Antimicrobial stewardship in practice: determinants of prescription behaviour and developing interventions to improve surgical prophylaxis in a Rwandan tertiary hospital—a mixed methods study using the behaviour change wheel

BACKGROUND: Behavioural sciences should be used to design and improve antimicrobial stewardship (AMS) interventions aiming surgical prophylaxis (SP). METHODS: A mixed-methods study at the University Teaching Hospital of Kigali, Rwanda. The study included an audit on SP practices and the development of SP interventions based on determinants of prescription behaviour yielded by 2 group discussions and by applying the Capability, Opportunity Motivation Behaviour (COM-B) model and the Behaviour Change Wheel (BCW) framework. RESULTS: The audit included 190 patients: SP prescription was inappropriate regarding determinable duration in 37% (51/139); dosage in 19% (32/167); choice in 77% (136/177) and adequate coverage of expected micro-organisms in 20% (34/175). In 31 patients (16%), SP was appropriate for all four determinants. Barriers of prescription behaviour change pertained to knowledge of guidelines, hierarchical dynamics, access to antimicrobials, inter-professional communication, entrenched routines, documentation issues and lacking surveillance of surgical site infections and antimicrobial resistance. Facilitators of prescription change were the development of a local guideline and audit and feedback processes after implementing change. Subsequent policies and interventions were developed, focusing on (1) developing a local SP guideline, (2) education and training, (3) strengthening drug availability and (4) monitoring and feedback on SP practices before and after implementing change. CONCLUSIONS: This mixed methods study showed suboptimal SP practices regarding to duration, dosage, choice and adequate coverage. Barriers and facilitators of prescription behaviour change touched on all COM-B categories and informed the development of tailored AMS interventions, focusing on the intervention functions "education", "training", "environmental restructuring" and "enablement".