Fear and hierarchy as drivers for antimicrobial prescribing

Surgical antimicrobial prophylaxis (SAP) is one of the areas of strength in the infection prevention literature: we have high quality evidence that it works, and evidence-based guidance on how to do it effectively. And yet, you don’t have to spend long in an operating theatre to see that it’s not always done according to local guidelines. So, why are these evidence-based guidelines for SAP not implemented effectively? A short review in the Journal of Hospital Infection highlights social factors, specifically fear and hierarchy, as important drivers of antimicrobial prescribing.

There is evidence that unhealthy ‘power’ relationships, where the senior consultant can basically do what they want without being challenged by juniors, are more prevalent in theatres than in other parts of the hospital. Whilst the reasons for this are not clear, the fact that the operating surgeon carries the burden of the operative risk may be the root cause. There is a common tendency to extend SAP beyond the recommended duration in order to maximise protection for the individual patient. Especially when there’s a local culture of ignoring SAP guidelines! Combined with this, emerging data suggests that guidelines are not necessarily perceived to be protective against the risk of litigation (which is a sad state of affairs)!

So, your beautifully written evidence-based guidelines for SAP may well be largely ignored on the ground. In order to implement SAP effectively, we need to understand the barriers and enablers that dictate human behaviour. And this isn’t just restricted to SAP: why don’t people wash their hands when they know they should? Or wear gloves when they know that they shouldn’t? Or tip bodily fluids down the hand hygiene sink? Our job is to modify human behaviour, and that’s no mean feat!

Image: Max Pixel.


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