Improving antibiotic prescribing practices among surgeons

Although most surgeons are aware of the problem of antimicrobial resistance, most underestimate this problem in their own hospital. Incorrect and inappropriate use of antibiotics and other antimicrobials, as well as poor prevention and control of infections, are contributing to the development of such resistance.

Surgeons regularly have to make complex decisions about antibiotic use, balancing the benefits of effective treatment against the risks to individual patients and public health from overuse of antibiotics. Not surprisingly, they may be confused by conflicting messages about how resistance should influence their prescribing and how their prescribing influences resistance. Furthermore, because medical professionals have already established their knowledge, attitudes, and behaviours about antibiotic use, it is difficult to change their deeply established views and practice patterns.

The necessity of formalized systematic approaches to the optimization of antibiotics use in the setting of surgical units worldwide, both for prophylaxis and therapy, has become increasingly urgent.

A growing body of evidence demonstrates that hospital based programs dedicated to improving antibiotic use, commonly referred to as “Antibiotic Stewardship Programs” (ASPs), can both optimize the treatment of infections and reduce adverse events associated with antibiotic use

It is well known that ASPs significantly reduce the incidence of infections and colonisation with antibiotic-resistant bacteria and C difficile infections in hospital inpatients. However, the best strategies for an antimicrobial stewardship program are not definitively established and are likely to vary based on local culture, policy and routine clinical practice.

“Antimicrobial restriction”, is not more effective than the persuasive strategy of achieving the goal of controlling antibiotic use in a long term. Moreover in many settings there may be inadequate personnel for a restrictive approach and restriction strategies do not consider the appropriateness of use of non-restricted antibiotics, which makes up the vast majority of antibiotics used in the hospital. Furthermore “antimicrobial restriction” may be perceived by the prescribing clinicians as a strong limiting factor for their autonomy in their clinical practice, also because they are directly responsible for their patients.

We propose that the best means of improving antimicrobial stewardship programs (ASPs) worldwide should involve collaboration among various specialties within a healthcare institution including prescribing clinicians. Since surgeons are at the forefront in managing patients with infections, they provide insight into source control within the operating theater. As a result, surgeons may be better able to stratify patients according to their risk for infectious complications and to guide their antibiotic therapy more effectively. In this context, the direct involvement of surgeons in ASPs can be highly impactful. The battle against antibiotic resistance should be ought by all health care professionals. However if surgeons around the world participate in this global fight and demonstrate awareness of the major problem of antimicrobial resistance, they will be really leaders.

Effective and optimal antibiotic prescribing and management is part of a decision making process that requires a fundamental understanding of the evolving relationship between antibiotic consumption and the emergence of resistance. Since physicians are primarily responsible for the decision to use antibiotics, educating them and changing the attitudes and knowledge that underlie their prescribing behavior may be crucial for improving antimicrobial prescription.

Education of all health professionals involved in antibiotic prescribing should begin at undergraduate level and be consolidated with further training throughout the postgraduate years. Hospitals are responsible for educating clinical staff about their local antimicrobial stewardship programs. Active education techniques, such as academic detailing, consensus building sessions and educational workshops, should be implemented in each hospital  worldwide according to its own resources.

Efforts to improve active educational programs raising awareness of the correct use of antibiotics are strongly required. The direct involvement of the surgeons in these programs may be a way to fight the cognitive dissonance that blocks surgeons in this process.

The role that surgeons will have in this important battle will depend on themselves and on their ability to understand their crucial role in combating antimicrobial resistance.

Massimo Sartelli