Compliance with PAP is an important factor in reducing the incidence of SSI and avoiding the costs associated with it . As in other non-infected surgical acts, antibiotic prophylaxis is recommended for all caesarean deliveries unless the patient is already receiving an antibiotic regimen for another existing infectious entity [10,12,14–18]. However, in our study only 569 patients (69.90%) received PAP.
PAP was administered to a higher percentage of patients in scheduled caesarean sections (83.14%) than in emergency caesarean sections (63.83%) (OR = 2.79, P = 0.000). No data have been found in the literature to corroborate this observation.
Furthermore, all women, including those who did not receive PAP, received post-surgical antibiotic treatment, which is in disagreement with guidelines recommendations. This is the most relevant result of the study and is consistent with that obtained by Saied et al in Egypt . Other studies have also shown the inappropriate duration of PAP and the use of different therapeutic schemes that are poorly described and unnecessary [7,20]. In patients with blood loss greater than 1.5 L or who had prolonged surgery (more than 4 h) the duration of prophylaxis, as in the rest of the patients, was approximately 7 days, in contrast to what was stated in the literature [12,16,17].
Several studies have shown that there is no significant difference in the incidence of postpartum infectious morbidity between the use of single and multiple doses of PAP [18,21–24]. The excessive use of antibiotics, therefore, does not reduce the incidence of SSIs, but could favour the emergence of microbial resistances, increase the risk of adverse reactions and generate unnecessary costs to the institution. The above findings highlight the need for strategies to raise the level of practitioner adherence to the recommendations for use of the PAP.
On the contrary, other variables studied showed agreement with the recommendations of the reference guidelines: the timing of administration, the selection of antibiotic and the dose administered (Table 3).
New research continues to recommend that PAP be administered within 60 minutes before the incision and, in the case of emergency surgery, as soon as possible after the incision, [8,10,12,18,19]. In the present study, the timing of PAP administration in all patients was considered appropriate, in contrast to the 80% non-compliance reported by Abubakar et alt. .
Antibiotic selection was consistent with ASHP in 98.07% of patients receiving PAP and the correct drug dose was administered to 94.27%; these results were similar to those obtained by Abdel Jalil et alt. . CPG-Ecuador does not recommend specific antibiotics, which could favour the use of a wide range of therapeutic schemes, as observed in this study.
There is widespread agreement on the use of first generation cephalosporins (cefazolin), or a combination of aminoglycosides and clindamycin for patients with a history of severe reaction to cephalosporins, to avoid SSI in most surgical procedures [12,25,26]. However, there are other proposals in terms of antibiotic selection and dosage for PAP in caesarean sections [18,27,28]. The difference could be justified by the characteristics of the circulating germs, the prescribing habits in each institution or the non-existence, inadequate design or non-compliance of clinical guidelines intended for this purpose.
The incidence of SSI in this study (1.35%) is lower than in other similar studies, where it reaches up to 40% [29–33]. In patients who were not given PAP, the incidence of SSIs was higher than in those who received pre-surgical antibiotics (1.63% vs 1.23%). At the sample level it is observed that the ratio between presence and absence of SSIs is 1.33 times higher in subjects without PAP as compared to subjects with PAP (OR = 1.33; P = 0.649). This difference increases (1.14 vs 1.74) if we compare patients who received the correct antibiotic at the appropriate dose (6 cases in 526) with those who did not receive PAP or who did not receive an appropriate choice of antibiotic and/or dose administered (5 cases in 288) (OR = 1.53, P = 0.485). These results may indicate a tendency to decrease the development of SSI when there is greater compliance with the guidelines' recommendations. It should be taken into account, however, that in all patients a post-surgical antibiotic was used for several days, which makes it difficult to statistically demonstrate the benefits of PAP on this variable.
It has also been observed that the incidence of SSIs increases with the age of the patients (16–19: 0%; 20–34: 0.7%; 35 or older: 3.3%). Thus, a significant relationship was found between these variables (Chisq = 8.08, P = 0.036), which is in line with similar data reported in other studies [33–35]. In contrast, no association was found between patient age and PAP administration (Chisq = 1.59, P = 0.44).
90.45% of the expenditure on antibiotics was associated with their inappropriate use, mainly due to their administration after surgery. The ideal PAP cost per patient was 0.59 USD; however, the actual average expenditure per patient was 3.37 USD, i.e. almost six times more (5.7) than needed (Table 4). Although the figures may seem small, the institution has limited capacity for acquiring resources that are indispensable in the health care of other patients.
Unfortunately, little research addresses the issue of costs of noncompliance with the PAP in caesarean sections. Instead, studies generally address the average cost of a patient receiving PAP and how cost-effective it is compared to a patient who does not receive it [34–36]. Jansson et al. found 99% savings from compliance with the PAP,  which is even higher than what was found in the present research.
The participation of the pharmacist within the health care team translates into a decrease in unnecessary costs, an increase in the quality of care and an improvement in the patient's quality of life. These results have led to the acceptance of this professional by other members of the health team [38–43]. To date, there is no clinical pharmacist at the target institution involved in the design, implementation and review of therapeutic protocols, including PAP.
The fact that the study conducted was retrospective is one of its limitations, as it made it difficult to analyse variables that would allow the risks associated with inappropriate duration of antibiotic use to be assessed.