Should surgeons be allowed to prescribe antibiotics without assistance?

It's the end of a long day on the ID consult service. You and the team have decided to recommend switching antibiotics on a post-op cardiac surgery patient since the S. aureus susceptibilities have returned and you'd prefer cefazolin over vancomycin for her MSSA bacteremia. The team text messages the primary surgical team and the intern meets the team in the ICU. You overhear the ID fellow's discussion with the surgical intern, who appears to not know the patient and who can't get approval from the senior resident, CT surgery fellow or the attending to make the antibiotic change since the whole team is scrubbed in the OR.

The above scenario is all too familiar to those who practice infectious diseases, and to be fair it could apply to other procedure-based subspecialties. But the question arrises, if only oncologists can prescribe chemotherapy, why is it that everyone is allowed to prescribe antibiotics? Is this really what is best for our patients? Yes, this is currently a controversial topic but these are the types of questions we need to ask if we're going to respond to the antimicrobial resistance crisis.

A group of researchers in the UK led by Esmita Charani and Alison Holmes began exploring the effects of culture and team dynamics on antimicrobial prescribing during surgical ward rounds and the results of their ethnographic study left me convinced that we must develop ways to improve antimicrobial prescribing on surgical services.

The research team observed the antimicrobial prescribing decision making of six surgical teams over a 3-month period. These included observation of 30 ward rounds and face-to-face, semi-structured interviews of 13 clinicians (5 consultant/attending surgeons, 3 registrars/residents, 2 nurses, 2 junior doctors/interns and the ward pharmacist). The qualitative analysis identified 4 key themes that influence antibiotic prescribing: (1) working in a constant state of flux; (2) communication jigsaw; (3) delegating antibiotic management; and (4) the need for an intervention. Here are a few quotes from the study:

Constant flux: There is a hierarchy as to who leads ward rounds (WR), but this is a shifting hierarchy whereby people are promoted or demoted from their position based on who is present on the WR...if the surgeon leading the WR is called away, for example to the OR, the line of authority shifts downwards and people must act up, for example the registrar takes on the role of the surgeon, the junior doctor ‘becomes’ the registrar and the medical student ‘becomes’ the junior doctor.

Communication jigsaw: WRs are often rushed, interrupted and dispersed and reconvened because of demands for the senior team to be in the OR. The constant disruption and people leaving and joining the WR means that members of staff will rarely be present for the entire WR. Because of being constantly split between the OR and the ward, communication within the surgical team occurs across different platforms. Key decisions are made, recorded and communicated not necessarily in medical health records but on handover sheets, text messaging, and applications on smartphones (e.g. WhatsApp). On many occasions a patient was thought to be on antibiotics by the team, and after further queries in notes and charts was found not to be on them, and vice versa.

Delegating antibiotic management: Surgeons tended to see the core elements of their role as relating to the surgical management of their patients, a role that is performed in the OR. The lack of priority given to antibiotic decision making is compounded by a lack of expertise, resulting in responsibility for antibiotic decisions being commonly delegated to others.

The need for intervention: The need and expectation to intervene means that often antibiotics are initiated for patients with no or little evidence of infection, but a high plausibility of infection in the minds of the surgeons. This process is rationalized by the surgeons as being an extension of their roles as ‘interventionists’. In the absence of evidence of infection what drives antibiotic decision making is a risk of failure, and a risk of blame. What is considered unique in surgery is that a patient has to be well enough to be able to undergo an operation, therefore any deterioration postoperatively is assumed to be a consequence of the surgery, and the decisions of the surgeon, and not the patient's underlying illness. These concerns drive a more conservative approach to antibiotic decision making leading to unnecessary and prolonged courses of antibiotics.

None of these points will appear very surprising to anyone who has cared for patients on a surgical service. However, the authors are to be commended for the care with which they completed this study and the wonderful structure they provided to the domains that influence antimicrobial prescribing. I agree with their assessment that "there is a need to explicitly assign the responsibility for antibiotic management of the surgical patient to a responsible, individual with necessary expertise... Diagnosis and treatment of infections is a specialty that requires expertise and training, therefore this is an opportunity to develop, with support from specialist microbiology laboratory and staff, a role for a clinician(s) responsible for perioperative antibiotic management. This will help to strengthen the antibiotic management for surgical patients and has the potential to facilitate continuity of care and to help overcome the substantial gaps in communication that have been identified in this study...The time is right to question whether we need to address the gap in antibiotic prescribing for surgical patients by developing this specific perioperative clinician role to manage infections. This is of critical importance considering the rising challenge of antibiotic resistance in postoperative patients."

What counts? An ethnographic study of counting central line infections

Special Guest Post by: Mary Dixon-Woods, University of Leicester

Surveillance of infections depends, of course, on being able to count them. Recent years have seen several studies (here, here and here) revealing differences in how central line infections get counted. Problems of non-comparability of infection data didn’t matter so much when institutions were conducting surveillance for their own internal purposes. Now that infection rates have become a high stakes metric, tied to financial and reputational sanctions, comparability has become much more important. But why differences in measurement occur is not clear, and one suspicion is that “gaming” – where healthcare workers deliberately manipulate the data – might be responsible. We set out to find out more.

We used the opportunity presented by Matching Michigan, a programme modeled largely on the iconic Michigan-Keystone project, to explore what English hospitals did when asked to collect and report their ICU-acquired central line infection rates. Funded by the Health Foundation, a major UK charitable foundation, we used ethnographic methods involving direct observations in intensive care units, interviews with hospital staff, and documentary analysis.

The results, published in the recent Milbank Quarterly,  showed that even though all hospitals in the programme were given standardised definitions based on those used by the US CDC, variability in how they gathered and interpreted the data was rife. But gaming played little or no role in explaining what happened. Most variability in fact arose because of what we called “mundane” reasons. These included challenges in setting up data collection systems (we identified three distinct systems in use), different practices in sending blood samples for analysis, and difficulties in deciding the source of infections. 

One interesting and unusual feature of Matching Michigan was that it asked units to distinguish, based on the CDC definitions, between catheter-associated infections and catheter-related infections. The difference between them relates to the standard of evidence needed to establish whether an infection originated in the central line or not.

To satisfy the catheter-associated infection, only one blood sample (or catheter tip) is needed, plus a clinical judgement about where the infection is coming from. This definition tends to increase sensitivity at the expense of specificity, but that may be good enough if the main purpose is to guide clinical decisions and provide a reasonable estimate of how well infections are being controlled. Satisfying the catheter-related definition, on the other hand, requires two blood samples: one from the central line and one from somewhere else in the body. Both must test positive for the same micro-organism, determined using semi-quantitative or quantitative techniques. While it provides a better standard of proof, it requires a lot more resources; many laboratories in England were not equipped to support it, and didn’t necessarily consider it a clinical priority to do so. A majority of infections reported to the program therefore relied on the catheter-associated definition.

Using the catheter-associated infection definition, because it relied on clinical judgement, invited inevitable ambiguities about what counted as a central line infection. Those decisions were typically made by ICU physicians (not infection preventionists as in the original Keystone study), and those decisions were made using different kinds of evidence in different ways. For instance, physicians varied in their practices for routine screening of catheter tips; in their propensity to initiate treatment in cases of suspected infection; and in the number and kinds of samples they sent to laboratories for analysis. This meant that those charged with counting the infections were using very different source information.

Despite absence of evidence of deliberate manipulation, the fact that data had to be reported externally to the programme did appear to have some bearing on “what counted”, though not in consistently predictable ways. For instance, some units decided that patients at low risk for central line infections (such as those who had a line in for just a few hours after cardiac surgery) were not eligible for counting in the programme, while others excluded those seen to be unusual in some way (such as those with multiple lines in after complex surgery). This meant that neither the denominators nor the numerators for calculating the infection rates were counted in exactly the same ways across all the ICUs in the programme.

We concluded that unless hospitals are deploying the same methods to generate the data, using their reported rates to produce league tables or performance or impose financial sanctions is probably not appropriate. Much more needs to be done to ensure that reported infection rates are credible, useful, fully integrated with clinical priorities, and comparable.

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