Investigating Integrated Pathways for Infection Prevention and Antibiotic Stewardship in Surgery in India and South Africa: A Qualitative Study

Abstract

Background: The surgical pathway remains a hard to reach, critical target for antimicrobial stewardship (AMS) and infection prevention and control (IPC) globally. We investigated the drivers for AMS and IPC across surgical teams, in two academic hospitals in South Africa (SA) and India. Methods: Between July 2018 and August 2019, we conducted an ethnographic study across cardiovascular and thoracic surgery (CVTS) and gastrointestinal surgery teams utilizing non-participant observations, face-to-face interviews, and in-depth case-studies. Data were analysed using an inductive-deductive approach, applying thematic framework informed by existing evidence. Observations totalling over 190 hours (138 India, 60 SA) included shadowing healthcare professionals (HCPs) attending daily ward activities and ward rounds. Patients (6 India, 7 South Africa), and HCPs (44 India, 61 SA) were interviewed. Six (4 India, 2 SA) patient case-studies were developed. Findings: Across surgical pathways, multiple steps in IPC and AMS include several key HCPs who have implicit roles. These existing roles of HCPs (including nurses, and senior surgeons) are overlooked as interventions target junior doctors, bypassing the critical roles of the wider range of HCPs. Critically, the ownership of decisions remains with the operating surgeons and entrenched hierarchies restrict the integration of other HCPs in IPC and AMS. Interpretation: IPC and AMS remain key priorities for safe surgery. Identifying the implicit existing roles in AMS and IPC is critical. Developing nurse leadership, empowering pharmacists and engaging surgical leads is essential for integrated care. Many lessons can be learnt from the integrated models of care in the ICU setting. Funding Statement: This study was funded by the Economic and Social Research Council (ESRC) as part of the Antimicrobial Cross Council initiative supported by the seven UK research councils, and the Global Challenges Research Fund (GCRF). Declaration of Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Ethics Approval Statement: Ethics approval for this study was granted by the University of Cape Town Human Research Ethics Committee (HREC ref. 499/2018) and the Amrita Hospital Institutional Research and Ethics Committee (IEC-AIMS-2018-INECONT-005A).