Descriptive research article: Abstract Background Objective Methods Findings Conclusion
Question Descriptive research article: Abstract Background Objective Methods Findings Conclusion “Perceptions of surgeons on surgical antibiotic prophylaxis use at an urban hospital.” Surgical Site Infections are a major cause of morbidity and mortality among operated patients. In spite of the accessibility of universal and national guidelines for surgical prophylaxis, recent studies surveying the present routine of prophylaxis have demonstrated overutilization of a wide range antibacterial medication for a single patient. Few studies have shown qualitatively factors influencing this and perceptions of surgeons on surgical antibiotic prophylaxis use. Unfortunately, none of these studies have been done in Tanzania. To describe the perceptions of surgeons on surgical antibiotic prophylaxis use at an urban tertiary hospital. A qualitative study involving in-depth interviews with surgeons was conducted in English by the primary investigator. The interviews were audio-recorded and transcribed verbatim. Systematic text condensation by Malterud was used for data analysis. Fourteen surgeons and obstetrics and gynaecologists participated. Their perceptions were summarized into three main categories: Inadequate data to support practice; one who sees the patient decides the antibiotic prophylaxis; prolonged antibiotic use for fear of unknown. The participants perceived that choice of antibiotic should be based on local hospital data for bacterial resistance pattern, however the hospital guidelines and data for surgical site infection rates are unknown. Fear of getting infection and anticipating complications led to prolonged antibiotics use. The study provides an understanding of surgical antibiotic prophylaxis use and its implementation challenges. This was partly expressed by unavailability of local data and guidelines to enhance practice. To improve this, there is a need of guidelines that incorporates local resistance surveillance data and enhanced antibiotic stewardship programmes. A strong consideration should be placed into ways to combat the fears of surgeons for complications, as these significantly affect the current practise with use of surgical antibiotic prophylaxis. Findings The perceptions of participants with regard to surgical antibiotic prophylaxis (SAP) use were summarised into three categories: Inadequate hospital data to support practice, antibiotics are prolonged for fear of unknown and the one who sees the patient should decide SAP. The quotations by participants are indented and labelled by responder number. A summary of major categories and subcategories is given in Table 3 below.A. Inadequate hospital data to support practice Multiple participants expressed the lack of hospital-based data to show bacterial patterns that would guide SAP use. This was shown together with unawareness of existence of hospital SAP guidelines and even those who were aware of the guidelines expressed that guidelines were not easily available when needed and hence could not be referred to frequently. Mostly participants who were working part-time were unaware of hospital guidelines. Table 2. Systematic text condensation method of analysis; an example of extract from the data analysis. Meaning unit Code Category From the pharmacy, it is ok they deal with drugs but . . . Pharmacists cannot decide but suggest, The one who sees the patientthey don’t know the patient and they don’t know how they don’t see the patient decides SAP we are dealing with this patient in theatre. It is ok to give suggestions but they cannot make the final decision. Table 3. A summary of categories and sub categories. Categories Sub categories Inadequate hospital data to support practice No hospital data for bacterial resistance patterns Hospital guidelines are not well known Unknown hospital data for SSI The one who sees patient decides SAP Surgeon decides SAP Team members decide SAP Prolonged SAP for fear of unknown Fear of getting infection Anticipating complications No hospital data for bacteria resistance patterns. Participants noted that appropriate choice of SAP should be made based on local patterns of bacteria and their susceptibility to antimicrobials. The hospital currently uses AMS laboratory committee to follow up bacteria susceptibility patterns and there isn’t a systemised data collection method in place to get adequate data to support practice. Hence international guidelines were used to make hospital guidelines. In discussion about choice of SAP some participants mentioned this below. . .yeah it is good to follow guidelines, but you need to have your own data which supports what you are using because the bacteria pattern is different in different areas. . . .But guidelines are there to help you out but they cannot dictate, so you need local data to support you more. (Responder 3) So, we need to know at the Aga Khan hospital when we are doing maybe perianal surgeries, which antibiotics seem to be more effective and which antibiotics seem to be more resistant. So, if we get infection, we should make sure that we do culture and sensitivity. (Responder 9) Hospital guidelines are not well-known. Few participants were not aware of availability of hospital guidelines with regards to surgical antibiotic prophylaxis and they reported to use other sources to guide them including WHO guidelines and literature. Some participants speculated that probably due to working as part-time specialists, not all hospital resources are availed to them. Participants who were aware of the guidelines expressed that a constant discussion with the pharmacy team with regards to availability and choice of SAP was done. Regardless of other participants being aware of hospital guidelines, they noted that the guidelines were not easily accessible when required. No, I have never seen guidelines at the Aga Khan Hospital. Maybe it is there. You know we are working part-time and maybe they do not show me the guidelines. (Responder 12) I use WHO guidelines, there are no local guidelines for that. (Responder 7) We have a guideline; it is user-friendly but it is not very well-known. I’m sure if you go there at the nurses’ desk you will take maybe 5 minutes to find it. (Responder 13) Inadequate hospital data for surgical site infections. The SSI rates were reported to be few by most participants. The part time participants reported having multiple cases of SSI in other places of work. Participants attributed the causes of surgical site infection to include change in SAP when bacterial resistance occurred, patient factors like co-morbid and immunosuppression, pre-existing infection at the surgical site, environmental factors like sterility of the theatre and the wards, sterility of surgical instruments, surgical technique and tissue handling. Participants expressed that multiple factors are involved in development of SSI and it’s not determined only by use of SAP. However, participants emphasized the importance of surgical technique and sterility in the prevention of surgical site infection than relying on SAP alone. Regardless of this, there is inadequate documentation and follow-up of patients who develop SSI to determine the exact rates of patients developing SSI and hence determine the root cause. For cases that we do at Aga Khan, that is not a problem. But for cases at Muhimbili especially when we do a lot of operations involved in the perineum like urethroplasty, infections occur for example patients with Fournier’s gangrene, hypospadias in children, they get contaminated, so it depends on the site. For the upper tract, maybe nephrectomies, exploration, infection is not much of a big problem. (Responder 9) We do not have proper statistics in terms of surgical site infections.(Responder 13) I have seen a couple of them but not that much. And I think it’s one of the devastating complications post-operative. It really doesn’t depend on whether prophylactic antibiotics was given or not, but rather a degree of wound contamination during the procedure. (Responder 14) B. The one who sees patient decides SAP There was a difference in opinion with regards to decision making of SAP. Some participants advocated for teamwork from pharmacists, surgeon, and residents to interns while some participants expressed that only the surgeon could make the final decision about which SAP to use. Participants expressed that for the decision to be made by another person other than the surgeon, the person had to be part of the team managing the patient and should be taught prior to being allowed to make the decision. Regardless of the fact that the surgeons had to make the decision, having a new batch of intern doctors or nurses was noticed to be associated with inappropriate SAP use which indicated that decisions most often fell onto the intern doctors. Surgeon decides SAP. The surgeon reviews the patient, is aware of the procedure to be carried out, knows all the factors involved in the patient and is in an informed position to decide SAP. The pharmacists do not see the patient and hence can only recommend SAP based on availability for the surgeon to decide. Having a new batch of intern doctors or nurses was noted to be associated with inappropriate surgical antibiotic prophylaxis use this could show that decision most often fell onto the intern doctors. So, the surgeon should decide. Even though I know there are committees dealing with making local guidelines, and they’re also international ones and everything. But when you are the surgeon, you are the one who is going deep into the patient. (Responder 4) Surgeon decides. So, a person in the pharmacy cannot just sit and decide that you should give this antibiotic. The pharmacist can sit in a meeting but include the surgeons, include everyone else, people who are working hand-in-hand with that patient in seeing the outcomes and then make the decision. (Responder 5) Team members decide SAP. Other participants advocated for a team decision-making process involving all stakeholders that are responsible for the patient. The surgeon should not be expected to follow up on SAP that each patient is receiving but it should be the responsibility of anyone who has seen the patient. The surgeons are not always aware of the SAP given to the patient and usually the resident or intern doctors that review the patient decides SAP. This would in turn explain the fact why multiple participants said having new residents or new intern doctors was associated with an increase in inappropriate use of surgical antibiotic prophylaxis. However, it was emphasized that the other team members making the decision had to be part of the team managing the patient and it was the responsibility of the surgeon to lead team members about appropriate SAP use. In the current practice the surgeon is not always aware of the surgical antibiotic prophylaxis given. They would admit the patient and say “send pre-operative antibiotics”. . . The resident or intern doctor on call decide SAP. (Responder 11) I think this has to be team work from the pharmacist, the Resident, the staff in the ward then the surgeon. Whoever has seen the patient and thinks that this is a different case has to inform the rest of the team, starting from the surgeon to the residents in the ward, the pharmacists. (Responder 2)C. Prolonged antibiotics for fear of unknownMultiple participants expressed that prolonged antibiotics duration was given for fear of wound contamination that may occur and fear of complications, sepsis or wound infection that could develop. Prolonged antibiotics were observed to be given to patients with comorbid or high-risk patients. The inability to control the theatre environment, ward sterility and home environment increased likelihood of postoperative antibiotics. Fear of getting infection. Participants are well aware of the recommendations about use of a single dose of preoperative antibiotics. Regardless of this they reported giving prolonged SAP with a duration of more than 24-hours up to two weeks. This was done due to some factors like the environment not considered to be sterile enough, overcrowding in the theatres and sterility in the wards not being adequate enough. These factors were considered as beyond the control of the surgeon. Because of the above, there is always a fear of a patient developing an SSI after the surgery. . . .if you think I can’t even maintain the theatre environment and the crowding there and there’s always a risk of infection, well then you have a fear that if you use a low antibiotic then maybe you would not be able to control infection. (Responder 3) We work in this environment, our wards are not so sterile and there is a lot of contamination everywhere, so probably it is their fear, or probably it is the ideal in our condition who knows. (Responder 6) Anticipating complications. Participants also expressed giving prolonged antibiotics in anticipation of complications that could occur, fear of wound contamination and sepsis. Prolonged antibiotics were observed to be given to patients with comorbid or high-risk patients. This would be decided depending on factors like patient having emergency procedures, intraoperative findings of necrosis on the operative site, and many more. In routine cases with no anticipated complications patients did not receive prolonged SAP. . .someone already having an emergency caesarean section with prolonged labour, so we are anticipating sepsis. These are the ones will continue giving antibiotics. (Responder 1) So, you need to see accordingly each patient, what would be the infection burden, so that you can use maybe 5 to 7 days or sometimes if you think there is a risk of prostatitis or epididymitis then that may be prolonged to 2 weeks (Responder 3)Questions 1.) Based on the interviews from responders, can you specify the codes and themes. Synopsis: 2.) Are specific pieces of data (i.e. direct quotes) and generalized statements (themes, theories) included in the study?3.) How did the researcher control his or her biases and preconceptions?4.) Does the researcher want to produce a description of experience, a social process, or an event, or is the goal to generate a theory?5.) What experience or subculture does the researcher seek to understand? Health Science Science Nursing BIO 333 Share QuestionEmailCopy link Comments (0)
