A scoping review of antimicrobial resistance and stewardship in surgical care in sub-Saharan Africa in the post-pandemic period

Abstract

Abstract Background Antimicrobial resistance (AMR) causes the highest regional mortality burden worldwide in sub-Saharan Africa (SSA). Surgical and perioperative care is a setting in which resistant pathogens, surgical site infections (SSIs), and intensive antibiotic consumption converge, a convergence that was sharpened by the COVID-19 pandemic, which increased empirical antibiotic prescribing and disrupted infection prevention, diagnostic, and surgical services, making rational perioperative antibiotic use a renewed priority in the post-pandemic period. Aim This review mapped the published evidence on AMR and antimicrobial stewardship (AMS) in surgical and perioperative care across SSA and identified knowledge and practice gaps in the literature. Methods A scoping review was conducted using the Arksey and O’Malley framework and reported in accordance with the PRISMA-ScR. PubMed/MEDLINE, Embase, and African Journals Online were searched, supplemented by citation tracking, for studies up to 30 June 2025 addressing surgical AMR, SSI microbiology, surgical antibiotic prophylaxis (SAP), or AMS in SSA. Eligible sources were charted and synthesised narratively. Results Evidence was unevenly distributed across countries but showed consistent microbiological and prescribing patterns where they were reported. SSIs are among the most common postoperative complications worldwide. The isolates are predominantly gram-negative, with high rates of multidrug resistance, frequent production of extended-spectrum β-lactamases, and methicillin-resistant Staphylococcus aureus (MRSA) reported in over 40% of S. aureus isolates in several settings. SAP was near-universal but poorly aligned with guidelines, with inappropriate agent choice, mistimed first doses, and prolonged postoperative courses that conferred no additional protection against SSI. AMS interventions, including pharmacist-led audits and feedback and local guideline adaptation, were associated with improved prescribing without a rise in SSI, although implementation was constrained by weak laboratory capacity, limited funding, staffing shortages, and fragile governance. Conclusion AMR is entrenched across surgical care in SSA, and SAP diverges widely from evidence-based recommendations. Because extended postoperative prophylaxis conferred no additional benefit, pragmatic, context-adapted AMS anchored in local antibiograms is both feasible and an achievable stewardship priority for the post-pandemic period.