Assessing Adherence to Prophylactic Antibiotic Guidelines in Cesarean Sections in Rwanda

Abstract Background: Surgical site infections (SSIs) remain a leading cause of maternal morbidity and mortality following cesarean sections, particularly in low- and middle-income countries. Although the World Health Organization (WHO) provides clear guidelines for prophylactic antibiotic use during cesarean delivery, adherence remains inconsistent across facilities, contributing not only to preventable infections but also to rising antimicrobial resistance (AMR). The WHO guideline recommends four key criteria for appropriate antibiotic prophylaxis: correct antibiotic type, correct dosage, timely administration (30–60 minutes before incision), and avoidance of unnecessary postoperative use. This study sought to assess adherence to these criteria as well as identify gaps in implementation at two Rwandan hospitals. Methods: A prospective observational study was conducted at Kirehe District Hospital and Ruhengeri Level 2 Teaching Hospital between June and July 2025. Data was collected using a checklist adapted from WHO guidelines, capturing antibiotic type, dosage, timing, and postoperative use. Descriptive statistics and chi-square tests were used for analysis, with statistical significance set at p ≤ 0.05. Results: A total of 295 cesarean sections were observed and analyzed. Nearly all mothers (99%) received prophylactic antibiotics although full adherence to WHO guidelines was achieved in only 17.6% of cases. Adherence to individual checklist components varied as follows; correct antibiotic type and dosage (56.6%), correct timing (61%), and rational postoperative use (51.2%), meaning antibiotics were given only when clinically justified and avoided when unnecessary. Ampicillin was the most frequently used antibiotic (57.1%), followed by ceftriaxone (40.4%). Nearly half (48.5%) of women received additional antibiotics postoperatively, most often without clinical justification. Conclusion: Although prophylactic antibiotic administration was nearly universal, adherence to WHO guidelines remained low, with inappropriate antibiotic selection and unnecessary postoperative use as major deviations. These practices maintain unnecessary and increase the risk of antimicrobial resistance. They also undermine infection prevention efforts, while imposing unnecessary costs. Strengthening antibiotic stewardship through continuous professional training, improved documentation, reliable access to first-line antibiotics, and regular audits is critical to ensure rational antibiotic use in cesarean sections in Rwanda.