Looming Antimicrobial Resistance Crisis: The Paradox of Non-Adherence to Cesarean Antibiotic Prophylaxis Guidelines in Ethiopia – A Commentary

Abstract The administration of prophylactic antibiotics is a cornerstone of infection prevention for Cesarean sections (CS), with global and Ethiopian national guidelines recommending a single, pre-operative dose of narrow-spectrum ‘Access’ antibiotics like cefazolin. However, a significant "implementation gap" exists in Ethiopia, characterized by a systemic "Ceftriaxone shift". Despite national policy alignment with WHO standards, hospitals frequently replace recommended narrow-spectrum agents with broad-spectrum ‘Watch’ antibiotics, primarily ceftriaxone. Furthermore, the ‘single-dose’ standard is often abandoned in favor of extended postoperative regimens lasting 24–48 hours, reflecting near-total noncompliance. This shift is driven by multifaceted factors: surgical teams’ fear of contamination, supply chain fragility causing inconsistent cefazolin availability, and hierarchical ‘prescribing etiquette’ where junior clinicians follow legacy practices. Paradoxically, despite this chemical overuse, surgical site infection rates remain high at 9% to 16%. This reliance on broad-spectrum agents worsens regional antimicrobial resistance (AMR), with multidrug-resistant (MDR) prevalence among Gram-negative bacilli reaching 82.7%. The risk extends to neonates, who are increasingly exposed to MDR pathogens through vertical transmission and hospital reservoirs. To address this crisis, Ethiopia must shift from individual prescribing habits to systemic antimicrobial stewardship. This requires the Federal Ministry of Health to ensure consistent procurement of ‘Access’ agents, a pivot toward holistic surgical bundles rather than chemical overuse, and the implementation of local context-tailored trials to build clinician confidence in evidence-based practices.