A Cross-country Audit Of Antimicrobial Prescribing In Emergency General Surgery: A Mixed-methods Analysis From The UK And Nepal

A Cross-country Audit Of Antimicrobial Prescribing In Emergency General Surgery: A Mixed-methods Analysis From The UK And Nepal

Jin Wei Choy , Bishow Karki, Prarthana Subedi, Ibiza Tiwarii, Sherwyn Ong, Li Hao Tee, Charlotte Foley

Background: Antimicrobial resistance (AMR) disproportionately affects lower-middle-income countries (LMICs) with limited stewardship infrastructure, microbiological and therapeutic options. Surgical antimicrobial stewardship (AMS) is a critical, achievable target for improving outcomes. A decade after the Lancet Commission on Global Surgery, cross-border collaboration remains vital to empower local action and elevate surgical care worldwide.

Aim: To compare therapeutic antimicrobial prescribing in emergency general surgery between a UK hospital and Nepalese tertiary centre, while assessing the impact of low-cost, cross-country educational interventions to explore transferrable quality improvement strategies.

Methods: A mixed retrospective-prospective audit was conducted at a UK district general hospital (pre-intervention n=102; post-intervention n=45) and Nepalese tertiary hospital (n=23). Indicators included documentation of indication, duration, 48-hour review, and compliance with local, national and World Health Organisation (WHO) guidelines. Interviews with Nepalese clinicians identified contextual AMS barriers. A joint intervention —cross-site peer-led teaching and visual prescribing aid—was implemented bilaterally.

Results: Guideline compliance in the UK increased by 9% (41.2% to 51.1%), with improved documentation of duration (85.3% to 100%), indication (93.1% to 100%), and 48-hour review (48.0% to 88.9%). In Nepal, absence of formal protocols limited compliance assessment; 48-hour reviews occurred in 21.7% of cases and indication undocumented in 39.1%, though duration was always recorded. Nepalese clinicians reported strong engagement with context-adapted educational tools.

Conclusion: This audit highlights disparities and shared challenges in antimicrobial prescribing. Synergistic peer-led, context adapted AMS education empowered stewardship improvements, demonstrating potential for adaptation in LMICs, combating AMR and advancing global surgical safety.

Keywords: global, surgery, antimicrobial, antibiotic, stewardship, collaboration, audit, cross-country, general surgery, emergency, prescribing