Improving behavior, knowledge and attitude in combating antimicrobial resistance across the surgical pathway

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.

Appropriate use of antibiotics and compliance with infection prevention and control measures should be integral to good clinical practice and standards of care. However both infection prevention and control measures and appropriate antibiotic prescribing practice among surgeons are often inadequate and a great gap exists between the best evidence and clinical practice across the surgical pathway.

In hospitals, cultural, contextual, and behavioral determinants influence clinical practice and improving behaviour in infection prevention and antibiotics prescribing practice remains a challenge. Despite evidence supporting the effectiveness of best practice, many surgeons fail to implement them, and evidence-based processes and practices that are known to optimize both the prevention and the treatment of  infections tend to be underused in routine practice.

In 2017 the Global Alliance for Infections in Surgery shared with over 230 experts from 83 different countries  a global declaration on appropriate use of antimicrobial agents in hospitals worldwide. Within this declaration, the authors  highlighted the contribution of antibiotic exposure, misuse, and overuse to antibiotic resistance and outlined the fundamental principles of appropriate antibiotic prophylaxis and therapy in surgery.

Not specifically highlighted in their declaration but of significant importance in limiting antibiotic exposure are efforts to prevent hospital-acquired infections. Prevention of
hospital-acquired infections can limit significantly the need for antibiotic therapy

Both the World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC) have recently published guidelines for the prevention of surgical site infections (SSIs). However, despite clear evidence and guidelines to direct SSIs prevention strategies, compliance is uniformly poor among surgeons.

Antibiotics can be life-saving when treating bacterial infections but are often used inappropriately, specifically when unnecessary or when administered for excessive durations or without consideration of pharmacokinetic principles.

Some of the most common surgical conditions, such as appendicitis and cholecystitis are infectious in nature. Additionally, healthcare-associated infections, such as surgical site infections, urinary tract infections, and pneumonia, are among the most common complications surgeons face in their clinical practice.

Clinicians 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 behaviors about antibiotic use, it is difficult to change their deeply established views and practice patterns. Due to cognitive dissonance (recognising that an action is necessary but not implementing it), changing behaviour is extremely challenging.

Clinicians should be aware of their role and responsibility for maintaining the effectiveness of current and future antibiotics.

However high rates of inappropriate use of antibiotics in surgery continue to be reported in the literature and although evidence-based guidelines exist, poor adherence to them has been reported worldwide.

The necessity of formalized systematic approaches to the optimization of antibiotics use across the surgical pathway, 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 may significantly reduce the incidence of antimicrobial reisstance and C difficile infections in hospital inpatients. Every hospital worldwide should utilize existing resources to create an effective multi-disciplinary team. 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.

One of the goals of ASPs is to create and sustain a hospital-wide safety culture focused appropriate use of antibiotics.

Dedicated efforts, such as establishment of locally adopted multi-disciplinary, evidence-based protocols and guidelines, unit specific antibiotic sensitivity data, compliance monitoring, etc., are required to maximize performance.

We propose that the best means of improving ASPs worldwide should involve collaboration among various specialties within a healthcare institution including prescribing clinicians. ASPs have many actors, steps, and actions specifically related to the prevention and management of infection. The multidisciplinary approach reinforces the concept that all professionals bring with them their particular expertise and is responsible for their respective contributions.

It is essential for an ASP to have at least one member who is an infectious diseases specialist. Pharmacists with advanced training or longstanding clinical experience in infectious diseases are also key actors for the design and implementation of the stewardship program interventions. Infection control specialists and hospital epidemiologists should coordinate efforts on monitoring and preventing healthcare-associated infections. Microbiologists should actively guide the proper use of tests and the flow of laboratory results. Being involved in providing surveillance data on antimicrobial resistance, they should provide periodic reports on antimicrobial resistance data allowing the multidisciplinary team to determine the ongoing burden of antimicrobial resistance in the hospital. Moreover, timely and accurate reporting of microbiology susceptibility test results allows selection of more appropriate targeted therapy, and may help reduce broad-spectrum antimicrobial use. Infections are the main factors contributing to mortality in intensive care units (ICU). Intensivists have a critical role in treating multidrug resistant organisms in ICUs in critically ill patients. They have a crucial role in prescribing antimicrobial agents for our most challenging patients and are at the forefront of a successful ASP.

In this context, the direct involvement of surgeons can be highly impactful.

Surgeons with satisfactory knowledge in surgical infections involved in an ASPs may provide feedback and integrate the best practice of antimicrobial use among surgeons.

Very few studies have focused the relationship between ASPs and surgeons. In 2015, Çakmakçi suggested that the engagement of surgeons in ASPs might be crucial to their success]. However, in 2013 Duane et al. showed poor compliance of surgical services with ASP recommendations; A retrospective study by Sartelli et al. showed that implementation of an education-based ASP achieved a significant improvement in all antimicrobial agent prescriptions and a reduction in antimicrobial drug consumption. In a surgical unit performing mainly elective major abdominal surgery and emergency surgery, both a local protocol of surgical prophylaxis and a set of guidelines for management of intra-abdominal infections (IAIs) and control of antimicrobial agent use were introduced. Comparing the pre-intervention and post-intervention periods, the mean total monthly antimicrobial use decreased by 18.8%, from 1,074.9 defined daily doses (DDD) per 1,000 patient-days to 873.0 DDD per 1,000 patient-days after the intervention. The model was based on the concept of the “surgeon champion”.

The “champion” was a surgeon who on a day to day basis, worked within the surgical unit, promoting and maintaining a culture in which infection prevention and control appropriate use of antibiotics were of  high importance.

Surgeons with satisfactory knowledge in surgical infections may provide feedback to the prescribers, integrate the best practices among surgeons and implement change within their own sphere of influence.

We believe that the only way to combat antimicrobial resistance across the surgical pathway is a collaboration between all healthcare professionals in order to gain the wider-possible acceptance, share knowledge and spread best clinical practices.

Massimo Sartelli


1. A Global Declaration on Appropriate Use of Antimicrobial Agents across the
Surgical Pathway. Surg Infect (Larchmt). 2017 Nov/Dec;18(8):846-853.

2. Çakmakçi M. Antibiotic stewardship programmes and the surgeon’s role. J Hosp Infect 2015;89:264-266.

3. Duane TM, Zuo JX, Wolfe LG, et al. Surgeons do not listen: evaluation of compliance with antimicrobial stewardship program recommendations. Am Surg 2013;79:1269-1272.

4. Sartelli M, Labricciosa FM, Scoccia L, et al. Non-Restrictive Antimicrobial Stewardship Program in a General and Emergency Surgery Unit. Surg Infect (Larchmt) 2016;17:485-490.

5. Sartelli M, Duane TM, Catena F, Tessier JM, Coccolini F, Kao LS, De Simone B, Labricciosa FM, May AK, Ansaloni L, Mazuski JE. Antimicrobial Stewardship: A all to Action for Surgeons. Surg Infect (Larchmt). 2016 Dec;17(6):625-631.