Understanding surgical antimicrobial prescribing behaviour in the hospital setting: a systematic review and meta-ethnography protocol

Antimicrobial resistance (AMR) represents a global patient safety risk. By 2050, AMR will be responsible for an estimated ten million deaths annually [1] unless policies are successfully implemented to tackle its spread. One of the key strategies to reduce AMR is antimicrobial stewardship which encompasses the careful and responsible use of antimicrobials to improve patient outcomes. Antimicrobial misuse—including unnecessary use; wrong dose, route or duration of therapy; wrong agent; delayed administration in critically ill patients and mistimed surgical prophylaxis—leads to increased AMR; hospital-acquired infections; and other antimicrobial-associated adverse events.

Twenty percent of human antimicrobial consumption occurs in hospitals, and over the last 5 years usage has increased by 6.3% (or 2.8% if adjusted for growth in patient admissions over this time) [2]. A high proportion of this prescribing occurs in surgical specialities where inappropriate prescribing has been widely reported [3‐7] with numerous calls for action [8‐11]. Around ten million patients undergo surgery within the National Health Service (NHS) each year [12] with advances in surgical technique and anaesthesia resulting in more patients, at increased risk of infection, being offered surgery [13]. A single dose of surgical antimicrobial prophylaxis (SAP) is vital for many procedures, usually on starting anaesthesia, to limit surgical site infection [13]. SAP efficacy relies on the availability of suitable agent(s) that ‘cover’ bacteria likely to be encountered during the surgical procedure. Antimicrobial treatment is only indicated if the patient develops an infection, for example, a surgical site infection. However, the prevalence of healthcare-associated infection is high amongst surgical patients (8.5%), second only to intensive care, and 39.5% of surgical patients are prescribed an antimicrobial on any given day [14]. In English hospitals, 1 in 12 patients are administered SAP: about half receive more than the recommended single dose and a third receive more than 24 h of antimicrobial cover [14]. Antimicrobial treatment courses prescribed by surgeons are less likely to be compliant with evidence-based guidelines, compared to treatment courses prescribed in general medicine, and more likely to be escalated to broader spectrum agents (which have activity against a wide range of microorganisms) [15]. This is despite the wide availability of international [16], national [13, 17‐20] and local [21] guidelines reinforcing the point that the provision of guidelines alone is insufficient to change practice [22]. There is an urgent need to improve surgical APB to minimise unintended patient harm.

Interventions that are informed by, and tailored to, a clear understanding of the contextual barriers to appropriate antimicrobial use are more likely to improve practice [23, 24]. However, little attention has been paid to how interventions work in different contexts and for different prescribing groups [25] and many interventions do not use effective behaviour change techniques [26]. To bring about meaningful, sustained behaviour change, it is essential to understand the contextual factors influencing surgical APB. Then, holistic, context-sensitive interventions can be co-designed and delivered accordingly, to improve patient care.

Multiple reasons for antimicrobial misuse within surgery have been postulated, including a lack of training, experience or confidence; inadequate knowledge of local AMR epidemiology; misinterpretation of microbiology results; uncertain diagnosis and/or lack of guidance or institutional leadership [8]. Additionally, a growing body of qualitative studies have described surgical teams’ APB, highlighting it as distinct from that of other physicians [27‐29]. Surgeons view antimicrobial management as peripheral to their role. Fear of failure, risk of blame and lack of expertise all contribute to inappropriate antimicrobial use [27]. Professional hierarchies within and between specialities influence SAP decisions [30], with obstacles to timely administration including organisational communication, inconvenience, workflow, role perception and the low priority assigned to antimicrobials [31]. Post-operatively, the ward round becomes central to decision-making. However, rounds are often rushed owing to pressure on the surgeons to be in theatre; responsibility for antimicrobial prescribing is often delegated to junior staff; team members are rarely present for the entire round (reducing continuity); and juniors, usually responsible for keeping track of key decisions and tasks, are frequently sent away from the round to chase results, or are omitted from critical conversations. As a result, team members become unclear about which patients are prescribed antimicrobials [27].

A synthesis of qualitative studies on surgical APB is warranted to generate a comprehensive and transferrable theory that will inform future research and antimicrobial stewardship programmes [32]. Meta-ethnography is a well-established qualitative evidence synthesis methodology with origins in the interpretive paradigm. It was first developed by Noblit and Hare (1988) in the field of education, because their aggregative synthesis could not explain the failure of desegregation in schools, but it is now widely used in health and social care research [33‐35]. The seven-phase process integrates and compares findings from multiple qualitative studies facilitating the identification of overarching constructs and development of new theory [36]. Overarching practical knowledge in the form of a theory (system of ideas explaining phenomena) has the potential to support healthcare workers and policymakers by providing a complex and comprehensive conceptual understanding of things that cannot be ‘pinned down’ [37]. Our aim is to synthesise qualitative studies on surgical APB in hospital settings to explain how and why contextual factors act and interact to influence APB amongst surgical teams. We will develop new, clinically applicable, theory to advance understanding and identify knowledge gaps to inform further research.

The meta-ethnography has been registered with the International Prospective Register of Systematic Reviews (PROSPERO); registration number CRD42020184343. Protocol development was informed by recent advances in meta-ethnographic theory and practice [33, 34, 36, 38‐42]; and with reference to the Preferred Reporting Items for Systematic Review and Meta-analysis Protocols (PRISMA-P) checklist (see Additional file). Data from eligible papers will be synthesised following the seven phases (see Fig. 1) outlined by Noblit and Hare; however, meta-ethnography is not a linear process and these phases will likely overlap and repeat as the synthesis proceeds [36]. Findings will be evaluated using the Confidence in Evidence from Reviews of Qualitative Research (CERQual) approach [43], and reported in accordance with the eMERGe reporting guidelines [44]. Ethical approval is not required for a synthesis of published peer-reviewed studies (http://​www.​hra-decisiontools.​org.​uk/​ethics/​).

As far as we know, there is no qualitative synthesis that explains how and why contextual factors interact to influence surgical APB. This knowledge is key to the development and implementation of effective, sustainable, interventions to improve practice. The meta-ethnography will develop new theory to broaden understanding of how and why contextual factors act and interact to influence APB amongst surgical teams. Insights will highlight research gaps and inform the development of context-fit quality-improvement interventions to change practice and to improve patient outcomes.

There are several strengths to the research: (1) the protocol has been written with reference to established guidance maximising rigour and transparency; (2) the multi-disciplinary research team brings varied interpretative repertoires and deep experiential knowledge of a wide range of qualitative methods, including qualitative synthesis, which is key in developing theory and explanation [47, 55] and (3) key stakeholders, including patient representatives, will continue to be included throughout the research process to ensure that findings are relevant to healthcare workers and patients who undergo surgery. Furthermore, the involvement of this broad group of stakeholders will support us in disseminating findings via suitable channels to facilitate improvement in practice, for example, one of our stakeholder group is a consultant surgeon and clinical lead for the South West Patient Safety Collaborative.