The Antibiotic Audit
A district hospital pharmacy reports that 68% of surgical inpatients received antibiotics for more than seven days post-operation, against a national guideline of 24 hours for uncomplicated procedures. The infection control nurse notes that surgical site infections have not fallen in two years despite rising antibiotic use. Two wards account for most of the prolonged prescriptions. Junior doctors say senior surgeons verbally instruct them to "keep the patient covered" and no formal stop date is recorded. The hospital has a functioning microbiology lab but wound cultures are rarely sent. The pharmacy budget for antibiotics rose 40% in one year.
1. Assess whether this is primarily a knowledge problem, a behavioural problem, or a systems problem, and justify your conclusion.
Read the worked answer
It is primarily a systems problem with a strong behavioural component, not a knowledge deficit. The prescribers are trained and the guideline exists; the barrier is that verbal senior instruction overrides written policy and no stop date is recorded. That is an accountability and documentation gap, not ignorance.
The evidence supports this ranking: prolonged use is concentrated in two wards, which points to local culture rather than hospital-wide knowledge; cultures are rarely sent despite a working lab, meaning decisions are made without data; and infections have not fallen, so the extra antibiotic exposure is buying no measurable benefit while costing 40% more.
A purely educational intervention would likely fail because the people prolonging prescriptions are responding to hierarchy and fear of infection, not to missing facts. The judgement is to fix the system - mandatory stop dates, automatic review, and culture-guided de-escalation - while engaging senior surgeons as owners of the change.
2. Design an intervention package and state two indicators you would track to judge success.
Read the worked answer
Package:
- Require a documented stop date or review date on every perioperative antibiotic order; default to 24 hours unless a stated indication is recorded.
- Empower pharmacists to query orders past the stop date and escalate to the duty surgeon.
- Make wound culture collection routine before any escalation of antibiotics.
- Engage the two high-prescribing wards with their own audit data, and recruit senior surgeons to endorse the policy publicly so verbal instruction aligns with written policy.
- Provide a brief, recurring feedback loop rather than one-off training.
Indicators:
- Proportion of surgical patients with antibiotic duration ≤24 hours (process measure, target a sustained shift).
- Surgical site infection rate per 100 operations (outcome measure), plus a balancing measure of culture submission rate to confirm decisions are data-guided.
Track process and outcome together: duration alone could fall while infections rise, which would signal under-treatment rather than success.