Ceftriaxone-by-default in surgical prophylaxis across the East African community: a measurement problem

Surgical antibiotic prophylaxis across the East African Community is dominated by ceftriaxone, a WHO Access, Watch, and Reserve (AWaRe) Watch-group third-generation cephalosporin not recommended for routine prophylaxis. The practice recurs across regional point prevalence surveys, yet consumption surveillance cannot distinguish prophylactic from therapeutic use. Drawing on antimicrobial-use surveys, surgical-prophylaxis studies, resistance surveillance, and medicine-availability reports, we argue that four interacting failure modes sustain it: substitution of first-line agents, prolongation of postoperative prophylaxis, unnecessary combination, and empirical spillover from ward prescribing. Resistance among surgical-site isolates is already high enough to threaten the value of prophylaxis itself. Prophylaxis is measured for duration, documented indication, and guideline concordance, and agent choice is captured in point-prevalence surveys, but none of this reaches the national consumption totals that govern procurement, and no indicator records the supply constraint determining the agent or the resistance it selects. We propose four measures, one requiring routing rather than building and three genuinely absent, that would convert an ungoverned practice into a governable one.