would use antibiotics in IHS, the trainee duration of use of antibiotics appeared to be likewise would be exposed to its use. This influenced by the location of practice of study evaluated practices amongst specialist respondents (p<0.05). Similarly, the timing of (trainers), further studies would address administration of the drugs depended on the practices at General/ District hospitals and the rationale for use of the drugs (p<0.05). impact of introduction of evidence based Discussion medical practices amongst doctors in these The response rate of 97.3% is very acceptable centres as we currently assume that most and could have reflected the simplicity of the inguinal hernia repairs in the sub-region are instrument that is confidential and easy to done with antibiotics administration. complete. The study population appeared Surgical wounds have been classified into skewed in favour of Nigeria and Ghana. clean, clean contaminated, contaminated and Remarkably, majority of the respondents were dirty wound based on the likelihood of SSI.(12) Nigerians despite the fact that the meeting was The place of antibiotics in uncomplicated held in Ghana. These may reflect the hernia may be questionable in the face of distribution of membership of the college and global best practices in theatre design and the country‘s (Nigeria) relatively larger asepsis protocol; especially as hernia surgery Sudan Med J 2017 August;53(2) 79

Original Article Antibiotics use in Inguinal hernia repair Amarachukwu C Etonyeaku has been classified as a clean procedure.(13) to prevent SSI(31); but recently, meta-analysis There have been divergent opinions on has shown that it is unnecessary to do so for whether antibiotics are indicated for hernia clean surgeries like herniorrhaphy except in repairs generally, or reserved for meshbased those with incisional hernia(32) or when repairs(14-16) only. Whereas therapeutic dose of implants (like mesh) are used.(15) Even in the antibiotics is recommended in contaminated latter scenario, some still advocate that and dirty wound, prophylactic doses is antibiotics are not beneficial.(33,34) Majority of recommended for clean contaminated wounds, the respondents would still administer and there is no need for antibiotics in clean antibiotics during uncomplicated hernia surgical wound.(17,18) This principle alongside surgery irrespective of the technique used others(19) guides the rational use of antibiotics. believing it would mitigate effects of In countries with high burden of infectious perceived breach in asepsis. This practice may (bacteria) diseases such judicious antibiotics have transcended generations of surgeons and use becomes imperative in order to control the may well be a dogma as exemplified by the emergence of drug resistant strains of the two respondents who have no special reason common microbes. This becomes pertinent for giving antibiotics during IHS. Since the bearing in mind that over 50% of antibiotics major reason adduced is premised on use in hospitals has been shown to be in- prevention of SSI, the need then arises for appropriate and generally ineffective(20). standardization of sterilization processes and Inappropriately use of antibiotics in clean theatre techniques. There is therefore need to surgeries does not confer any additional evaluate the role of antibiotics in IHS for benefit in terms of prevention of SSI.(21) uncomplicated groin hernia in our sub-region; Rather, the patient is made to incur additional if global best practices in asepsis and cost(22) and increased risk of experiencing antisepsis is applied. As noted in earlier adverse reactions peculiar to the drug. This reports suture based repair techniques (Bassini practice in addition to increased financial cost and Nylon darn) still rank high amongst of care, may contribute to emergence of surgeons in the sub-region,(1, 36-37) this may be microbial resistance to such overused drug.(23) as a result of the relatively high cost of mesh Abuse of antibiotics includes its used when and poor infrastructure.(36) Notably, over a not indicated, or using lesser dosage than quarter of respondents (35.9%) performed required or use of the drug for less than the meshbased repair alongside other sutured- minimum duration required to treat an based methods (Fig. 1). infection. When these drugs are repeatedly This study further highlights divergent abused, the microbe could undergo some practices on timing of antibiotics genetic mutations which make them resistant administration. Recommended standards in to these agents. Asides antibiotics use, various antibiotics prophylaxis is to administer the protocols have been advanced to prevent or drug, which is usually a single dose, except in control SSI. These include theatre attire and colonic surgery, 30 minutes to one hour design, asepsis techniques, sterilization before skin incision for penicillins and processes, scrubbing, incision site preparation cephalosporins, and one to two hours for (including shaving, pre-operative bath and quinolones.(38-40) The goal here is to achieve antiseptic cleansing), and draping.(24-26) bactericidal levels of the antibiotics at the site Randomized clinical trials had led to the of surgery by the time the skin incision is establishment of consensus and guidelines made. Based on timing of antibiotics use it which reduces the rate of SSI in patients. would be safe to infer that majority of those These guidelines are reviewed from time to who use antibiotics do so with the intention of time based on available data from evidence prophylactic use of the drug. But, based medical practices and researches.(27-30) administering the drug intra-operatively (on- Previously, it was common a practice to table) may not give enough room for the administer antibiotics for all surgeries in a bid 30mins−2hours required to achieve Sudan Med J 2017 August;53(2) 80

Original Article Antibiotics use in Inguinal hernia repair Amarachukwu C Etonyeaku bactericidal levels before incision is made; the principal reason for the routine use of especially in those who use local anaesthesia. antibiotics in IHS. There is a need to further Furthermore, the duration of antibiotics use evaluate if these concerns are real when global also varied. While some would administer best practices are operational. This is antibiotics for ≤24hours in what appear to be a imperative to ensure rational and judicious use prophylactic dosage, others would administer of antibiotics especially in a region where the drug(s) for >72hours suggesting a infectious diseases burden is high, with therapeutic dosage protocol. However, in a greater risk of emergence of drug resistant quarter of respondents, the 25-72hours dosage microbes. protocol does not quite fit into either the Authors’ contributions: prophylaxis or therapeutic schedule. But EAC, OO, and AEA conceived the study and remarkably, those who commence the drugs were involved in the design and data after surgery were also those who gave them collection. TA, AA and KOA were involved for longer period. Perhaps, this may be due to in the design, data collation and analysis. heightened fear of SSI following intra- EAC, AEA, KOA and OO made the final operative events. draft of the manuscript. All authors read and In conclusion, in the West African sub-region, approved the final manuscript. the routine use of antibiotics during repair of Funding: No funding or grant received. The uncomplicated inguinal hernia is common research was carried out with personal funds amongst some specialist surgeons irrespective of the authors. of the country, location and duration of Conflict of Interest: None practice, or technique of repair adopted. Concerns regarding possibility of SSI were Ethical clearance: obtained

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Original Article Antibiotics use in Inguinal hernia repair Amarachukwu C Etonyeaku

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