Surgical antimicrobial prophylaxis for open reduction internal fixation procedures: prescribing patterns and factors that influence guideline adherence

Background Despite the extensive research that has been conducted, practice often differs from established guidelines for a multitude of reasons and will vary between individuals and organisations. National and local hospital guidelines contain contemporary evidence-based measures to assist with practice and are used alongside a clinician’s judgement to provide the best outcomes for a patient. The extent of guideline implementation, however, may vary depending on patient presentation as well as individual or personal factors pertaining to a clinician. Translating current, evidence-based knowledge into practice has proven difficult, with multiple obstacles preventing the timely transition of medical information into the clinical setting. As a result, patients may receive suboptimal care or treatments based on guidelines that are outdated, potentially leading to patient harm. Surgical antimicrobial prophylaxis (SAP) guidelines contain recommendations on antibiotic prescribing for a wide array of surgical procedures, including orthopaedic surgeries. In Australia, national guideline recommendations for SAP prescribing can be found in the Therapeutic Guidelines: Antibiotic. The Therapeutic Guidelines: Antibiotic are frequently reviewed and revised, with the most recent update in April 2019. Current recommendations (version 16) highlight the use of single dose prophylaxis (i.e., no postoperative doses to be administered) for most orthopaedic procedures, including open reduction internal fixations.  As compliance to SAP guidelines remains poor globally, there is a need to investigate the factors that hinder guideline uptake in practice. In addition, by understanding practice behaviours of orthopaedic surgeons and the factors that result in variable SAP prescribing, tailored interventions can be designed to improve guideline uptake, ultimately reducing the excessive use of antibiotics and hence antibiotic resistance.   Aims The aims were to explore how orthopaedic surgeons at a metropolitan hospital in Melbourne, Victoria, Australia prescribe antibiotics for open reduction internal fixation (ORIF) of closed fractures as well as to identify the factors that influence SAP guideline use. Methods A systematic review was first undertaken to investigate the reported barriers and enablers to SAP guideline adherence. The Theoretical Domains Framework (TDF) was used to identify how individual, social, and environmental factors influence adherence to SAP guidelines. Barriers and enablers were identified and mapped to various domains of the TDF (Chapter 2). To understand how local orthopaedic surgeons prescribe SAP for ORIF of closed fractures, a retrospective audit of medical records was conducted at a major metropolitan hospital. Prescribing patterns were also assessed against recommendations in the Therapeutic Guidelines: Antibiotic (version 15 and 16 to compare practice prior to and post-guideline update respectively) to determine whether practice complies with national standards (Chapter 3). Following on from the audit, the self-reported practices of Australian orthopaedic surgeons were evaluated through a self-administered survey to understand nationwide practice as compared to national guidelines (Chapter 4). Local SAP guidelines were recently introduced at the audited hospital and was followed by a brief period of education and dissemination. Thus, SAP prescribing for ORIF procedures was also assessed against local guideline recommendations. This was accomplished through a second retrospective audit at the same hospital in which patient medical records were reviewed (Chapter 5). The outcomes of the systematic review and audits formed the foundation for the qualitative study, with the TDF used to identify determinants of practice. Interviews (focus groups and one-on-one sessions) were held with key guideline users to understand the factors that influence multidose SAP prescribing for ORIF patients. User perceptions of the barriers and enablers to SAP guideline adherence were also investigated, with the aim of identifying measures that can enhance guideline uptake for ORIF procedures (Chapter 6). Due to the evolving COVID-19 situation, education and dissemination of local SAP guidelines were impacted. Thus, a final study was introduced to examine how education provision has been impacted at Victorian public hospitals. Semi-structured interviews were held with education pharmacists from various hospitals to understand the barriers and enablers to education provision in the face of external pressures (Chapter 7). Results A multitude of barriers and enablers to SAP guideline adherence were identified from the systematic review, with factors mapped to 11 TDF domains including knowledge, social/professional role and identity and environmental context and resources (Chapter 2). The first retrospective audit highlighted suboptimal adherence to the Therapeutic Guidelines: Antibiotic, particularly version 16, with the vast majority of patients receiving postoperative antibiotics (Chapter 3). Although a small cohort of surgeons were surveyed, the results of the self-administered survey also showed heterogeneity in practice and adherence against current Therapeutic Guidelines recommendations (Chapter 4). Despite local guideline introduction, postoperative antibiotics continue to be prescribed for ORIF of closed fractures at the previously audited hospital, with suboptimal adherence to guideline recommendations (Chapter 5). Factors that influence postoperative antibiotic prescribing and the barriers and enablers to the use of SAP guidelines were identified from the semi-structured interviews. Orthopaedic surgeons expressed how patient comorbidities and fracture site may influence SAP decision making, with guideline simplicity and inaccessibility possibly preventing the implementation of guidelines (Chapter 6). Finally, excessive workloads, role changes and hospital directives prevented the effective delivery of education at Victorian public hospitals. Where possible, virtual platforms were employed to convey educational material, however, with varying levels of success and audience engagement (Chapter 7).   Conclusion Postoperative antibiotics continue to be prescribed for ORIF of closed fractures despite guideline recommendations. Effective dissemination is required to ensure the adequate uptake of guidelines. By considering the perceptions and experiences of key guideline users and by understanding perceived barriers and enablers to guideline adherence, tailored interventions can be developed to enhance guideline use. As education remains a key means of conveying guideline information, greater efforts are required to improve engagement, particularly during times of high pressure. Thus, the combination of effective education and tailored interventions may assist in the effective implementation of SAP guidelines, minimising the inappropriate use of antibiotics and ultimately reducing antibiotic resistance.