Understanding antibiotic prophylaxis prescribing in pediatric surgical specialties

Abstract

Background:Overuse of antibiotics has caused secondary poor outcomes and has led to a current rate of antibiotic resistant infections that constitutes a public health crisis. In pediatric surgical specialties, children continue to receive unnecessary antibiotics.Objective:To understand the factors that contribute to pediatric surgeons’ decisions regarding the use of perioperative antibiotic prophylaxis.Methods:Focus groups included pediatric proceduralists/surgeons from the following specialties: interventional cardiology, otolaryngology, orthopedic surgery, cardiothoracic surgery, and general surgery.Results:A total of 23 surgeons with a median of 9 years of experience (range, 0.5–29 years) participated in the focus groups that lasted 30–90 minutes each. Five themes emerged influencing beliefs about antibiotic prescribing practices: (1) reliance on previous experience and early education, (2) balancing antibiotic use with risk of infection, (3) uncertainty about the state of the scientific evidence, (4) understanding importance of communication and team collaboration, and (5) a prevalence of hospital-level concerns.Conclusions:Surgeons describe a complex set of factors that impact their antibiotic prescribing in pediatric surgical cases. They reported initial, but not ongoing, training and a use of individual weight of risk and benefit as a major dictator of prescribing practices. Antimicrobial stewardship programs should work with surgeons to develop acceptable implementation strategies to optimize antibiotic prescribing.

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

“…A range of qualitative techniques were used to gather data including: focus groups and/or interviews (7 bodies of work/8 papers); and ethnographic methods including observation, interviews, and in one case illustration of sociograms (4 bodies of work/6 papers). Several studies targeted specific surgical specialties, for example orthopedics and cardiothoracics [ 61 ] or pediatric surgery [ 56 , 60 ]; and others sought to include a diverse range of specialties e.g. Ierano, Thursky (59).…”

“…Disagreement of surgical staff with surgical antimicrobial prophylaxis guidelines is a barrier to adherence [ 56 ]. In addition, surgeons may be distrustful of the literature and guidelines [ 60 ]. They perceive the existence of many gaps in the current evidence [ 59 ]; and consider guidelines to be too general and inadequate to account for the broad range of surgical procedures and any environmental and patient-specific factors [ 66 ].…”

“…They perceive the existence of many gaps in the current evidence [ 59 ]; and consider guidelines to be too general and inadequate to account for the broad range of surgical procedures and any environmental and patient-specific factors [ 66 ]. Furthermore, some surgeons question the applicability of guidelines to their patient population, commonly mentioning the uniqueness of each patient and therefore an unwillingness to change their antibiotic practices without first having evidence of high quality and direct relevance to their specific subspecialty and/or a specific procedure [ 60 ]. Among surgeons, prescriber autonomy and discretion are considered to be paramount in SAP decision making [ 59 ]; and improvisation behaviors are driven by: concern around adverse patient outcomes; a sense of benevolence towards the patient (held by the surgeon)–conferring a sense of having done everything possible to prevent an infectious complication; an internalized sense of what is perceived conventional practice for a particular operation; and the perceived extra layer of safety for the surgeon (safety from both litigation and also from personal responsibility for a complication) [ 28 ].…”

“…Surgeons evaluate the risks and benefits of antibiotic use and weigh many factors, for example patient risk of infections and their previous learning and experience [ 60 ]. However, an overvalued perception of the benefit of antimicrobials drives overuse [ 61 ]; and knowledge of hospital data on quality of SAP administration, and outcomes for surgical procedures (such as the incidence of surgical site infections) is often limited [ 56 ].…”

Effects of restrictive-prescribing stewardship on antibiotic consumption in primary care in China: an interrupted time series analysis, 2012–2017

“…The intensive use of antibiotics has been regarded as a main driver of AMR and the unnecessary use further worsened such situation [1,6]. The global antibiotic consumption increased by 65% between 2000 and 2015, which was primarily driven by increased consumption in low-and middle-income countries (LMICs) [7].…”