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Improvisation versus guideline concordance in surgical antibiotic prophylaxis: a qualitative study

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Abstract

Purpose

Surgical antibiotic prophylaxis (SAP) is a common area of antimicrobial misuse. The aim of this study was to explore the social dynamics that influence the use of SAP.

Methods

20 surgeons and anaesthetists from a tertiary referral hospital in Australia participated in semi-structured interviews focusing on experiences and perspectives on SAP prescribing. Interview data were analysed using the framework approach.

Results

Systematic analysis of the participants’ account of the social factors influencing SAP revealed four themes. First, antibiotic prophylaxis is treated as a low priority with the competing demands of the operating theatre environment. Second, whilst guidelines have increased in prominence in recent years, there exists a lack of confidence in their ability to protect the surgeon from responsibility for infectious complications (thus driving SAP over-prescribing). Third, non-concordance prolonged duration of SAP is perceived to be driven by benevolence for the individual patient. Finally, improvisation with novel SAP strategies is reported as ubiquitous, and acknowledged to confer a sense of reassurance to the surgeon despite potential non-concordance with guidelines or clinical efficacy.

Conclusions

Surgical-specific concerns have thus far not been meaningfully integrated into antimicrobial stewardship (AMS) programmes, including important dynamics of confidence, trust and mitigating fear of adverse infective events. Surgeons require specific forms of AMS support to enact optimisation, including support for strong collaborative ownership of the surgical risk of infection, and intra-specialty (within surgical specialties) and inter-specialty (between surgery, anaesthetics and infectious diseases) intervention strategies to establish endorsement of and address barriers to guideline implementation.

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References

  1. National Centre for Antimicrobial Stewardship and Australian Commission on Safety and Quality in Health Care. Antimicrobial prescribing practice in Australian hospitals: results of the 2015 Hospital National Antimicrobial Prescribing Survey. Sydney: ACSQHC, 2016.

    Google Scholar 

  2. Tarchini G, Liau KH, Solomkin JS. Antimicrobial stewardship in surgery: challenges and opportunities. Clin Infect Dis. 2017;64:S112–4.

    Article  Google Scholar 

  3. Versporten A, Bielicki J, Drapier N, Sharland M, Goossens H, Group AP. The Worldwide Antibiotic Resistance and Prescribing in European Children (ARPEC) point prevalence survey: developing hospital-quality indicators of antibiotic prescribing for children. J Antimicrob Chemother. 2016;71:1106–17.

    Article  PubMed  CAS  Google Scholar 

  4. Balch A, Wendelboe AM, Vesely SK, Bratzler DW. Antibiotic prophylaxis for surgical site infections as a risk factor for infection with Clostridium difficile. PLoS One. 2017;12:e0179117.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  5. Muller A, Leroy J, Henon T, Patry I, Samain E, Chirouze C, et al. Surgical antibiotic prophylaxis compliance in a university hospital. Anaesth Crit Care Pain Med. 2015;34:289–94.

    Article  PubMed  Google Scholar 

  6. Ariyan S, Martin J, Lal A, Cheng D, Borah GL, Chung KC, et al. Antibiotic prophylaxis for preventing surgical-site infection in plastic surgery: an evidence-based consensus conference statement from the American Association of Plastic Surgeons. Plast Reconstr Surg. 2015;135:1723–39.

    Article  Google Scholar 

  7. Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Surg Infect (Larchmt). 2013;14:73–156.

    Article  Google Scholar 

  8. de Jonge SW, Gans SL, Atema JJ, Solomkin JS, Dellinger PE, Boermeester MA. Timing of preoperative antibiotic prophylaxis in 54,552 patients and the risk of surgical site infection: a systematic review and meta-analysis. Medicine (Baltimore). 2017;96:e6903.

    Article  Google Scholar 

  9. Graves N, Wloch C, Wilson J, Barnett A, Sutton A, Cooper N, et al. A cost-effectiveness modelling study of strategies to reduce risk of infection following primary hip replacement based on a systematic review. Health Technol Assess. 2016;20:1–144.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Barchitta M, Matranga D, Quattrocchi A, Bellocchi P, Ruffino M, Basile G, et al. Prevalence of surgical site infections before and after the implementation of a multimodal infection control programme. J Antimicrob Chemother. 2012;67:749–55.

    Article  PubMed  CAS  Google Scholar 

  11. Brink AJ, Messina AP, Feldman C, Richards GA, van den Bergh D, Netcare Antimicrobial Stewardship Study A. From guidelines to practice: a pharmacist-driven prospective audit and feedback improvement model for peri-operative antibiotic prophylaxis in 34 South African hospitals. J Antimicrob Chemother. 2016;72(4):1227–34.

    Google Scholar 

  12. Hansen S, Sohr D, Piening B, Pena Diaz L, Gropmann A, Leistner R, et al. Antibiotic usage in German hospitals: results of the second national prevalence study. J Antimicrob Chemother. 2013;68:2934–9.

    Article  PubMed  CAS  Google Scholar 

  13. Robert J, Pean Y, Varon E, Bru JP, Bedos JP, Bertrand X, et al. Point prevalence survey of antibiotic use in French hospitals in 2009. J Antimicrob Chemother. 2012;67:1020–6.

    Article  PubMed  CAS  Google Scholar 

  14. Riggi G, Castillo M, Fernandez M, Wawrzyniak A, Vigoda M, Eber S, et al. Improving compliance with timely intraoperative redosing of antimicrobials in surgical prophylaxis. Infect Control Hosp Epidemiol. 2014;35:1236–40.

    Article  PubMed  Google Scholar 

  15. Giordano M, Squillace L, Pavia M. Appropriateness of surgical antibiotic prophylaxis in pediatric patients in Italy. Infect Control Hosp Epidemiol. 2017;38:823–31.

    Article  PubMed  Google Scholar 

  16. EU Guidelines for the prudent use of antimicrobials in human health. European Centre for Disease Prevention and Control, 2017.

  17. Broom A, Broom J, Kirby E. Cultures of resistance? A Bourdieusian analysis of doctors’ antibiotic prescribing. Soc Sci Med. 2014;110:81–8.

    Article  PubMed  Google Scholar 

  18. Broom J, Broom A, Adams K, Plage S. What prevents the intravenous to oral antibiotic switch? A qualitative study of hospital doctors’ accounts of what influences their clinical practice. J Antimicrob Chemother. 2016;71:2295–9.

    Article  PubMed  CAS  Google Scholar 

  19. Charani E, Castro-Sanchez E, Sevdalis N, Kyratsis Y, Drumright L, Shah N, et al. Understanding the determinants of antimicrobial prescribing within hospitals: the role of “prescribing etiquette”. Clin Infect Dis. 2013;57:188–96.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  20. Touboul-Lundgren P, Jensen S, Drai J, Lindbaek M. Identification of cultural determinants of antibiotic use cited in primary care in Europe: a mixed research synthesis study of integrated design “Culture is all around us”. BMC Public Health. 2015;15:908.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  21. Giusti A, Spila Alegiani S, Ciofi Degli Atti ML, Colaceci S, Raschetti R, Arace P, et al. Surgical antibiotic prophylaxis in children: a mixed method study on healthcare professionals attitudes. BMC Pediatr. 2016;16:203.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Borg MA. Prolonged perioperative surgical prophylaxis within European hospitals: an exercise in uncertainty avoidance? J Antimicrob Chemother. 2014;69:1142–4.

    Article  PubMed  CAS  Google Scholar 

  23. Green J, Thorogood N. Qualitative methods for health research. Third ed. Los Angeles: SAGE; 2014.

    Google Scholar 

  24. Pope C, Mays N. Qualitative research in health care. 3rd ed. Malden, MA: Blackwell Publishing/BMJ Books; 2006.

    Book  Google Scholar 

  25. Parker D, Lawton R. Judging the use of clinical protocols by fellow professionals. Soc Sci Med. 2000;51:669–77.

    Article  PubMed  CAS  Google Scholar 

  26. Fitzpatrick R, Boulton M. Qualitative research in health care: I. The scope and validity of methods. J Eval Clin Pract. 1996;2(2):123–30.

    Article  PubMed  CAS  Google Scholar 

  27. More J. “Perfectly healthy, but dead”: the myth of inter-rater reliability. Qual Health Res. 1997;7(7):445–7.

    Article  Google Scholar 

  28. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19:349–57.

    Article  PubMed  Google Scholar 

  29. Doumouras AG, Hamidi M, Lung K, Tarola CL, Tsao MW, Scott JW, et al. Non-technical skills of surgeons and anaesthetists in simulated operating theatre crises. Br J Surg. 2017;104:1028–36.

    Article  PubMed  CAS  Google Scholar 

  30. Griffen FD, Turnage RH. Reviews of liability claims against surgeons: what have they revealed? Adv Surg. 2009;43:199–209.

    Article  PubMed  Google Scholar 

  31. McDonald R, Waring J, Harrison S, Walshe K, Boaden R. Rules and guidelines in clinical practice: a qualitative study in operating theatres of doctors’ and nurses’ views. Qual Saf Health Care. 2005;14:290–4.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  32. Abbo LM, Cosgrove SE, Pottinger PS, Pereyra M, Sinkowitz-Cochran R, Srinivasan A, et al. Medical students’ perceptions and knowledge about antimicrobial stewardship: how are we educating our future prescribers? Clin Infect Dis. 2013;57:631–8.

    Article  PubMed  Google Scholar 

  33. De Bono S, Heling G, Borg MA. Organizational culture and its implications for infection prevention and control in healthcare institutions. J Hosp Infect. 2014;86:1–6.

    Article  PubMed  Google Scholar 

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Acknowledgements

The authors would like to acknowledge the work of Dr. Alexandra Gibson who conducted the interviews for this study. This study was supported by an Australian Research Council Linkage Grant (LP140100020). Support from the Australian Society for Infectious Diseases is acknowledged.

Author information

Authors and Affiliations

  1. Sunshine Coast University Hospital, The University of Queensland, 6 Doherty Street, Birtinya, QLD, 4575, Australia

    Jennifer Broom

  2. Centre for Social Research in Health, UNSW, Sydney, NSW, 2052, Australia

    Alex Broom

  3. School of Social Sciences, UNSW, Sydney, NSW, 2052, Australia

    Emma Kirby

  4. Prince of Wales Hospital, The University of New South Wales, Sydney, Australia

    Jeffrey J. Post

Authors
  1. Jennifer Broom
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  2. Alex Broom
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  3. Emma Kirby
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  4. Jeffrey J. Post
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Contributions

JB conceived of the study, recruited participants, analysed data, and wrote the paper. AB conceived of the study, analysed data, revised drafts of the paper and reviewed the final manuscript prior to submission. EK analysed data, revised drafts of the paper and reviewed the final manuscript prior to submission. JP analysed data, revised drafts of the paper and reviewed the final manuscript prior to submission.

Corresponding author

Correspondence to Jennifer Broom.

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Conflict of interest

The authors declare no conflict of interest.

Ethical standards

This study was approved by South Eastern Sydney Local Health District Human Research Ethics Committee (HREC/15/POWH/246). All persons gave their informed consent prior to their inclusion in the study. Details that might disclose the identity of the subjects under study have been omitted.

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Broom, J., Broom, A., Kirby, E. et al. Improvisation versus guideline concordance in surgical antibiotic prophylaxis: a qualitative study. Infection 46, 541–548 (2018). https://doi.org/10.1007/s15010-018-1156-y

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  • DOI: https://doi.org/10.1007/s15010-018-1156-y

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