Surgical infections, guidelines and surgeons

keeping patients safe from infection and ensuring that effective antibiotic use is available for future generations should be based, on collaboration between all healthcare professionals in order to gain the wider-possible acceptance, share knowledge and spread best clinical practices. In this context the role of surgeons is crucial. 

Dr Catena, you are with Prof Ernest Moore one of the founders of the World Society of Emergency Surgery (WSES). In recent years WSES published several sets of guidelines about the management of surgical infections (intra-abdominal infections, soft tissue infections, Clostridium difficile infections…). What is the role of guidelines in implementing best practices among healthcare workers?
The purpose of guidelines is to improve the quality of care for patients and improve clinical effectiveness by implementation of evidence-based care in daily practice.
The development of global guidelines ensuring the appropriate use of evidence represents one of the core functions of a global scientific society.
Actually a decisive role in the organization and management of health facilities is played by the risk management although the classification of errors in health care represents a complex task under different points of views. In the risk management evaluation it has always to be pointed out the specificity of individual patients, the risk of some types of procedures with the multiplicity of professional experiences and the range of management models of the various health care facilities. In the prevention of clinical risks, although attention has focused primarily on improving the knowledge and training of the individual practitioner, however it has been noted that often the error, rather than depend on the conduct of the health professional, is the result of objective shortcomings organizational structures themselves. In this arrangement, a central role is taken by the clinical guidelines that are usually prepared by scientific societies and, on the basis of Evidence Based Medicine, may be recognized as real rules of professional conduct and certified practices to which the professionals and the hospitals must follow. These recommendations regarding the practical clinical behavior are based on the latest scientific studies and may come directly or indirectly from public and private organizations, national or international.
In general the use of guidelines as a criterion for identifying the responsibility of the physician has long been used by law prone to assess the legitimacy of the behavior of health professional as the compliance with “good clinical practice”, without thereby hiding the limits that this criterion in itself entails. Guidelines are not, in fact, mandatory rules in absolute terms, but general guiding principles and sometimes a bit theoretical, that may become soon obsolete due to the rapid and steady progress of science and relatively inapplicable due to the margins of unpredictability of the medicine related to the concrete individual case.
The risk of guidelines is to reduce the freedom of action of the health professional and constrain the choices at the expense of possible alternative solutions, eventually still effective and even more beneficial to scientific progress. In fact the surgeon, who in the daily practice is limited to adhere to the guidelines, inevitably produces an arrest of the evolution of scientific thought and of clinical trials.
While bearing in mind these limitations and disadvantages of the guidelines is important that the scientific societies provide for their construction and updates to help the surgeons in their common daily practice.
This tool is especially useful in emergency and trauma surgery where treatment decisions are to be taken in times that are not compatible with the usual scientific update.
WSES guidelines about surgical infections are very cited worldwide. What do WSES guidelines differ from the other guidelines?
The world’s burden of emergency surgery diseases is significant and appears to be increasing. Emergency services and acute surgical care constitute a major gap in the focus of the health sector worldwide, and several issues need to be addressed in order to promote a global dialogue on what is the most appropriate way to configure acute care surgery worldwide. Although variations in the spectrum of surgical diseases are observed among and within countries, “essential” surgery and anaesthesia in emergency should be viewed as a core group of services that can be delivered within the context of universal access. Particularly for the rural populations in low- and middle-income countries, there are enormous gaps in access to life-saving and disability-preventing surgical services. Furthermore, many hospitals continue to have logistic barriers associated with the application of evidence-based practice. This may lead to an overall poorer adherence to international guidelines, making them impractical to a large part of the world’s population.
The mission of WSES guidelines is to present to all surgeons from all regions of the world evidence-based international consensus positions with a view to promoting global standards of care for the management of emergency surgery and surgical infections.

Despite published guidelines, knowledge, attitude, and awareness of infection prevention and management in surgery are often inadequate and a great gap exists between best evidence and clinical practice.
According to you, which are potential barriers to implementing guidelines recommendations?
Despite evidence supporting the effectiveness of best practice, many clinicians fail to implement it, and evidence-based processes and practices that are known to optimize prevention and management of infections tend to be underused in routine practice.
On an individual level, healthcare workers should have the necessary knowledge, skills, and abilities to implement best practices. Increasing the knowledge may influence their perceptions and motivate them to change behavior. Education and training represent an important component for accurate implementation of recommendations. Education of all health professionals in preventing and managing should begin at undergraduate level and be consolidated with further training throughout the postgraduate years.
Peer-to-peer role modeling, and champions on an interpersonal level have been shown to positively influence implementation of best practices too. Many clinicians use educational materials or didactic continuing medical education sessions to keep up-to-date. However, these strategies might not be very effective in changing practice, unless education is interactive and continuous, and includes discussion of evidence, local consensus, feedback on performance (by peers), making personal and group learning plans, etc. Identifying a local opinion leader to serve as a champion may be important because the “champion” may integrate best clinical practices and drive the colleagues in changing behaviors, working on a day to day basis, and promoting a culture in which infection prevention and control is of high importance.
Finally, organizational obstacles may influence best practice implementation. Many different hospital disciplines are typically involved in infection process across the surgical pathway, making collaboration, coordination, communication, teamwork and efficient care logistics essential.
The vital work of infection control and prevention, antimicrobial stewardship and correct approach to surgical infections cannot be performed independently and requires interdependent and coordinated action across multiple and overlapping disciplines and clinical settings.
keeping patients safe from infection and ensuring that effective antibiotic use is available for future generations should be based, on collaboration between all healthcare professionals in order to gain the wider-possible acceptance, share knowledge and spread best clinical practices. In this context the role of surgeons is crucial.
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.
What is the role of surgeons in this fight? 
Antimicrobial resistance has emerged as one of the principal public health problems of the 21st century. This has resulted in a public health crisis of international concern.
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 across the surgical pathway. 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 and these guidelines should be implemented.
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.
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 antimicrobial therapy more effectively. 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.
Surgeons should be aware of their role and responsibility for maintaining the effectiveness of current and future antibiotics.
Excessive antimicrobial use contributes to the emergence and spread of multi drug-resistant organisms, and there is a direct correlation between the overuse of antibiotics and the development of antibiotic resistance. If surgeons around the world participate in this global fight and demonstrate awareness of the major problem of antimicrobial resistance, they will be pivotal leaders in this battle. If surgeons fail to prevent and treat infections adequately, they will find themselves deprived of the autonomy to manage their patients and restrictive strategies will be necessary.

Dr Catena, do you think that an interdisciplinary approach is helpful in preventing and managing infections in surgery?
May the figure of the surgeon “champion” be impactful to implement best practices on infection prevention and management across the surgical pathway?
Leading international organizations, such as the WHO, acknowledge that collaborative practice is essential for achieving a concerted approach to providing care that is appropriate to meet the needs of patients, thus optimizing individual health outcomes and overall service delivery of health care.
The use of such approaches reinforces the concept that each one brings with them their particular expertise and is responsible for their respective contributions to patient care. We think that the best means of improving a correct approach to infections worldwide should involve collaboration among various specialties within a healthcare institution including prescribing clinicians. The infection process has 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. In this context the direct involvement of surgeons may be crucial.
Surgeons with satisfactory knowledge in surgical infections may integrate the best practice in prevention and management of infections among surgeons.
Identifying a local opinion leader to serve as a champion may be important because the “surgeon champion” may drive the colleagues in changing behaviors.
We believe that the concept of the “surgeon champion” can be a crucial way to improve infection prevention and management across the surgical pathway.

Dr. Fausto Catena is currently chief of the Department of Emergency Surgery at Parma University Hospital. He is general secretary of the World Society of Emergency Surgery (WSES) and editor-in-chief of the World Journal of Emergency Surgery (WJES).

World Society of Emergency Surgery

Global Alliance for infections in Surgery