Evaluating the implementation and effectiveness of antimicrobial stewardship interventions for surgical antimicrobial prophylaxis at a quaternary hospital in a lower-middle-income country: a secondary data analysis

Abstract Objective: To evaluate the implementation and effectiveness of handshake antimicrobial stewardship interventions for surgical antibiotic prophylaxis at a quaternary hospital in Ghana. Design: Retrospective cross-sectional secondary data analysis. Setting: Quaternary referral hospital in Accra, Ghana. Participants: Adult surgical encounters (n = 227) with complete antimicrobial stewardship documentation between June and September 2024. Methods: We analyzed antimicrobial stewardship audit records to assess recommendation acceptance, implementation, antibiotic selection concordance, and duration patterns. Outcomes were stratified by surgical service and procedure urgency. Descriptive statistics were used. Results: Of 227 encounters, 109 (48.0%) required stewardship recommendations, of which 78 (71.6%) were verbally accepted. However, only 39 (50.0% of accepted recommendations) were implemented. Implementation failures were primarily due to patient discharge (19.3%) and prescriber unavailability (16.5%). Duration optimization accounted for 76.1% of interventions. Overall, 43.2% of encounters exceeded the recommended prophylaxis duration (>24 hours). Emergency procedures had lower acceptance and higher missed opportunity rates compared to elective cases. Conclusions: Handshake stewardship demonstrated moderate acceptance but limited implementation. Execution failures were primarily associated with specific operational bottlenecks, including patient discharge and prescriber unavailability, which were exacerbated in emergency and high-volume surgical services. These findings suggest that in resource-limited settings, stewardship models must incorporate asynchronous communication and automated system safeguards (e.g., stop orders) to overcome workflow barriers.