The primary goal of IPC programs is to prevent the acquisition and dissemination of HAIs within health care facilities. IPC programs should always include policies, procedures, and activities designed to prevent or reduce the spread of HAIs within health care facilities. Different hospital disciplines are typically involved in IPC programs, making collaboration and teamwork essential. IPC teams are effective in improving patients’ clinical outcomes, and cost-effective in providing important cost savings . Raising awareness of IPC measures to stakeholders is a crucial factor in changing behaviour. The data of our survey demonstrated that the median number of professionals comprising the IPC team was 6 [IQR 4–7], including microbiologists (72.4%), infectious diseases specialists (70.2%), nurses (68.4%), hospital pharmacists or pharmacologists (67.6%), surgeons (56,7%), infection control specialists (56.4%), intensivists or anaesthesiologists (48.7%), hospital administrators (45.8%), epidemiologists (38.9%), public health specialists (30.2%), and emergency medicine specialists (18.2%).
Preventing SSIs is a priority for all surgical departments around the world. Bacteria are becoming increasingly resistant to antibiotics. SSIs are among the most common HAIs, making SSI prevention especially important. SSIs are associated with longer post-operative hospital stays, and higher attributable morbidity and mortality. SSIs prevention requires integrating a range of measures before, during, and after surgery. Both the WHO and the U.S. Centers for Disease Control and Prevention (CDC) have published guidelines for preventing SSIs [16,17,18]. The 2016 WHO Global guidelines for preventing SSIs are evidence-based, including systematic reviews presenting additional information supporting actions to improve practice [17, 18]. The guidelines include 13 recommendations for the pre-operative period and 16 for preventing infections during and after surgery, ranging from simple precautions such as ensuring that patients bathe or shower before surgery, effective skin disinfection for patients and surgical teams, guidance on when and for how long to use prophylactic antibiotics, and which sutures to use. According to the WHO Global guidelines, the use of alcohol-based solutions for the surgical site preparation is a strong recommendation and may be considered an important process indicator for SSIs prevention. In our survey, 68.7% of participants stated that alcohol-based solutions for surgical site preparation were used in all wards, while 12.2% in some wards, and 19.1% stated that alcohol-based solutions were not used.
The availability of guidelines is essential to provide a robust framework to support good clinical practice [17, 18]. Guidelines for the prevention of HAIs, including SSIs, have been published in recent years. Despite the clear evidence, compliance is uniformly poor, and significant difficulties arise when introducing evidence and clinical guidelines into routine daily practice.
Notably, guidelines alone are not sufficient to ensure adoption and the implementation of their principles and findings. Local adaptation is a prerequisite for successful guideline adoption and adherence. One way to engage HCWs in guideline development and implementation is to translate recommendations into a protocol or pathway that specifies and coordinates responsibilities for particular actions and timing among multidisciplinary team members in an acute care facility. Surveillance and outcomes assessment are crucial to monitor adherence with guideline recommendations. The results of our survey demonstrated that a protocol on HAIs prevention was in place in all hospital wards in the vast majority of acute facilities (85.9%), and only in 6.2% a protocol on HAIs prevention was not in place.
Hand hygiene is an important indicator of safety and quality of care in any health care setting. There is substantial evidence demonstrating the correlation between good hand hygiene practices and low HAI rates . Failure to perform appropriate hand hygiene is considered the leading cause of HAIs and the spread of MDRO and has been recognized as an important contributor to outbreaks. There is convincing evidence that improved hand hygiene through multimodal implementation tactics can reduce HAI rates. In addition, several studies showed a sustained decrease in the incidence of MDRO isolates and patient colonization following the implementation of improved hand hygiene . The point of care may be the starting point for an implementation program for hand hygiene, but an effective program of hand hygiene functions facility-wide with the participation of all HCWs. Most participants (89%) stated that hand washes dispensers of alcohol-based hand rub at the point of care were in place.
It is widely acknowledged that surveillance systems allow the evaluation of the local burden of HAIs and AMR and contribute to the early detection of HAIs and new patterns of AMR, including the identification of clusters and outbreaks. HAI surveillance is a challenging task as well because it requires particular expertise to analyse and assess epidemiologic data as to its quality and interpretation to tailor intervention and prevention measures. In our survey, participants stated that surveillance systems for SSIs were in place in all wards in 61.8% of acute care facilities, while in 23.4% were not in place. Systematic reports about AMR data were in place in all wards in 58.5% of acute care facilities, while in 22.4% were not in place.
AS programs have been promoted to optimize antimicrobial usage and patient outcomes and reduce the prevalence of AMR. However, the best tactics for an AS program are not definitively established and identifying optimal efforts to impact system change has been challenging. As programs are likely to vary based on local culture, available antibiograms, policy and routine clinical practice, and probably on resources . Many hospitals remain without formal programs, and those that do continue to struggle to gain acceptance. Restriction of prescribing may be effective at controlling use but raises issues of prescriber autonomy and requires a large commitment of resources, including personnel. Multidisciplinary collaboration within health systems is mandatory to ensure that prophylactic, empiric, and directed use of antimicrobial agents results in optimal patient outcomes in the current era of AMR.
Every hospital worldwide should utilize existing resources to create an effective multidisciplinary team for AS . Preferred aspects of AS programs include comprehensive collaboration among various specialties within a health care institution. The AS program is generally coordinated by infectious diseases specialists, whether physicians or pharmacists. Pharmacists with advanced training or longstanding clinical experience in infectious diseases should be key participants in the design and implementation of AS interventions. Infection control specialists and hospital epidemiologists should coordinate efforts to monitor and prevent HAIs and analyse and report “real-time” data to prevent infections, reduce antimicrobial use, and minimize the spread of AMR. Microbiologists should actively guide the proper use of tests and the flow of laboratory results, including periodic reports on AMR data within the facility, so as to allow the multidisciplinary team to determine the ongoing burden of AMR in the hospital. Moreover, timely and accurate reporting of antimicrobial susceptibility test results allows de-escalation to more appropriate targeted therapy and may help reduce broad-spectrum antimicrobial use.
Surgeons with expertise in surgical infections and surgical anatomy, when involved in AS programs, may audit antibiotic prescriptions, provide feedback to the prescribers, integrate best practices of antimicrobial use among surgeons, and act as champions among colleagues. Intensivists have a crucial role in treating MDROs of critically ill patients and thus are at the forefront of successful AS programs. Nurses are crucial for maintaining patient safety and monitoring the consequences of antimicrobial therapy. The engagement of hospital administration is a key factor for both developing and sustaining of AS programs. Without adequate support from hospital administration (AS programs do not generate revenue), programs will be inadequate or inconsistent.
In our survey 68.8% of participants stated that their hospital had a multidisciplinary AS team; 43.5% of respondents stated they were currently members of it. The median number of professionals working inside the AST was 5 [IQR 3–7], mainly represented by infectious diseases specialists, microbiologists, hospital pharmacists or pharmacologists, and infection control specialists.
Especially in resource-poor-settings, the IPC and AS teams can optimize bidirectional communication and collaborate in sharing resources and personnel. Data review, monitoring and reporting, and interventions such as audit and feedback and education are integral processes to both AS and IPC. Integrating these activities can make for more efficient workflow for both programs.
AS policies should be based on international and national antibiotic guidelines and tailored to local microbiology and AMR patterns. Based on the guidelines and local formulary options promoted by the AS team, facility-specific treatment recommendations can guide clinicians in antibiotic selection and duration of therapy. Standardizing and monitoring a shared protocol of surgical antibiotic prophylaxis is a logical first step in developing an AS program.
Local protocols for antimicrobial therapy of surgical infections were present in the majority of the hospitals (76.6%). Most participants (85.8%) declared the protocol for antimicrobial therapy included interventions to reduce the duration of therapy, while 79.8% stated the protocol advocated for alternative dosing tactics based on pharmacokinetic and pharmacodynamic principles. It is important to observe that 83.1% of participants stated all hospital wards have local protocols that included discontinuation of prophylaxis in the postoperative period. A surgical antibiotic prophylaxis protocol was significantly less likely to be implemented in hospitals with < 100 inpatient beds compared with hospitals with a larger number of inpatient beds (60.0% vs. 91.8%, p < 0.001).
Pharmacy’s contribution to AS programs has evolved substantially during the twenty-first century. Although infectious diseases specialist physicians and microbiologists have been responsible conventionally for providing advice on clinical management of infected patients, many pharmacists in clinical practice have now established roles complementing the expertise in multidisciplinary antimicrobial stewardship teams. Pharmacists’ responsibilities for AS include promoting the optimal use of antimicrobial agents. Typical interventions include patient-specific recommendations on optimization or de-escalation of antimicrobial therapy; and implementation of policies, education, therapeutic drug monitoring, and participation in AS ward rounds. Antibiotics are prescribed in up to one-third of hospital inpatients, often inappropriately, and more than two-third of critically ill patients are on antibiotics at any given time during hospitalization. Antibiotic use is one of the most direct and important parameters to assess the impact that an AS program has on a hospital and its patient population , although AMR and clinical outcomes are also important measures. Antimicrobial use (consumption) is a commonly used measures and is described by defined daily dose (DDD) or days of therapy (DOT), usually normalized per 1000 patient-days. The results of the survey demonstrated that monitoring systems of used antimicrobials were in place in all wards in just over half of acute care facilities.
Some of the most common clinical conditions that surgeons manage are infectious in nature. Additionally, HAIs such as SSIs, CA-UTIs, and HABP/VABP are among the most common complications surgeons face in clinical practice. Therefore, compliance with IPC measures and AS practices is integral to good clinical practice. However, both IPC and AS practices among surgeons are often inadequate. Surgeons are at the forefront in preventing infections in that they are responsible for many health care processes that impact the risk of HAIs and their prevention. Surgeons are also at the forefront of infection management of surgical patients, achieving prompt source control and providing adequate antibiotic therapy. In this context, surgeons’ participation in multidisciplinary efforts to improve surgical quality is crucial, including efforts to increase the evidence base [22, 23].
Increasing knowledge alone may be insufficient and ineffective unless education is continuous and interactive, including discussions of evidence, achievement of local consensus, and peer feedback on performance. Identifying a local opinion leader “champion” is important to facilitate integration of best clinical practices and encourage colleagues to change behaviours. Surgeon champions may provide feedback to prescribers and lead by implementing change personally, interacting directly with the AS team and the IPC team. The majority of participants stated to have at least one surgeon with an interest or skills in surgical infections within their hospital department. A surgeon with an interest or skills in surgical infections was significantly less likely to be present in hospitals with less than 100 inpatient beds (50.0%, p = 0.018) compared to hospitals with a larger number of inpatient beds (80.6%). Moreover, a surgeon with an interest or skills in surgical infections was significantly less likely to be part of the IPC team in hospitals with less than 100 inpatient beds (10.0%, p = 0.003) compared to larger hospitals (51.3%).
Appropriate SC is of utmost importance in managing complicated intra-abdominal infections and soft-tissue infections, Furthermore, adequate SC can also shorten the course of antibiotic therapy. The adequacy of SC is unrelated to appropriate antibiotic administration. Although each is an independent predictor of mortality, antibiotic therapy may have no effect without adequate SC. The level of urgency of treatment is determined by the affected organ(s), the relative speed at which clinical symptoms progress, and the underlying physiological stability of the patient. The challenges of multiple patients requiring emergency surgery or of limited resource availability highlight the importance of triage patients according to anatomic diagnosis and physiologic state. An expedient diagnosis of infection that requires emergent source control is crucial for patients with sepsis or septic shock; the source control intervention must be implemented as soon thereafter as is medically and logistically practical. Delays of as little 6 h have been associated with increased mortality [24,25,26]. Two hundred fifty (250/304 82.2%) participants stated that a dedicated operating room for emergency surgery was available 24 h a day.
Education spans all domains of health service delivery and is relevant to all health care workers, ranging from frontline workers to administrative management. Education of all health professionals in preventing and managing infections should begin at the undergraduate level and be supplemented with further training throughout the postgraduate years. Hospitals are responsible for educating clinical staff about IPC programs. According to available resources, education programs such as academic detailing, consensus building, and educational workshops should be implemented in each hospital worldwide.
Respectively 56.6% and 59.2% of participants stated the contribution of education and motivation of HCWs to the design and delivery of safe systems for infections management was very important or important in their hospital. A greater importance about the education of HCWs was significantly more likely to be present in hospitals with an AS team (64.6%, p < 0.001) compared to hospitals without (39.0%).
Effective teamwork in health care delivery can have an immediate and positive impact on patient safety. Health care teams that communicate effectively reduce the potential for human error, resulting in enhanced patient safety and improved clinical performance. Implementation research has demonstrated that best practice interventions are most effective when applied by teams that support the translation of evidence and guideline recommendations into practice, intending to change HCW behaviour. The majority of participants stated the culture of teamwork was considered very important or important in their hospitals. Patient safety is a crucial component of health care quality and is related to preventing and managing infections. Patient safety is a serious global public health issue that is defined as the prevention of harm to patients, with an emphasis on a culture of safety that involves health care professionals, organizations, and patients in a collaborative system of care delivery that prevents errors and learns from errors that do occur. In our survey, most participants stated that the culture of patient safety was very important or important in their hospitals.
Finally, many authors highlighted the need to increase patient involvement in IPC implementation in health care settings. Patient involvement in IPC may ensure a more patient-centred health care prioritising their needs and empowering them to take control of their own IPC [27, 28]. Patients and family involvement in IPC management was considered to be slightly or not important in their own hospital by the majority of respondents (65.1%). Although the low importance among respondents of patient involvement in IPC, both patients and HCWs should jointly advocate for a culture of patient involvement in reducing the burden of HAIs . It would require changes to the organisational cultural model in which HCWs tend to control their organisation and also play an “authoritarian” role over patients . The required cultural changes should imply a reversion in the relation between HCWs and patients and the need to put patients in a responsible and protagonist role as experts in their own care and IPC, rather than being passive participants and observers of HCWs’ behaviours.
This study has several limitations: a response rate of just 21.2% should be considered a response bias, and it is possible that non-participating HCWs may have been less interested in surgical infections than the participants and therefore it is possible that results are biased towards a better picture than it actually is. According to specialty, no stratification or sampling was pre-planned to ensure that all stakeholders were adequately represented and the questionnaire was self-reported. The major strength of the study is its multinational (global) and multidisciplinary approach, to our best knowledge the first in this setting. Thus, our survey provides a benchmark to all interested stakeholders; it can be repeated over time to explore if better uniformity on a global platform of health care environments would develop in the future, and may be used to build consensus around the best practices in the field of prevention and management of surgical infections a future project.