How can I improve antibiotic stewardship on a surgery unit where surgeons are hesitant to follow recommendations?

Improving Antibiotic Stewardship on a Surgery Unit with Resistant Surgeons

Creating a multidisciplinary antimicrobial stewardship team that includes pharmacy, infectious disease specialists, and surgical champions is the most effective approach to improve antibiotic stewardship on surgical units with hesitant surgeons. 1

Core Implementation Strategies

1. Establish a Formal Stewardship Structure

• Form a multidisciplinary team including:
  • Clinical pharmacist with infectious disease expertise
  • Infectious disease physician
  • At least one surgical champion (essential for buy-in)
  • Microbiologist
  • Hospital administrator 1
• Develop facility-specific clinical practice guidelines for common surgical infections 1
• Create a formal antibiotic policy and formulary with restricted lists of key agents 1

2. Implement Targeted Interventions for Surgical Prophylaxis

• Focus on surgical prophylaxis as an initial target:
  • Promote single-dose surgical prophylaxis (strong evidence base) 1
  • Develop standardized order sets for surgical prophylaxis 1
  • Create automatic stop orders for prophylactic antibiotics 1
• Target specific surgical infection syndromes rather than individual antibiotics 2
  • For example, implement protocols for skin/soft tissue infections that can reduce therapy duration by 3 days and broad-spectrum antibiotic use by 30% 2

3. Use Prospective Audit and Feedback

• Implement prospective audit and feedback for surgical patients 1
  • Review antibiotic orders after they're written
  • Provide direct feedback to surgeons about appropriateness
  • Focus on education rather than restriction initially
• Use antibiotic "time-outs" at 48-72 hours to prompt review of necessity 1
• Implement daily checklists for surgical teams that include antibiotic review 3

4. Leverage Data and Technology

• Regularly share local antibiotic resistance patterns with surgeons 1
• Measure antibiotic consumption with benchmarking against peers 1
• Implement computerized clinical decision support if available 1
• Report outcomes data specific to surgical patients (SSI rates, C. difficile rates) 2

Overcoming Surgeon Resistance

1. Engage Surgical Leadership

• Identify and recruit respected surgical champions 1
• Present data on improved patient outcomes, not just reduced antibiotic use 1
• Focus messaging on patient safety and quality of care 4

2. Use Educational Approaches

• Provide targeted education on:
  • Local resistance patterns specific to surgical patients
  • Evidence-based duration of therapy for surgical infections
  • Appropriate surgical prophylaxis 1
• Use case-based learning with real examples from your institution 2

3. Make Stewardship Convenient

• Develop pocket cards or mobile apps with guidelines 2
• Create standardized order sets for common surgical scenarios 1
• Ensure microbiology results are rapidly communicated 1
• Implement automatic stop orders to reduce workload 1

4. Adapt to Surgeon Availability

• Schedule brief in-person meetings during times surgeons are available (early morning)
• Use asynchronous communication methods (secure messaging)
• Attend surgical morbidity and mortality conferences 4
• Provide feedback through established surgical quality committees 1

Measuring Success

• Monitor and report:
  • Adherence to surgical prophylaxis guidelines 5
  • Surgical site infection rates 5
  • C. difficile infection rates 1
  • Length of antibiotic therapy for surgical patients 3
  • Cost savings 5

Common Pitfalls to Avoid

• Implementing restrictive policies without surgeon input 1
• Focusing only on antibiotic restriction rather than appropriate use 6
• Failing to provide timely feedback to surgeons 1
• Not addressing workflow concerns of busy surgeons 4
• Using a one-size-fits-all approach rather than targeting specific surgical scenarios 2

By implementing these strategies with a focus on collaboration rather than confrontation, you can improve antibiotic stewardship even with surgeons who are initially hesitant or unavailable. The key is to make the process convenient, data-driven, and focused on improving patient outcomes.