Optimising antibiotic use along surgical pathways: addressing antimicrobial resistance and improving clinical outcomes.

Context of the research:

Antibiotics are important to prevent infections after several types of surgery. The growing number of infections that cannot be treated with antibiotics may mean that many basic types of surgeries cannot continue. Around the world a large amount of all antibiotics are used during the surgical process. Antibiotics in surgery are used to prevent infections from happening after surgery (it is called 'prophylaxis') and for the treatment of infections after surgery. Infection after surgery is a growing concern in many countries. 23 million infections after surgery (or 'surgical site infections', SSIs) lead to 2 million deaths every year. Using antibiotics in the right manner is a sure way of preventing infections after surgery. For example, if the right antibiotics are given at the right time before surgery, then up to seven times less antibiotics are needed after surgery because less people get infections.

Aims and objectives:

The care before, during and after surgery (inside and outside of hospital) must include using the right antibiotics at the right time for the correct amount of time, making sure that there are no missed or late doses. The wellbeing of patients including nutrition and ability to move about can also affect how quickly they recover if they do get an infection. To get this care right at each stage, a lot of coordination and communication is needed between all the different health professionals (nurses, surgeons, anaesthetists, pharmacists), patients and carers involved. Because so many key parties are involved in this process, it is an ideal place to do research to understand ways of thinking about the correct use of antibiotics and behaviours such as hand hygiene which can prevent infections from happening in the first place. This study will use social science research to find out what helps individuals, teams and patients to practice safely and use antibiotics in the right way as described above.

The study will research these issues in England and Scotland as they each have different ways of organising and managing surgery. We will also carry out research in countries where there are less resources but they still manage surgery in the same way (India, South Africa and learning from Rwanda). The studies in countries outside of the UK will also tell us how behaviours can be changed when different health professionals are involved, and when antibiotics are less available within hospitals but also available from other sources.

Methods: The study will last four years and will start with an analysis of all factors within and outside of healthcare organisations which may influence how antibiotics are used. The methods we use at the moment to change behaviours of professionals and patients will be evaluated. New methods will also be designed, developed and also evaluated, and may include using new technologies such as computers or smartphones. We may also change the roles and expectations of different professionals within teams or changing the incentives or penalties associated with proper use of antibiotics. Some of these may involve patients and carers taking a more active role.

Potential applications and benefits:

By understanding the full context where surgery occurs, we will cover aspects of care within and beyond healthcare settings. As we will understand factors such as availability of antibiotics, financial pressures, regulation as well as what patients expect of their healthcare system and professionals, the solutions we will propose will be tailored for each setting. As we will be looking at how professionals, patients and carers behave and use antibiotics, it is likely that the new solutions that we propose would become part of routine practice, helping us to keep antibiotics working for much longer.

The intended beneficiaries are public/patients/carers, healthcare professionals in primary, community, secondary care and public health, national/international and organisational policy makers, medical, surgical and health professional associations and networks.

The short term benefit to patients will be reduced risks of infection and better recovery after surgery. Patients and carers will be better equipped when preparing for surgery by knowing all the steps that they can take to help prevent infections. These will be about the role of general health and wellbeing as well as specific issues relating to infection control and the role of antibiotics. In the long term, future patients will still have access to surgery (currently threatened by AMR).

In addition, if we are able to streamline the antimicrobial stewardship processes around surgery in all healthcare organisations, then new and advanced forms of surgery can continue to develop. Here, industry and innovators will benefit from this research.

Healthcare professionals will benefit from this enhanced way of working and using efficient behavioural (proven) methods to optimise antibiotic use.

Policy makers will benefit by having access to a user-friendly (transparent) decision tool to look at how previously intangible behavioural effects can be modelled in real settings.

What will be done to ensure that they have the opportunity to benefit from this activity?

Because the research will be conducted in a way that includes co-design with multi-disciplinary professionals, researchers, patients and carers and informed by rich qualitative work, the proposed solutions will be relevant and realistic.

Our detailed plan of pathways to impact (enclosed) shows how this research institute and team and collaborators have a very strong track record in ensuring that research outputs are effectively translated to interventions for practitioners and patients to address antibiotic use. Nationally, the NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance at Imperial College London (Director: Alison Holmes) is an established collaboration with Public Health England, utilising data and expertise across a range of themes and leveraging wider networks for dissemination. To address the global threat of AMR, in 2015 Imperial established the Antimicrobial Research Collaborative (www.imperial.ac.uk/arc/), led by Prof Alison Holmes. ARC is a truly multidisciplinary, cross-College approach to AMR, addressing the complex interlinking biological and societal drivers of this threat. ARC involves over 100 PIs working across the Imperial College Academic Health Science Centre. Through ARC and infrastructure awards such as the NIHR Diagnostic Evidence Cooperative we also have strong industrial networks.