Antibiotic decision making in surgical intensive care: a qualitative analysis

Cultures of antibiotic prescribing in medical intensive care

Antimicrobial resistance (AMR) continues to present a challenge to international healthcare systems and structures of public health. The focus on optimizing antibiotic prescribing in human populations has challenged healthcare systems charged with making responsible their physician-prescribers. In the United States, physicians in almost every specialty and role use antibiotics as part of their therapeutic armamentariums. In United States hospitals, most patients are administered antibiotics during their stay. Therefore, antibiotic prescribing and utilization is a commonly accepted part of medical practice. In this paper, we utilize social science work on antibiotic prescribing to examine a critical space of care in United States hospital settings. From March to August 2018, we used ethnographic methods to study hospital-based medical intensive care unit physicians at the offices and hospital floors they frequent in two urban United States teaching hospitals. We focused on eliciting the interactions and discussions surrounding antibiotic decision-making that are uniquely influenced by the context of medical intensive care units. We argue that antibiotic use in the medical intensive care units under study was shaped by urgency, hierarchy, and uncertainty representative of the medical intensive care unit's role within the larger hospital system. We conclude that by studying the culture of antibiotic prescribing in medical intensive care units, we can see more clearly both the vulnerability of the looming antimicrobial resistance crisis and by contrast the perceived insignificance of stewarding antibiotic use when considered alongside the fragility of life amidst acute medical concerns regularly experienced in the unit.

Tipping the balance: A systematic review and meta-ethnography to unfold the complexity of surgical antimicrobial prescribing behavior in hospital settings

Surgical specialties account for a high proportion of antimicrobial use in hospitals, and misuse has been widely reported resulting in unnecessary patient harm and antimicrobial resistance. We aimed to synthesize qualitative studies on surgical antimicrobial prescribing behavior, in hospital settings, to explain how and why contextual factors act and interact to influence practice. Stakeholder engagement was integrated throughout to ensure consideration of varying interpretive repertoires and that the findings were clinically meaningful. The meta-ethnography followed the seven phases outlined by Noblit and Hare. Eight databases were systematically searched without date restrictions. Supplementary searches were performed including forwards and backwards citation chasing and contacting first authors of included papers to highlight further work. Following screening, 14 papers were included in the meta-ethnography. Repeated reading of this work enabled identification of 48 concepts and subsequently eight overarching concepts: hierarchy; fear drives action; deprioritized; convention trumps evidence; complex judgments; discontinuity of care; team dynamics; and practice environment. The overarching concepts interacted to varying degrees but there was no consensus among stakeholders regarding an order of importance. Further abstraction of the overarching concepts led to the development of a conceptual model and a line-of-argument synthesis, which posits that social and structural mediators influence individual complex antimicrobial judgements and currently skew practice towards increased and unnecessary antimicrobial use. Crucially, our model provides insights into how we might ‘tip the balance’ towards more evidence-based antimicrobial use. Currently, healthcare workers deploy antimicrobials across the surgical pathway as a safety net to allay fears, reduce uncertainty and risk, and to mitigate against personal blame. Our synthesis indicates that prescribing is unlikely to change until the social and structural mediators driving practice are addressed. Furthermore, it suggests that research specifically exploring the context for effective and sustainable quality improvement stewardship initiatives in surgery is now urgent.

Barriers and Facilitators in Perioperative Antibiotic Prophylaxis: A Mixed-Methods Study in a Small Island Setting

Few studies have addressed antibiotic guideline adherence in small island settings, such as Aruba. This study aimed to evaluate the appropriateness of perioperative antibiotic prophylaxis (PAP) and identify barriers for PAP guideline adherence. A mixed-methods study was carried out at the operating theatre (OT) in the Dr. Horacio E. Oduber Hospital (HOH) in Aruba. First, a prospective audit was performed on the appropriateness of guideline-derived quality indicators (QIs). Then, interviews based on the Flottorp framework were conducted to identify barriers for guideline adherence. Finally, a survey was distributed to verify the outcomes of the interviews. The appropriateness of QIs was measured: correct indication (50.6%); antimicrobial agent (30.8%); dose (94.4%); timing (55.0%); route of administration (100%); duration (89.5%); and redosing (95.7%). The overall appropriateness was 34.9%. The main barriers discovered were poor knowledge about PAP and the guidelines and professional interactions regarding PAP, specifically poor communication and lack of clarity about responsibilities regarding PAP. This study was the first to evaluate the appropriateness and to identify barriers for PAP guideline adherence in a small island hospital. The overall appropriateness of PAP was poor with just 34.9%. Future interventions should be focused on communication, education and awareness of the possibility to consult an ID physician or microbiologist.