Cephalosporin Prescribing Falls Short of Guidelines in Tertiary Care

Cephalosporins remain among the most prescribed antibiotic classes in hospital settings globally, valued for broad-spectrum cover and a familiar safety profile. That familiarity, however, appears to encourage prescribing habits that outpace the evidence. A prospective study at a tertiary care hospital in South India evaluated cephalosporin prescribing against established guidelines, examining clinical appropriateness, local susceptibility and resistance profiles, potential drug-drug interactions, and the frequency of de-escalation once culture results were available.¹ Concurrently, researchers in South Africa conducted three global point prevalence surveys at a tertiary referral centre to characterise broader antimicrobial prescribing patterns, capturing guideline adherence and documentation practice across multiple audit cycles.²

Antibiotic resistance continues to complicate empirical prescribing decisions, particularly where resistance profiling is delayed or absent from the prescribing workflow.³ Both study settings reflect real-world conditions in which prescribers must balance urgency against the risk of accelerating resistance through inappropriate agent selection or prolonged broad-spectrum use.

What the studies found

The South India prospective evaluation assessed cephalosporin prescribing across adult inpatients, measuring adherence to guideline recommendations at each stage of the prescribing cycle, from initial agent selection through to de-escalation decisions.¹ The study captured susceptibility and resistance profiles alongside prescribing choices, allowing direct comparison between the empirical agent selected and the organism's actual sensitivity pattern.¹ Potential drug-drug interactions involving cephalosporins were also catalogued as part of the evaluation.¹

The South African point prevalence surveys offered a complementary picture of systemic prescribing behaviour. Conducted across three separate survey rounds at a single tertiary referral hospital, the methodology captured a cross-sectional snapshot of every antimicrobial prescription in use on the survey day, including the documented indication, compliance with local or international guidelines, and the presence or absence of a stop or review date.² Repeating the survey three times strengthened the reliability of the observed patterns beyond what a single prevalence audit could achieve.²

Both investigations identified cephalosporin and broader antimicrobial prescribing as falling short of guideline standards in a clinically consequential proportion of cases, with de-escalation practices identified as a particular area of weakness.^1,2 Resistance profiling data from the South India study confirmed discordance between empirical choices and susceptibility results in a subset of prescriptions, underscoring the cost of initiating broad cover without a defined review plan.¹ The South African surveys found documentation gaps, including missing indications and absent stop dates, across all three survey rounds, suggesting these are structural problems in the prescribing environment rather than isolated errors.²

Both studies acknowledge limitations inherent to their designs. Point prevalence surveys capture a single moment and cannot track clinical outcomes or the downstream consequences of prescribing decisions.² The prospective South India study, conducted at one tertiary centre, reflects a specific institutional context that may not generalise to primary care or lower-resource settings.¹ Neither publication reported patient-level outcome data such as mortality, length of stay, or rates of Clostridioides difficile infection attributable to prescribing patterns, which limits the ability to translate prescribing gaps directly into quantified patient harm.