Understanding antibiotic decision making in surgery-a qualitative analysis.
OBJECTIVE
To investigate the characteristics and culture of antibiotic decision making in the surgical specialty.


METHODS
A qualitative study including ethnographic observation and face-to-face interviews with participants from six surgical teams at a teaching hospital in London was conducted. Over a 3-month period: (a) 30 ward rounds (WRs) (100 h) were observed, (b) face-to-face follow-up interviews took place with 13 key informants, (c) multidisciplinary meetings on the management of surgical patients and daily practice on wards were observed. Applying these methods provided rich data for characterizing the antibiotic decision making in surgery and enabled cross-validation and triangulation of the findings. Data from the interview transcripts and the observational notes were coded and analysed iteratively until saturation was reached.


RESULTS
The surgical team is in a state of constant flux with individuals having to adjust to the context in which they work. The demands placed on the team to be in the operating room, and to address the surgical needs of the patient mean that the responsibility for antibiotic decision making is uncoordinated and diffuse. Antibiotic decision making is considered by surgeons as a secondary task, commonly delegated to junior members of their team and occurs in the context of disjointed communication.


CONCLUSIONS
There is lack of clarity around medical decision making for treating infections in surgical patients. The result is sub-optimal and uncoordinated antimicrobial management. Developing the role of a perioperative clinician may help to improve patient-level outcomes and optimize decision making.
NIHR Health Protection Research Unit in Antimicrobial Resistance and Healthcare Associated Infection, Department of Medicine, Imperial College, London, UK. Electronic address: e.charani@imperial.ac.uk.
E
E
Charani
Department of Health Sciences, University of Leicester, Leicester, UK.
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C
Tarrant
Department of Surgery and Cancer, Imperial College Healthcare NHS Trust, London, UK.
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K
Moorthy
Centre for Implementation Science, Health Service and Population Research Department, King's College London, London, UK.
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N
Sevdalis
Department of Anaesthesia, Cambridge University Teaching Hospitals, Cambridge, UK.
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L
Brennan
NIHR Health Protection Research Unit in Antimicrobial Resistance and Healthcare Associated Infection, Department of Medicine, Imperial College, London, UK.
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AH
Holmes
D000328:Adult; D000900:Anti-Bacterial Agents / Q000008:administration & dosage*; D019072:Antibiotic Prophylaxis / Q000379:methods*; D000073602:Antimicrobial Stewardship; D003657:Decision Making; D006784:Hospitals, Teaching; D006801:Humans; D007407:Interviews as Topic; D008131:London; D066231:Surgeons; D013530:Surgical Wound Infection / Q000188:drug therapy*
D000900:Anti-Bacterial Agents
Antibiotic decision making; Antibiotic stewardship; Infection management; Perioperative; Surgery